Cystocele (Prolapsed Bladder): Symptoms and Treatment

✓ This content has been medically reviewed by an obstetrician and gynaecologist
Written & medically reviewed by: Op. Dr. Ayşet Jane Özcan, Obstetrics & Gynaecology Specialist
Istanbul Faculty of Medicine · Medical Park Bahçelievler · TJOD and TSRM member
Last updated: 24 October 2026 · Last medical review: 24 October 2026

If you have been told you have a cystocele, or you have felt a soft bulge at the entrance of the vagina and found that your bladder no longer empties the way it used to, this article is written for you. A cystocele is also called a prolapsed bladder, bladder prolapse, anterior vaginal wall prolapse or anterior compartment prolapse. All of these names describe the same thing: the bladder has lost some of the support that normally holds it up behind the front wall of the vagina, and it now bulges into that wall.

This is a common, benign and very manageable condition. It is not a cancer, it is not dangerous in itself, and it does not mean your bladder is about to fall out. What it does mean is that the supporting layer of connective tissue and muscle in your pelvis has been weakened, usually by a combination of childbirth, time, hormonal change and years of pressure from above. Below I explain what a cystocele actually is, what it feels like, how it is assessed, and what the real treatment choices are, from physiotherapy and pessaries through to the different surgical repairs and what recovery involves. Because the aim is to be useful rather than alarming, I also describe the symptoms that are not typical of a cystocele, and the small number of situations where you should seek help promptly.

What a cystocele (prolapsed bladder) actually is

A cystocele is a prolapse of the bladder into the front wall of the vagina. The bladder and the vagina sit directly against each other, separated by a layer of fibrous connective tissue often called the pubocervical or vesicovaginal layer. That layer is anchored sideways to strong fascia running along the pelvic side walls, and it is held up from below by the pelvic floor muscles. When the fibrous layer stretches, thins or detaches, the bladder has nothing firm behind the vaginal skin to rest on, and it pushes forward. What you see or feel as a bulge is the vaginal wall with the bladder behind it.

It helps to know that the pelvis is usually described in three compartments. The front (anterior) compartment holds the bladder and urethra, the middle holds the uterus or, after hysterectomy, the top of the vagina, and the back (posterior) compartment holds the rectum. A cystocele is anterior compartment prolapse. A rectocele is posterior, and descent of the uterus or vaginal vault is apical. Anterior prolapse is the compartment most often affected, and it very commonly occurs together with some descent of the apex. If you want the broader picture of how the compartments and stages relate to each other, that is covered in detail in our overview of pelvic organ prolapse, its stages and treatment options; this article stays with the bladder.

Central and lateral defects

Not all cystoceles are structurally the same. In some women the supporting layer gives way in the middle, so the bladder bulges through a central gap, and the vaginal skin over it typically looks smooth and shiny with the normal folds flattened out. In others the layer peels away from its sideways attachment on the pelvic wall, a lateral or paravaginal defect, and the vaginal folds are often preserved. Many women have elements of both. Your surgeon will look for this distinction, because a repair that only closes a midline gap may not hold if the real problem is at the sides.

One further term you may hear is cystourethrocele. This means the urethra, the short tube that carries urine out, has descended along with the bladder base. It is relevant because urethral mobility influences whether you leak urine with coughing, and how continence is handled if you go on to have surgery.

Symptoms: the bulge, the pressure and the dragging feeling

The symptom most specific to a cystocele is the sensation of a bulge or of something coming down in the vagina. Nothing else in gynaecology quite reproduces it. Women describe it as a lump at the entrance, a feeling of sitting on a small ball, a tampon that has slipped and needs pushing back, or simply fullness and heaviness low in the pelvis. Some notice it only when washing or wiping; others can see or feel smooth, moist tissue at or just outside the vaginal opening.

