What is a Dropped Bladder? What is Prolapse?

Dropped bladder is a general term used by doctors and patients to describe a condition known as pelvic organ prolapse. Pelvic organ prolapse means that one or more of the pelvic organs - the bladder, the uterus, the intestines or the rectum has fallen down into the vagina. Often, more than one of the pelvic organs is involved in the prolapse. Prolapse ranges in severity from very mild (i.e. it can only be felt by your doctor on examination) to severe, where one or more of the pelvic organs actually protrude through the vaginal opening. When the prolapse is severe you can actually see it, it looks like a red ball protruding from the vagina.

Here is what normal pelvic anatomy looks like:

Here is what a bladder prolapse (dropped bladder) also called a cystocele looks like:

What causes prolapse?

A weakening of the muscles, which normally hold the pelvic organs in place, causes prolapse. Childbirth (labor and delivery) is the most common cause of weakening of these muscles. The aging process itself (blame it on gravity), particularly in women who do a lot of heavy lifting, may be another cause.

Can anything be done to prevent prolapse?

Although no one knows for sure, it makes sense that if you do regular strengthening exercises called Kegel exercises, the muscles will maintain their strength and prolapse can be prevented. Many doctors believe that undergoing an elective cesarean section (before labor has begun) instead of natural childbirth will reduce the likelihood of subsequent prolapse. Beware though, a cesarean section has its own complications and it might not be the best option for you. Elective cesarean section is a controversial subject, which you should discuss in detail with your doctor if you are considering it.

What are the symptoms of prolapse?

The most common symptom of prolapse is a feeling of pressure in the lower abdomen, vaginal or rectal area - a feeling like you are 'sitting on a ball.' In severe cases you may actually see the prolapse protruding from the vagina and, if so, it may get irritated and cause a discharge or even bleeding. With more severe degrees of prolapse it may be difficult to urinate, causing you to have to push or strain. You may experience a weak urine stream and feel like you do not empty your bladder completely. You may (though it's rare) be unable to urinate at all, in which case you would need to have a catheter (tube) passed into the bladder to empty the urine. Sometimes the prolapse can block the kidneys causing kidney failure. Fortunately, provided that the condition is caught early enough, when the prolapse is repaired the kidneys usually return to normal.

Does prolapse cause incontinence (loss of urine control)?

It sounds confusing, but prolapse can both cause and prevent incontinence. When the prolapse is mild, the part of the bladder and the urethra that drops downs actually causes incontinence. But when the prolapse is severe, it may actually block the urethra, preventing incontinence. This is very important to understand because if you elect to have surgery to fix the prolapse, unless the possibility of incontinence is evaluated beforehand, the surgery often makes the incontinence much worse or even brings on new incontinence. Fortunately though, with proper pre-operative evaluation this can be recognized and the incontinence repaired at the same time so that the surgery is successful.

How do I know if I need treatment?

For the overwhelming majority of patients with prolapse, treatment is completely elective. That means that you (not your doctor) decide whether the symptoms are bothersome enough to warrant surgery. There are some instances though, when surgical treatment is medically necessary? 1) if the prolapse causes a blockage to the kidneys causing a backup of urine called hydronephrosis, 2) if there is a blockage to the urethra causing you to retain urine or be unable to urinate at all, 3) if you are getting recurring bladder infections, and 4) if you are getting vaginal ulcers or bleeding from the prolapsed organ.

What are the treatment options?

There are only two. A pessary or surgery.

What is a pessary?

A pessary is a device that is usually made out of a plastic type substance and is usually in the shape of an 'O', a donut or ring. It is placed in the vagina, like a tampon, to hold organs in place. Pessaries come in many different sizes and shapes and need to be fitted by your doctor to the size and shape of your vagina. Pessaries are quite safe, although in some patients they seem to be associated with recurring bladder infections. If a pessary works for you, and it is comfortable, it can be a lifetime treatment. It can be left in place for several months at a time and may be changed by either your doctor or yourself (so long as you are properly instructed first.

If the pessary is so good, why should I consider surgery?

