Bladder Prolapse

[vika bhandari]

Hi Steve
Are you able to shed some light on a TRUE bladder prolapse and technique ?

Thanks!

[Stephen Bird]

Hi Vika,

Bladder prolapse comes in two main types.

Cystocele and cystourethrocele.

The technique is simple enough. Scan sagittal using a midline transmitter perineal technique.
You will see the symphysis pubis bone most anteriorly, then the uretha leading to the bladder neck, then more posterior you see the vagina, then the rectum , then the elevator ani muscle.

Draw a line along the urethra with the patient resting and also measure the distance from a horizontal line level with the symphysis pubis (base line) down to the bladder neck.

Then ask the patient to valsalva.

If they are normal, nothing really moves.

If they have a bladder prolapse one of two things happen.

If it is a cystocele, the bladder neck will move towards your transducer and descend past the base line. But the urethra will stay stationary in a vertical orientation.

If a cystourethrocele is present the bladder neck will descend as with a cystocele, but the urethra will rotate with it and become more horizontal.

There is no published consensus for the amount of bladder neck descent before you call it a cystocele. In Peter Deitz’ds book he states there are published opinions ranging from 5 to 25mm. For me, if the bladder neck passes through the baseline I call it bladder neck hypermobility and if it is more than 15mm below the baseline I call it a cystocele. Deitz also states in his book unpublished observational data from his personal experience that a descent of greater than 30mm is strongly associated with stress incontinence.

As for cystourethroceles I put a line on the screen in the line of the urethra with the patient resting and then ask them to valsalva. Place another line on the urethra while they are performing valsalva and if the angle is 60 degrees or more I call it a cystourethrocele. If it rotates, but not 60 degrees I call it urethral hyper mobility.

I would like it is we has concensus numbers for this, but I think these guidelines work well in practice.

I have attached a screen shot from peter Deitz’s book (which is excellent) to help explain.

I hope this helps.

Steve.

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