Bladder Prolapse: Causes, Stages and Treatment

What Is Bladder Prolapse?

The bladder normally sits behind the front wall of the vagina. Pelvic floor muscles, connective tissue, and ligaments help keep the bladder and other pelvic organs in place.

When these supports weaken, the front vaginal wall can drop downward and create a bulge. This is called anterior vaginal wall prolapse, often referred to as a cystocele or bladder prolapse.

It is one type of pelvic organ prolapse (POP). Other types include:

• Uterine prolapse: the uterus descends into the vagina.
• Rectocele: the rectum bulges into the back wall of the vagina.
• Vaginal vault prolapse: the top of the vagina loses support, usually after hysterectomy.

More than one type can occur at the same time.

What Causes Bladder Prolapse?

Bladder prolapse usually develops because the muscles and connective tissues of the pelvic floor have weakened or stretched over time.

Pregnancy and Childbirth

Pregnancy and vaginal childbirth are among the strongest risk factors for pelvic organ prolapse. Pregnancy places extra pressure on the pelvic floor, while vaginal delivery can stretch or injure muscles, nerves, and connective tissues that support the vagina and bladder.

The risk tends to increase with the number of vaginal births and with other childbirth-related factors that place greater strain on the pelvic floor. A systematic review identified vaginal delivery and parity as established risk factors for pelvic organ prolapse.

Aging and Menopause

The risk of prolapse increases with age as pelvic muscles and connective tissues gradually lose strength and elasticity. A systematic review found increasing age to be an important risk factor for pelvic organ prolapse.

Prolapse also becomes more common after menopause. However, menopause itself is difficult to separate from the effects of aging, childbirth history, and other factors.

Chronic Increased Abdominal Pressure

Repeated pressure inside the abdomen can place extra strain on the pelvic floor over time. Factors associated with prolapse include:

• Chronic constipation and repeated straining
• Persistent coughing
• Obesity
• Jobs or activities that involve frequent heavy physical work

A 2023 systematic review found associations between prolapse and obesity, particularly BMI > 30 kg/m2, constipation, persistent cough, and certain physically demanding occupations.

Previous Pelvic Surgery

Pelvic surgery can sometimes change the support structures around the vagina. For example, after hysterectomy, the top of the vagina may lose support and develop vaginal vault prolapse.

Previous surgery does not mean prolapse will occur, but surgical history is one factor doctors consider when evaluating pelvic support problems.

What Are the Stages of Bladder Prolapse?

Doctors commonly describe pelvic organ prolapse using the Pelvic Organ Prolapse Quantification system, or POP-Q.

During a pelvic examination, the position of the vaginal walls is measured in relation to the hymen, which serves as a fixed reference point. POP-Q ranges from Stage 0, meaning no prolapse, to Stage 4, meaning almost complete or complete vaginal eversion.

These descriptions simplify the formal POP-Q measurements, but they show how doctors judge the degree of descent.

Why Stage Is Not Everything

The anatomical stage does not always match how much discomfort a woman experiences. Stage 2, for example, includes both women with significant symptoms and women who notice little or nothing. Studies have found that anatomical measurements alone do not always predict how patients feel or how successful they consider treatment.

This is why a higher stage does not automatically mean surgery is necessary.

When Should You See a Doctor?

Arrange an evaluation if you:

• Feel or see a bulge at the vaginal opening
• Have pelvic pressure or prolapse symptoms that interfere with normal activities
• Regularly feel that your bladder does not empty completely
• Develop recurrent urinary tract infections
• Need to push the prolapse back to urinate or feel comfortable
• Notice bleeding, irritation, or sores on exposed vaginal tissue

Seek more urgent medical attention if you suddenly cannot urinate, develop severe pain, or have significant bleeding.

Advanced prolapse can occasionally interfere with bladder emptying, so persistent problems passing urine should not be ignored.

How Doctors Diagnose Bladder Prolapse

In most cases, doctors diagnose bladder prolapse through a medical history and pelvic examination. Additional tests depend on the symptoms and are not routinely needed.

Common assessments include:

• Medical history: Reviews vaginal bulging, urinary or bowel symptoms, childbirth and previous pelvic surgery.
• Pelvic examination: Identifies which vaginal wall or pelvic organ has descended. The doctor may ask you to cough, bear down or stand.
• POP-Q measurements: Record the location and stage of the prolapse using a standardized system.
• Cough stress test: Checks for urine leakage when stress incontinence is suspected.
• Post-void residual: Measures how much urine remains after emptying the bladder.
• Urodynamic testing: May be used when bladder symptoms are complicated or the cause remains unclear.
• Ultrasound or MRI: May provide additional anatomical information in selected complex cases.

Most people do not need imaging for straightforward bladder prolapse. A medical history and pelvic examination often provide enough information for diagnosis.

What Are the Treatment Options?

Treatment depends on your symptoms, lifestyle, general health, future pregnancy plans, and personal preferences.

Women without bothersome symptoms may simply be monitored. For symptomatic prolapse, nonsurgical treatments are usually considered before surgery.

Lifestyle Changes

Reducing repeated pressure on the pelvic floor may help prevent symptoms from becoming worse.

Practical steps may include:

• Treating constipation and avoiding repeated straining
• Managing a chronic cough
• Maintaining a healthy weight
• Adjusting activities that consistently worsen prolapse symptoms

These measures cannot necessarily reverse established prolapse, but they may reduce pressure on weakened pelvic tissues.

Pelvic Floor Muscle Training

Pelvic floor muscle training strengthens the muscles that support the pelvic organs.

NICE recommends supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic Stage 1 or Stage 2 prolapse.

Exercises are most useful for mild to moderate prolapse. They may improve symptoms and muscle support, but they are unlikely to physically correct a large prolapse that extends well outside the vagina.

Working with a pelvic floor physiotherapist can also help make sure the exercises are performed correctly.

Vaginal Pessary

A pessary is a removable device placed inside the vagina to support the prolapsed tissues.

It can be used at different stages of prolapse and may be especially useful for women who:

• Want to avoid or delay surgery
• Are planning future pregnancy
• Have medical conditions that increase surgical risk
• Prefer a nonsurgical option

Some women use a pessary temporarily, while others use one for years. The correct size and shape may take more than one fitting. Regular follow-up is important because pessaries can sometimes cause discharge, bleeding, irritation, or vaginal tissue changes.

Surgery

Surgery may be considered when prolapse causes significant symptoms and conservative treatment has not helped or is not acceptable to the patient. 

The type of surgery depends on which areas of the vagina have lost support.

Anterior colporrhaphy is a vaginal procedure commonly used for anterior vaginal wall prolapse. The surgeon reinforces the weakened vaginal tissue with stitches so it can better support the bladder.

If bladder prolapse occurs together with loss of support at the top of the vagina, additional suspension surgery may be needed.

Sacrocolpopexy is mainly used for vaginal vault or apical prolapse. During this operation, surgical mesh is attached to the vagina and the sacrum to restore support. It is not necessarily the appropriate operation for an isolated cystocele.

Native tissue repair uses a woman's own tissues and stitches to restore support.

Mesh is still used in some abdominal or laparoscopic procedures such as sacrocolpopexy, but transvaginal mesh for prolapse has raised significant safety concerns because complications can include mesh exposure, pain, infection, and injury to nearby organs. NICE states that transvaginal mesh repair for anterior or posterior vaginal wall prolapse should only be used in the context of research.

The risks and benefits depend on the type of prolapse, surgical route, previous operations, and individual circumstances.