The pattern through the day is characteristic and worth recognising, because it reassures you that what you are feeling is mechanical. Prolapse symptoms are typically absent or mild in the morning after a night lying down, and build through the day with standing, walking, lifting and exercise. They are usually worst in the evening and ease again when you lie down. They often feel worse when you are constipated and have been straining, during a chest infection with a lot of coughing, in the days before a period when tissues are more congested, and after a long day on your feet. A bulge that behaves this way is behaving like prolapse.

Pressure and a dull dragging sensation low in the pelvis, the groin or the lower back are common. Sharp or severe pelvic pain, on the other hand, is not a typical feature of a cystocele, and if that is your main complaint it usually points elsewhere and deserves its own assessment; the possible explanations are set out in our guide to the causes of pelvic pain in women.

If the bulge sits outside the vaginal opening for much of the day it can rub against underwear. The vaginal skin, which is not designed to be exposed to air and friction, may then become dry, thickened or superficially ulcerated, and this can cause a watery or blood-stained discharge or light spotting. Sexually, women report dryness, reduced sensation, awareness of the bulge during intercourse, or simply avoiding sex because of how the area feels. These effects are real and worth raising at your appointment.

Symptoms that commonly come with a cystocele

• A soft bulge or lump felt at or near the vaginal opening, worse by the end of the day
• Heaviness, pressure or a dragging feeling in the pelvis, groin or lower back
• A sense that the bladder has not emptied even though you have just been
• Needing to go again soon after passing urine, or needing to push the bulge back to empty
• Urinary urgency, frequency and getting up at night
• Repeated urinary infections
• Dryness, discomfort or loss of sensation during sex
• Light spotting or watery discharge if the bulge is exposed and rubbing

Urinary symptoms: incomplete emptying, urgency and leaking

Bladder symptoms are the reason many women come in, and they follow logically from the anatomy. When the bladder base drops forward and downward, urine collects in the lowest part of the sagging pouch rather than draining straight into the urethra. The practical result is incomplete emptying.

That shows itself in several ways. The stream may be slow, hesitant or stop and start. You may need to sit forward, lean back, rock, or stand and sit again before anything comes. Many women discover for themselves the two manoeuvres that help: double voiding, which means waiting half a minute and passing urine a second time before leaving the bathroom, and splinting, which means supporting or pushing the bulge back with the fingers so that the bladder can drain. If you have been doing either of these without mentioning it, say so, because it is a strong clue to how much the prolapse is affecting bladder function.

Urine that stays behind in the bladder explains the next cluster of symptoms. A bladder that is never completely empty fills to its trigger point sooner, so you feel the urge again quickly, go more often, and get up at night. Residual urine is also a reason for repeated urinary infections, which is why women with a cystocele sometimes have cycles of cystitis. If you are unsure whether recurrent burning and frequency is infection or something else, our comparison of yeast infection, bacterial vaginosis and urinary infection explains how the three are told apart, although repeated proven infections should always be assessed properly rather than treated blindly.

Leaking, and the leak that appears later

Stress urinary incontinence, meaning leaking with a cough, laugh, sneeze or exercise, often coexists with a cystocele because the same childbirth and tissue changes affect urethral support. But there is an important twist that surprises many women. A large anterior prolapse can kink the urethra, acting like a bend in a hose, so that leaking actually stops as the prolapse worsens. When that prolapse is then supported with a pessary or repaired surgically, the kink is released and stress leaking can appear or return. This is sometimes called occult or masked incontinence. It is not a sign of a poorly performed operation; it is the unmasking of a problem that was always there, and it is one of the main reasons your doctor will test for leaking while the prolapse is held back, before planning surgery.

Urgency and frequency behave less predictably. Some of it improves once emptying improves, and some of it comes from an overactive bladder that exists alongside the prolapse and needs its own treatment. Knowing this in advance prevents disappointment later.

What causes a cystocele

A cystocele develops when the connective tissue and muscle supporting the front vaginal wall are damaged or weakened. In almost every woman it is a combination of factors rather than a single cause, and in particular it is almost never the result of one unlucky lift.

