Vaginal wall prolapse (cystocele): symptoms and causes

Cystocele – what it is and why it occurs

A cystocele is the prolapse of the anterior (upper) wall of the vagina together with the bladder. This is linked to weakness in the pelvic floor muscles, ligaments and fasciae that hold the pelvic organs in the correct position. Pelvic organ prolapse as a whole affects approximately 28.8% of women, and in the US, around 13% of women undergo surgery for this condition at some point in their lives. The risk is often increased following vaginal childbirth, particularly if the baby was large, there were tears, prolonged pushing or multiple pregnancies.

A cystocele differs from ordinary postnatal muscle weakness in that it involves not just a sensation of a “weak pelvic floor”, but specifically a displacement of the anterior wall of the vagina and the bladder. After childbirth, the muscles may remain stretched for 2-3 months and gradually recover, provided there is no significant prolapse. With cystocele, a woman often feels pressure, heaviness, incomplete emptying of the bladder or a “lump” in the vagina. In other words, the problem affects not only comfort, but also urination, sexual function and daily activities.

Degrees of vaginal wall prolapse

The degree of prolapse indicates how far the vaginal wall has shifted downwards and whether this affects neighbouring organs, such as the bladder in the case of a cystocele. The doctor determines the stage during a gynaecological examination: sometimes symptoms are already noticeable at an early stage, whilst at other times significant prolapse is long perceived as “mere discomfort”. For convenience, the degrees are usually described as follows:

Stage	What happens	How it may feel
Grade 1	The vaginal wall descends slightly but remains inside	A slight feeling of heaviness, pressure after exertion, discomfort in the evening
Grade 2	The prolapsed wall reaches the entrance to the vagina	A sensation of a foreign body, discomfort when walking or during sexual intercourse
Grade 3	The wall protrudes partially beyond the vaginal opening	Noticeable bulge, problems with urination, chafing from underwear
Grade 4	Marked prolapse of the vaginal wall	Constant discomfort, difficulties with hygiene, risk of irritation to the mucous membrane

Symptoms of vaginal wall prolapse

Vaginal wall prolapse often begins not with pain, but with a strange sensation of heaviness in the lower pelvis. A woman may notice that by the evening a feeling of pressure sets in, as if “something is in the way” in the vagina, and that the discomfort becomes more severe after walking, coughing or lifting bags. It is particularly important to pay close attention to such sensations if there was vaginal wall prolapse following childbirth, perineal tears, a large baby or a prolonged recovery period. Symptoms may vary, but most commonly patients describe the following complaints:

• a sensation of a foreign body or a “ball” in the vagina;
• a feeling of heaviness, fullness or pressure in the lower abdomen or perineum;
• frequent urge to urinate or a feeling that the bladder has not emptied completely;
• urine leakage when coughing, laughing, running or lifting heavy objects;
• discomfort, dryness or unpleasant sensations during sexual intercourse;
• symptoms worsening in the evening, after physical exertion or prolonged standing.

If these symptoms recur, it is best not to wait until they start to interfere with your daily life. At Avicenna, you can undergo a gynaecological examination and further diagnostic tests, including a pelvic ultrasound scan for women, to assess the condition of the uterus, ovaries, bladder and surrounding structures. This helps the doctor determine whether the sensation of pressure is related to a cystocele, another type of prolapse or associated changes.

Causes of vaginal wall prolapse: childbirth, age, physical strain

Vaginal wall prolapse develops when the muscles, ligaments and fascia of the pelvic floor gradually lose their ability to hold the pelvic organs in the correct position. More often than not, it is not a single cause but a combination of several factors: childbirth, hormonal changes, daily physical strain, chronic coughing or being overweight. To make it easier to understand where the problem stems from, the main causes can be categorised as follows:

1. Childbirth, particularly if the baby was large, there were tears, an episiotomy was performed, labour was prolonged, or there were multiple pregnancies.
2. Age-related changes and a drop in oestrogen levels during perimenopause and menopause.
3. A chronic cough, in which intra-abdominal pressure regularly exerts pressure on the pelvic floor.
4. Heavy physical labour or frequent lifting of heavy loads without using the correct technique.
5. Excess weight, which places additional daily strain on the muscles and ligaments of the pelvis.
6. Frequent constipation, where a woman regularly strains during bowel movements.

If urinary leakage, frequent urges or a feeling of incomplete bladder emptying accompany the prolapse, it is important to assess not only the condition of the vaginal walls but also the functioning of the urinary system. At our Avicenna Med clinic, you can undergo diagnostic tests and discuss treatment for urinary incontinence in women, if the symptoms are linked to a cystocele, stress incontinence or pelvic floor weakness following childbirth. This approach helps to identify the underlying cause of your discomfort rather than simply masking the problem.

