How Do You Treat Second-Degree Cystocele?

A 46-year-old woman presents to your office complaining of something bulging from her vagina for the past year. It has been getting progressively more prominent. She has started to notice that she leaks urine with laughing and sneezing. She still has periods regularly every 26 days. She is married. Her husband had a vasectomy for contraception. After appropriate evaluation, you diagnose a second-degree cystocele. She has no uterine prolapse or rectocele.

Which of the following is the best treatment plan to offer this patient?

a. Anticholinergic medications
b. Surgical correction with a bladder neck suspension procedure
c. Placement of a pessary
d. Antibiotic therapy with Bactrim
e. Le Fort colpocleisis

The answer is b

Explanation

Surgical therapy for stress urinary incontinence due to cystocele and loss of urethral support involves suspension of the bladder neck via Kelly plication, retropubic suspension (Marshall-Marchetti-Krantz and Burch procedures), or sling procedures (Pererya and Stamey procedures). Placement of a pessary is an option to relieve a cystocele, but is not ideal in this patient, who is sexually active. Antibiotics such as Bactrim would be used to treat a urinary tract infection, but would not affect stress incontinence. A Le Fort procedure is performed in patients with vaginal vault prolapse and pelvic relaxation who are poor surgical candidates and not sexually active. The procedure involves obliterating the vaginal canal to provide support to the pelvic structures. Anticholinergic drugs such as Ditropan (oxybutynin chloride) are used to relax the bladder in the treatment of bladder dyssynergia.

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