Childbirth

Vaginal birth is the single most important contributor. The pelvic floor muscles, their nerve supply and the fascial layers are stretched substantially during the second stage of labour. The risk is greater with more than one vaginal birth, with a long second stage, with instrumental delivery by forceps or vacuum, and with a larger baby. In some women one end of the main pelvic floor muscle pulls away from the pubic bone during delivery, an injury called levator avulsion, which leaves a permanently wider gap and less support from below. Significant tearing of the perineum also reduces support, and our article on perineal tears, their degrees and repair describes that in more detail. Importantly, the prolapse itself may not appear for years or even decades after the birth that set it up, which is why many women first notice a bulge around the menopause rather than in their thirties.

Menopause and tissue change

Oestrogen keeps vaginal and supporting tissue thick, elastic and well supplied with blood. After the menopause those tissues thin and lose elasticity, and collagen quality changes with age throughout the body. This is why an existing prolapse often becomes noticeable or more troublesome in the years after periods stop. Vaginal dryness and soreness frequently accompany it, and both are discussed in our guide to menopause symptoms and treatment options.

Years of pressure from above

Anything that repeatedly raises pressure inside the abdomen pushes down on the pelvic floor. Chronic constipation with habitual straining is probably the most under-recognised factor, and it is also the most modifiable. A chronic cough, whether from smoking, asthma or lung disease, does the same thing hundreds of times a day. Heavy lifting, particularly repeated occupational lifting or lifting weights while holding the breath and bearing down, loads the same tissues. Carrying excess body weight increases resting pressure continuously.

Other contributors

• Age, independently of childbirth and menopause
• Previous hysterectomy or other pelvic surgery, which can alter support at the vaginal apex
• A family history of prolapse, which is common and suggests inherited tissue characteristics
• Inherited connective tissue disorders such as Marfan or Ehlers-Danlos syndrome, and joint hypermobility
• Pregnancy itself, through the weight of the uterus and the effect of pregnancy hormones on ligaments
• Chronic heavy physical work sustained over many years

It is worth saying plainly that a cystocele is not a sign that you did something wrong, neglected your body or exercised badly. The main drivers are birth, biology and time.

How a cystocele is diagnosed and graded

A cystocele is diagnosed by examination, not by a scan or a blood test. The consultation has two halves: understanding what is bothering you, and establishing which compartments have lost support and by how much.

The history matters more than people expect, because the decision to treat is driven by symptoms rather than by appearance. I will usually ask whether you feel a bulge, how it changes through the day, how your bladder empties, whether you splint or double void, whether you leak and in what circumstances, how your bowels work and whether you strain, whether sex is affected, and what you have stopped doing because of it. A bladder diary kept over two or three days, recording drinks, voided volumes, urgency and leaks, is often more informative than anything else.

The examination is done lying down, commonly in the left lateral position with a single-bladed Sims speculum, which allows each vaginal wall to be inspected separately while the other is held back. You will be asked to cough and to bear down, because prolapse is a dynamic finding and may be almost invisible at rest. If what is seen does not match what you describe, examining you standing or later in the day will often reveal more.

What the stages mean

Severity is recorded against the hymen, which is used as a fixed reference point because it does not move with straining. The formal system, POP-Q, turns that into stages. Stage 0 means no descent at all. Stage I means the leading edge of the prolapse stays more than a centimetre above the level of the hymen, so it is still well inside. Stage II means it has come to within a centimetre either side of the hymen, in other words at or very close to the vaginal opening, and this is the stage at which most women begin to feel a bulge. Stage III means it protrudes more than a centimetre beyond the hymen without the vagina being completely turned out, and Stage IV means complete eversion, where the wall is essentially fully outside.

Two things are worth understanding about staging. The first is that the stage describes anatomy and nothing else: it does not tell you how much trouble the prolapse is causing, and women with the same stage can have entirely different symptoms. The second is that the stage is often recorded separately for each compartment, so your notes may describe a Stage II anterior prolapse alongside a lesser degree of apical or posterior descent.

