CYSTOCELE

Presented by :Rahila Najihah Ali

DPH/0102/11

Anatomy of Pelvic

Definition

• Also known as prolapsed bladder• Occurs when the supportive tissue between a

woman's bladder and vaginal wall weakens and stretches, allowing the bladder to bulge into the vagina

• May associated with problems emptying the bladder, urinary tract infections or incontinence

Causes

• Stress on the supportive "hammock" during childbirth

• Frequent heavy lifting• Chronic coughing (or other lung problems)• Constipation (frequently straining to pass stool) • Obesity,• menopause (estrogen levels start to drop) • previous pelvic surgery.

Symptoms

• Frequent urination or urge to urinate• Stress incontinence • Not feeling bladder relief immediately after urinating; • Frequent UTI • Discomfort or pain in the vagina, pelvis, lower

abdomen, groin or lower back• Heaviness or pressure in the vaginal area; • Painful intercourse• Tissue protruding from the vagina that may be tender

and/or bleeding.

Grade of cystocele

• Divided into 4 grade

Investigation

• Pelvic examination• Voiding cystourethrogram• Urodynamics • Cystoscopy• Fluoroscopy.

Treatment

• Kegel exercises• Estrogen replacement therapy• Pessary (vaginal support device)• Surgery

Complication

• If case is left untreated, over time the condition may get worse.

• Can cause to urinary retention (inability to urinate) which may lead to kidney damage or infection

Subjective Assessment

Name : Madam BAge : 57 y/oSex : Female D.O.Ax : 3rd October 2013Dr. dx: Mild cystocele with grade I uv

prolapseDr. mx : conservative mx and refer to

physio

C/c : Pt. c/o having incomplete urine and feel there’s mass protrusion at vaginal opening when BO. Problem occur many times in a week but no pain

Current Hx : Pt. start having this problem since many years ago (not remember since when) but just recently came to see doctor at Klinik Kesihatan batu 14 and referred to physiotherapy

General Health : Good PMHx : Pt. has DM and under medication ( since 5

years ago)

Medication / Steroid : • Pt. cannot remember the nameObstetric Hx : • Gravida 3• 1st child, do abortion in 1975. 8/52 . D&c done

Gynecological Hx : Pt have 2 children- 2nd female child, born in 1976 wt. 3.9kg

through svd. Episiotomy done. - 3rd female child, born in 1979 wt. 4.2 kg

through SVD. Episiotomy done.Menopausal Status : already menopause since 5

years ago

Bowel fx : NormalStress Incontinence : Present during coughing

wt. minimal leakageIncontinence frequency : Everyday wt.

moderate severity.Micturation Frequency :

Day : 9 timesNight : 1 time

No. of drinks : 1Type of drink : Warm water (6 cups/day) Urgency : No

Social Hx : Every evening, pt. go to jogging nearly 2 hrs.

Objective Assessment

Observation : • Pt. is moderate size of Chinese lady. She

presented with mild flabbiness of abdominal muscle.

Palpation : • Unable to palpate d/t patient resist Special test : • Provocation test (-ve)

Analysis

• Incontinence and bladder prolapse d/t pelvic floor muscle weakness

• Pelvic floor muscle d/t weakness of slow twitch fiber (STF) and fast twitch fiber (FTF)

Goals

Short term Goal : • To strengthen the pelvic floor muscle• To minimal the amount of protrusion

Long term goal : To regain pelvic floor muscle control during

stress activity

Plan of Treatment

• Do kegel’s exercise

• Biofeedback’s training

• Kegel’s exercise on the gym ball

• HEP

Intervention

Kegel’s exercisePosition : Supine lying wt both knees flexInstruction : Tighten your pelvic floor muscles, hold the contraction for five seconds, and then relax for five seconds.Repetition : Do for 10 times

Biofeedback’s trainingPosition : Supine lying with both knees flexInstruction : Put Ten’s pad to the pt. 2 at between ASIS. 2 at the pt.s’ gluteal fold.Cross the tens’ wire. Do the kegel’s ex. along with ten’s contraction.Duration : 15 minutes Precaution : Keep breathing and do not use help from abdominal muscle

Kegel’s exercise on the gym ballPosition : Pt. sit on the gym ball with the leg slightly apartInstruction : During sitting, bring the gym ball to forward, backward and side. While bring the ball, do the kegel’s exercise.Duration : do for 10 minutes

Home exercise programmeAsk pt. to do the kegel’s exercise at home for 80 times per day. Kegel’s can do in every static position like sitting and standing.

Do kegel’s every times pt. fell like to do stress activity to pelvic floor muscles.

Evaluation

• Pt able to do the kegel’s exercise correctly

• KIV biofeedback training

Review

• Reassess the grade of the pelvic floor muscle

• Continue with biofeedback training and kegel’s ex. On the gym ball on next visit

Reference

Book • Mantle J , Haslam J , Barton S ; Physiotherapy

in Obstretrics and Gynaecology . 2nd edition . ELSEVIER ( 2005)

• Madhuri G.B (2007) Textbook of Physiotherapy for Obstretrics and Gynaecological conditions , Jaypee Publishers.