Cystocele

CYSTOCELE, the descent of the wall of the urinary bladder together with the anterior wall of the vagina (Fig. 1). Cystocele is one of the most frequent forms of downward displacement of the pelvic organs. Cystocele occurs either independently or, which is more often the case, together with prolapse or descent of the uterus. Depending on the degree of descent of the urinary bladder, cystocele is revealed either only during straining of the abdominal press in the form of a protrusion of the anterior vaginal wall, which disappears in the calm position of the patient, or else in cases of significantly pronounced cystocele and in a calm position in the form of protrusions of the anterior vaginal wall of various sizes. Diagnosis usually presents no difficulties and can be confirmed by introducing a probe or a long catheter, the end of which can be felt through the protruded vaginal wall. According to E. Martin, the descent of the urinary bladder is discovered primarily in the form of a depression of the part of the urinary bladder located behind the line between the openings of the ureters. Subsequently, the base of the urinary bladder and the upper section of the urethra are involved in the descent. In connection with this, with a significantly pronounced cystocele, the internal orifice of the urethra acquires an oval shape, and the urethra in the upper section forms an acute angle in relation to its lower part. In the origin of cystocele, according to Halban and Tandler, tears of the perineum and the urogenital diaphragm are of great importance. As a result of the divergence of the crura of the levator ani muscle, a large part of the base of the urinary bladder and the anterior vaginal wall falls into the region of the genital hiatus. Consequently, the urinary bladder is deprived of support on the part of the levator ani muscle and is supported by the urogenital diaphragm and the perineum.

Figure 1. Sagittal section of the pelvis. The descending part of the urinary bladder is shaded. The anterior wall of the vagina also protrudes together with the urinary bladder.

E. Martin assigns exceptional importance in the origin of cystocele to those connective tissue formations that are located between the uterus and the symphysis (the anterior section of the uterine retinacula). Upon weakening of these connective tissue formations, they part and, like through hernia orifices, let through the part of the urinary bladder descending under the influence of intra-abdominal pressure. In connection with this, according to E. Martin, the origin of cystocele is connected with those moments that entail the weakening and insufficiency of connective tissue formations—frequent births, operative deliveries, weakening of tissues on the basis of senile atrophy, debilitating diseases (as a result of which cystocele is also encountered in women who have not given birth). All these moments manifest their influence especially easily in cases where there is congenital tissue failure. Usually the patients themselves note the protrusion of the vagina, which is often mistaken for prolapse of the uterus. Not infrequently, a feeling of pressure and pushing downward is added to this. Very frequently patients note disorders of urination, frequent urination, a sensation of incomplete emptying of the urinary bladder; urinary incontinence is frequently added (with coughing, laughing, straining) when, besides cystocele, there is also urethrocele. In cases of significantly pronounced cystocele, especially with complete prolapse of the uterus, difficulty in emptying the urinary bladder arises, and the latter becomes possible only after reposition of the urinary bladder, respectively the uterus. Treatment of cystocele, exclusively surgical, must be directed toward restoring the correct position of the urinary bladder and its supporting apparatus. Therefore, all methods proposed previously, in which the operation was reduced almost exclusively to cutting out flaps of various shapes from the vaginal mucosa for its narrowing, did not yield the proper result. The rationally performed operation consists of the following. A longitudinal incision, somewhat retreating from the external urethral orifice to the cervix of the uterus; the incision must

Figure 3. be made to a sufficient depth, because only under this condition is it possible to easily push aside the vaginal mucosa. By placing a series of purse-string sutures, the protrusion

Fig. 2. Placement of a purse-string suture on the fascia of the urinary bladder: 1 - urinary bladder; 2 - vaginal portion of the uterus; 3 - external urethral orifice. (After Gersuny-Sänger.)

of the wall of the urinary bladder is eliminated and along with this the fascial plate located between the vagina and the urinary bladder is strengthened, and those connective tissue thickenings that support the urinary bladder are sutured (Fig. 2). E. Martin recommends making a longitudinal incision down to the very muscular wall of the urinary bladder (Fig. 3), after which the latter is pushed upward and to the sides (Fig. 4).

Figure 4.

Figure 5. After this, between the urinary bladder and the vaginal mucosa, bundles of connective tissue are clearly visible, which are then sutured with separate sutures along the midline (Fig. 5); then the vaginal mucosa is sutured. With concomitant cystocele, rupture of the perineum, or weakening of the pelvic floor, the operation of restoration of the pelvic floor and perineum is added. In cases where surgery is contraindicated, one can try the use of pessaries, the insertion of cotton tampons moistened with tannin in glycerin, or physiotherapy, without counting, of course, on a complete cure.