What the examination is specifically looking for

Beyond staging, there are several questions specific to the front wall. Does the vaginal apex, meaning the cervix or the vault, also descend? Is the defect central, lateral or both? Is the urethra mobile, and do you leak when the prolapse is pushed back? And is the bulge truly a cystocele, or one of the conditions that can mimic it, such as a cyst in the vaginal wall, a urethral diverticulum, a fibroid presenting low, or a loop of bowel in an anterior enterocele?

Tests are used selectively rather than routinely. A measurement of the urine left behind after you pass water, taken by bladder ultrasound or occasionally by catheter, tells us whether emptying is genuinely impaired. A urine dipstick and culture are appropriate if you have had repeated infections. Urodynamic studies, which measure bladder pressure and flow, are not needed for a straightforward prolapse but are often arranged when urinary symptoms are mixed or confusing, or before surgery when incontinence may also need to be addressed. Imaging of the kidneys is reserved for very advanced prolapse with a large residual volume, where drainage from the kidneys can occasionally be affected.

Conservative treatment: pelvic floor muscle training and lifestyle

For a mild to moderate symptomatic cystocele, supervised pelvic floor muscle training with a women's health physiotherapist is the recommended starting point. UK NICE guidance recommends offering a properly supervised programme of at least around sixteen weeks before surgery is considered. Training will not restore a bladder that has dropped well outside the vagina, but it can meaningfully reduce the feeling of bulge and heaviness, improve bladder and bowel control, and it is worth doing whatever else you go on to have.

The word supervised is doing real work in that sentence. A large proportion of women who have been told to do pelvic floor exercises are not in fact contracting the right muscles. The common faults are squeezing the buttocks and inner thighs instead, holding the breath, or bearing down rather than lifting. A physiotherapist confirms by examination that you are generating a genuine inward lift, grades its strength and endurance, builds a programme suited to what you can actually do, and then progresses it. Adjuncts such as biofeedback, weighted vaginal cones or electrical stimulation are sometimes added when a voluntary contraction is weak or hard to find.

You will also be taught timing, not just strength. Contracting the pelvic floor just before and during a cough, sneeze or lift, sometimes called the knack, protects the tissues at the moment pressure spikes. Over time this becomes automatic. Because the underlying tissue weakness does not go away, maintenance matters: a short daily or near-daily routine continued indefinitely is more valuable than an intensive burst that stops.

The lifestyle changes that genuinely matter

• Treat constipation properly. Adequate fibre and fluid, not ignoring the urge, unhurried time on the toilet, feet supported so the knees sit above the hips, and never straining. Ask about a stool softener or bulking agent if diet alone is not enough.
• Deal with a chronic cough. Stopping smoking and optimising asthma or lung disease treatment removes hundreds of daily pressure spikes.
• Reduce excess weight where applicable. Lower body weight means a lower constant downward load on the pelvic floor.
• Change how you lift rather than stopping lifting. Breathe out through the effort, engage the pelvic floor first, keep loads close to the body, and avoid repeated maximal lifts with a held breath.
• Modify rather than abandon exercise. Walking, swimming, cycling and resistance work with good technique are usually all fine. High-impact work and very heavy overhead lifting are the activities most likely to provoke symptoms, and a physiotherapist can help you adapt them.
• Empty your bladder properly. Allow time, do not hover or rush, and use double voiding if emptying feels incomplete.

These are the measures I refer back to throughout the rest of this article, because they remain relevant whether you are managing a mild cystocele without any treatment, living with a pessary, or protecting a surgical repair years later.

In postmenopausal women, topical vaginal oestrogen is often added. It does not lift the prolapse, but by improving the thickness and resilience of the vaginal tissue it reduces soreness and dryness, helps the tissue tolerate a pessary, and is sometimes used for a period before surgery. It is prescribed as a cream, a tablet or a ring, and acts locally in low dose.

Pessaries: physical support without surgery

A vaginal pessary is a silicone device placed in the vagina to hold the prolapse up mechanically. It deserves to be presented as a proper long-term treatment rather than only as something to tide you over, because many women use one for years and are entirely satisfied with it.