If the pessary works for you, there is no need to ever consider surgery. However, it does not work well for everyone. Here are some of the reasons why:

What kind of surgeries are there?

When it comes to prolapse there are almost as many different kinds of surgeries as there are surgeons. That means that it is very important for you to discuss the particulars of your case with a surgeon in whom you have great confidence. In very general terms, all of the operations are designed to hold the pelvic organs in place and keep them from falling back down. There are operations that are done through the vagina and operations that are done through the abdomen. Those done through the abdomen can be done with an incision (open surgery) or through a laparoscopic or robotic technique. Further, the repairs can be performed using your own natural (autologous) tissue or a variety of foreign material including synthetic plastic-like mesh or tissue derived from animals (xenografts). If the uterus is prolapsed it may be necessary to have a hysterectomy as well, but it is also possible to leave the uterus in place, and resuspend it (hysteropexy). In addition, it may be necessary to repair incontinence.

So if you are considering surgery, be sure that you do your homework and learn a lot about the different surgical possibilities, the potential risks and benefits, and most importantly, about how to select your doctor.

How to choose the right doctor

First, do your homework. Learn some things about prolapse (you've already got a head start reading this). Ask for recommendations from friends, family, your doctor, nurses or anyone you think might know about this stuff. But don't take anyone's word as gospel. Do your own research - get on the internet or go to a bookstore and read as much as you are comfortable reading.

Check out the doctors credentials. Make sure he or she is board certified in either Urology or Obstetrics & Gynecology and, if he graduated from medical school after about 1990, look for an added credential -- that the surgeon is fellowship trained to do prolapse surgery (prior to that, there were very few fellowships, but doctors who have been doing the surgery for that long are usually expert at it). The doctors credentials are listed on his curriculum vitae (CV) which may be available on a website or, at least the diplomas should be hanging on his office wall.

Before making an appointment with the doctor, prepare a written list of questions that you should ask after he has finished evaluating you and when you are discussing treatment options:

How to decide on the kind of surgery

This is the most difficult problem of all for one simple fact -- most surgeons are not expert at all of the different categories of prolapse surgery, so you really have to do your homework. That means if you ask your doctor what operation he recommends, he is likely to recommend the ones that he knows how to do best. That's OK if the operation is appropriate for you and you understand the risks and benefits and are willing to accept them. You might think that this is always the case when deciding on surgery for any condition, but it is not. For example, surgery for prostate cancer is pretty much the same no matter who the surgeon (of course, not all surgeons are equally expert, but they all do the same operations).

So, there are really two decisions you need to make -- choosing the right doctor and choosing the right operation.

How to choose the right operation

First of all, there is rarely 'a right operation,' there are usually many to choose from. But there are 'wrong operations.' The first 'wrong operation' is the one that you don't need! Remember, surgery is usually elective, so if you don't have symptoms and don't have complications from the prolapse (see above), you don't need surgery. No surgery can improve symptoms if you don't have any! If you have no symptoms, but you are told that you have prolapse and need surgery, you probably don't. The other categories of 'wrong operations' are too technical for this discussion and can usually only be determined by an experienced surgeon. When in doubt, seek another opinion.

The operations for prolapse are initially successful in the majority of patients, probably over 90% after a year, but long term results are very difficult to assess. The best series show a success of about 85% at 5 years, but five years is not a very long time for a 50 year old woman. Moreover, those are the best rates, and in the hands of the average surgeon, the results may be worse.

Some complications are common to all of the surgeries; some are only specific to the particular kind of surgery. For example vaginal erosion only occurs when synthetic mesh is used for the repair.

The operations for prolapse can be classified as follows:

In addition, all of these operations can be performed using your own natural (autologous) tissue or by performing 'augmented repairs' using either synthetic plastic-like mesh or processed tissue derived from animals (xenografts). Here are the pros and cons of the three methods:

Transvaginal operations, as the name implies, are done entirely through the vagina.

Open abdominal operations require an incision in the lower abdomen.

Laparoscopic and robotic abdominal operations are done through tiny puncture wounds in the abdomen and usually leave insignificant scars.