Cystocele

1. CYSTOCELE Presented by : Rahila Najihah Ali DPH/0102/11

2. Anatomy of Pelvic

3. 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

4. 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.

5. 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.

6. Grade of cystocele Divided into 4 grade

7. Investigation Pelvic examination Voiding cystourethrogram Urodynamics   Cystoscopy Fluoroscopy.

8. Treatment   Kegel exercises Estrogen replacement therapy Pessary  (vaginal support device) Surgery

9. 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

10. Subjective Assessment Name : Madam B Age : 57 y/o Sex : Female D.O.Ax : 3 rd October 2013 Dr. dx : Mild cystocele with grade I uv prolapse Dr. mx : conservative mx and refer to physio

11. 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)

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

13. Gynecological Hx : Pt have 2 children 2 nd female child, born in 1976 wt. 3.9kg through svd . Episiotomy done. 3 rd female child, born in 1979 wt. 4.2 kg through SVD. Episiotomy done. Menopausal Status : already menopause since 5 years ago

14. Bowel fx : Normal Stress Incontinence : Present during coughing wt. minimal leakage Incontinence frequency : Everyday wt. moderate severity. Micturation Frequency : Day : 9 times Night : 1 time

15. No. of drinks : 1 Type of drink : Warm water (6 cups/day) Urgency : No Social Hx : Every evening, pt. go to jogging nearly 2 hrs.

16. 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 )

17. 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)

18. 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

19. Plan of Treatment Do kegel’s exercise Biofeedback’s training Kegel’s exercise on the gym ball HEP

20. Intervention Kegel’s exercise Position : Supine lying wt both knees flex Instruction : Tighten your pelvic floor muscles, hold the contraction for five seconds, and then relax for five seconds. Repetition : Do for 10 times

21. Biofeedback’s training Position : Supine lying with both knees flex Instruction : 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

22. Kegel’s exercise on the gym ball Position : Pt. sit on the gym ball with the leg slightly apart Instruction : 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

23. Home exercise programme Ask 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.

24. Evaluation Pt able to do the kegel’s exercise correctly KIV biofeedback training

25. Review Reassess the grade of the pelvic floor muscle Continue with biofeedback training and kegel’s ex. On the gym ball on next visit

26. Reference Book Mantle J , Haslam J , Barton S ; Physiotherapy in Obstretrics and Gynaecology . 2 nd edition . ELSEVIER ( 2005) Madhuri G.B (2007) Textbook of Physiotherapy for Obstretrics and Gynaecological conditions , Jaypee Publishers.