Several shapes exist. Ring pessaries, rings with a central support, and dish shapes are the ones most often used for anterior prolapse, and they are the easiest to insert, remove and live with. Space-filling designs such as the Gellhorn, the cube and the shelf are used for more advanced prolapse or when a ring will not stay in, but they are usually clinician-managed. Fitting is a practical process of trial and error: you are fitted with a size, then asked to walk, cough, strain and pass urine before leaving, and if it is uncomfortable or falls out, a different size or shape is tried. Needing more than one attempt is normal and does not mean a pessary cannot work for you. A correctly fitted pessary should not be felt at all.

How well it stays in depends partly on anatomy. A pessary needs something to sit against, so a very wide vaginal opening with little perineal support makes retention harder. Where possible I prefer to teach self-management: you remove the pessary yourself at an agreed interval, wash it with soap and water, and reinsert it, which gives you independence and reduces the chance of problems from a device left in too long. Women who cannot manage it themselves attend for a change and check, typically every few months. Either way, a pessary must not simply be left and forgotten, because a neglected device can become embedded in the vaginal wall.

Side effects are usually minor and manageable: increased discharge, a change in odour, and occasionally light spotting from a pressure point. Vaginal oestrogen is frequently used alongside a pessary after the menopause to keep the tissue healthy. As with surgery, supporting the prolapse can unmask stress incontinence that the bulge had been hiding, which is actually useful information when you are deciding about an operation. Intercourse is possible with ring and dish pessaries left in place, and with other designs the device can be removed beforehand.

Contact your doctor about a pessary if you notice

• Pain, or persistent awareness of the device
• New or heavier vaginal bleeding
• Offensive or markedly increased discharge
• The pessary falling out repeatedly, or being unable to remove it
• Difficulty passing urine, or new difficulty opening the bowels, after fitting
• A missed review appointment, so that it can be rebooked rather than left

A pessary particularly suits women who want to avoid or delay surgery, who may still wish to have a baby, whose general health makes an operation inadvisable, who are in the early months after birth, or who want to find out whether supporting the bulge actually relieves the symptoms they are attributing to it.

Surgical repair options for a cystocele

Surgery is for a cystocele that still troubles you after a fair trial of conservative treatment, or where conservative treatment is not appropriate. The standard operation for the front wall is an anterior repair, also called anterior colporrhaphy, and the single most important judgement around it is whether support of the vaginal apex needs to be addressed at the same time.

Anterior repair

The operation is performed through the vagina, so there is no cut on the abdomen. A midline incision is made in the front vaginal wall, the vaginal skin is separated from the bladder, the stretched supportive layer beneath is drawn together in the midline with dissolving stitches to recreate a firm shelf behind the bladder, any redundant vaginal skin is trimmed, and the wall is closed. It typically takes under an hour and is done under general or regional anaesthetic. Where the defect is lateral rather than central, a paravaginal repair reattaches the supporting layer to the fascia on the pelvic side wall, approached either vaginally or abdominally.

Supporting the apex

This is the point I most want you to take away from the surgical section. Anterior and apical prolapse so often travel together that repairing the front wall alone, while the top of the vagina continues to descend, is a recognised route to early recurrence. The front wall is in effect being asked to hold up a structure that is still sinking behind it. Depending on the findings, an apical procedure may therefore be combined with an anterior repair or chosen instead of one. Sacrospinous ligament fixation and uterosacral ligament suspension are performed vaginally and attach the apex to strong pelvic ligaments. Sacrocolpopexy, or sacrohysteropexy when the uterus is kept, attaches the vaginal apex or cervix to the ligament overlying the sacrum using a mesh, and it is now commonly performed through small incisions, as described in our overview of laparoscopic surgery. Keeping the uterus is often perfectly possible; a hysterectomy is not an automatic part of prolapse surgery and should be a specific, discussed decision. If you are offered an anterior repair, it is entirely reasonable to ask what was found at the apex and whether it needs anything.