Can prolapse be stopped without surgery: Kegel exercises and pessaries

In the early stages, prolapse can be managed without surgery by strengthening the pelvic floor muscles and reducing the daily strain on them. Kegel exercises help to improve support for the bladder and vaginal walls, but they only work if performed regularly and with the correct technique: it is important to contract the pelvic floor muscles specifically, rather than the abdominal muscles or buttocks. If there is prolapse of the vaginal walls following childbirth, your doctor may also recommend a pessary – a special vaginal device that supports the tissues from within and reduces the feeling of pressure. This approach is more commonly used for grades 1–2, where there is no significant prolapse or severe urinary problems.

When vaginal wall prolapse requires surgery

Surgery for vaginal wall prolapse is considered when symptoms are already interfering with walking, working, having a sex life or emptying the bladder normally. The decision is made by the doctor following an examination, an assessment of the degree of prolapse and the patient’s symptoms; therefore, the first step is usually a consultation with a gynaecologist. Indications for surgical correction may include:

1. Significant protrusion of the vaginal wall beyond the vaginal opening.
2. A persistent sensation of a foreign body, pressure or chafing.
3. Difficulty passing urine or a feeling that the bladder has not been completely emptied.
4. Frequent inflammation, irritation of the mucous membrane or discomfort during personal hygiene.
5. A combination of prolapse and urinary incontinence.
6. No improvement from Kegel exercises, pessaries or other conservative treatments.

If prolapse is accompanied by urinary leakage, frequent urges to urinate or urinary retention, it is advisable to consult a urologist. At Avicenna Med, a doctor will help determine whether surgery is required at this stage or whether it is possible to continue with monitoring and non-surgical treatment.

What is important to remember about vaginal wall prolapse

Vaginal wall prolapse is not a “minor age-related issue” nor an inevitable consequence of childbirth, but a condition that can affect urination, your sex life and your day-to-day comfort. When it involves the anterior vaginal wall and the bladder, this condition is known as a cystocele. If you experience heaviness, pressure, a sensation of a foreign body, or urine leakage, it is best not to wait until the symptoms worsen: a face-to-face consultation at Avicenna Med will help determine the extent of the prolapse and select the appropriate treatment without unnecessary guesswork.

FAQ

1. How can I recognise a cystocele myself?

You can recognise a cystocele by a feeling of pressure, a sensation of a “ball” in the vagina, discomfort when walking, and problems with urination. However, it is not possible to determine the degree of prolapse at home. Similar sensations can occur with uterine prolapse, rectocele, inflammation or vaginal cysts. Therefore, relying solely on photos, forums or descriptions of symptoms is risky. A gynaecological examination is required, sometimes involving straining.

2. Does vaginal wall prolapse after childbirth resolve on its own?

Sometimes, mild muscle weakness after childbirth improves in the first few months, especially if there were no tears and the woman takes care of her pelvic floor. However, vaginal wall prolapse after childbirth does not always resolve on its own. If there is a bulge, urine leakage, a sensation of a foreign body, or a feeling of heaviness by the evening, it is best not to wait. A doctor will assess the degree of prolapse and advise whether Kegel exercises, a pessary or other treatment is required.

3. Do Kegel exercises help with cystocele?

Yes, Kegel exercises can help with early stages of cystocele if performed correctly and regularly. It is important to contract the pelvic floor muscles, rather than the abdominal muscles, buttocks or thighs. In cases of severe prolapse, exercises alone are often insufficient, as the ligaments and fascia have already lost their support. It is therefore best to have an examination first, and then receive a training programme and a schedule for monitoring progress.

4. Is an ultrasound scan necessary for vaginal wall prolapse?

An ultrasound scan is sometimes necessary, but it is no substitute for a gynaecological examination. In the case of a cystocele, the doctor can see the prolapse of the vaginal walls during the examination, particularly when the patient strains. An ultrasound scan helps to assess the pelvic organs, the bladder, residual urine and any associated changes. It is useful in cases of pain, menstrual irregularities, frequent urinary tract infections or a sensation of incomplete bladder emptying.

5. When should you not delay seeing a doctor?

You should see a doctor straight away if the bulge has become visible from the outside, if you are having difficulty passing urine, if you suffer from frequent bouts of cystitis, or if you notice blood, pain, sores or severe irritation of the mucous membrane. You should not delay seeing a doctor if the symptoms are preventing you from walking, working, exercising or having a sex life. The earlier a cystocele is assessed, the easier it is to choose a treatment and reduce the risk of it getting worse.