Mesh, obliterative surgery and continence

You will almost certainly have read about mesh. The position now is that transvaginal mesh inserted through the vagina to reinforce a prolapse repair is no longer used routinely, following safety concerns and regulatory restriction in the United Kingdom and elsewhere. That is a different procedure from abdominal or laparoscopic sacrocolpopexy, where the mesh is placed abdominally and which remains an accepted option in selected cases. If mesh is proposed in any form, ask specifically which operation is meant, why it is being recommended for you, and what the alternatives are.

For older women with advanced prolapse, significant medical problems and no wish for vaginal intercourse in future, colpocleisis is an option. It closes or narrows the vagina rather than reconstructing it, is relatively quick, can often be done without a general anaesthetic, and is generally well tolerated, but it is irreversible with respect to penetrative sex and so needs very clear discussion beforehand.

Finally, continence surgery. If you leak with coughing as well as having a bulge, you and your surgeon will decide whether to treat both at once or to repair the prolapse first and reassess, since prolapse repair itself changes the position of the urethra. Many surgeons prefer a staged approach, so that an additional procedure is only performed if it turns out to be genuinely needed.

How the decision between conservative care and surgery is made

The decision rests on how much the prolapse interferes with your life, not on the stage written in your notes. A cystocele reaching the vaginal opening that you barely notice needs no treatment at all, while a smaller one that leaves you unable to empty your bladder or stops you exercising may well justify an operation. A prolapse found incidentally at a smear appointment, causing no symptoms, calls for explanation and reassurance rather than intervention.

These are the considerations I work through with a patient.

• How much it bothers you, in your own words, and what you have stopped doing because of it
• Whether conservative treatment has had a fair trial, meaning properly supervised physiotherapy, real lifestyle change and, where appropriate, a pessary attempt
• Whether bladder function is objectively affected, for instance a significant residual volume or repeated proven infections, which raises the priority of treatment
• Future pregnancy plans. If you may have another baby, surgical repair is usually deferred, since a subsequent pregnancy and birth can undo it, and a pessary bridges the gap well
• Sexual activity and preferences, which influence both the choice of pessary and whether obliterative surgery could ever be appropriate
• General health and anaesthetic risk, including heart and lung disease, diabetes control, mobility and smoking status
• Previous prolapse or continence surgery, and whether a hysterectomy has already been performed
• Occupation and lifting demands, which affect both recurrence risk and realistic recovery planning
• What the examination showed, especially whether the apex also needs support and whether the defect is central or lateral

Setting expectations is part of the decision, not an afterthought. The symptom that responds most reliably to a well-chosen prolapse repair is the bulge itself, together with the emptying difficulty that comes from the bladder sagging. Urinary urgency and frequency may improve, may stay the same, or may occasionally appear for the first time afterwards. Stress leaking can become apparent once the kink in the urethra is removed. Discomfort during sex may improve, but can also be affected by the surgery itself. Knowing all of this beforehand is what makes the decision genuinely yours rather than one made for you.

You are also allowed to choose no treatment at all. Prolapse is not an emergency and does not inevitably progress in a straight line. Reviewing the situation in six or twelve months, with physiotherapy continuing in the meantime, is a perfectly legitimate plan.

Recovery after bladder prolapse surgery

Most women having an anterior repair go home the same day or after one night, manage with simple painkillers, return to light everyday activity within about two weeks, and feel essentially recovered by six to twelve weeks. The vagina heals quickly, but the deeper repair needs time before it is loaded.

In the first day or two, a catheter and sometimes a vaginal pack are often used, and both are usually removed the following morning. You will not be discharged until you are passing urine and emptying reasonably well, because temporary difficulty emptying after an anterior repair is not unusual and is caused by swelling around the bladder neck. If it persists, you may go home for a short period with a catheter, or be taught to pass a fine catheter yourself a few times a day. This is inconvenient rather than serious, and it almost always settles.

At home, expect vaginal bleeding like a light period for a few days, followed by brownish or yellowish discharge that can continue for up to four to six weeks as the stitches dissolve. You may notice small pieces of suture material. Discomfort is usually modest, sits low in the vagina, and is worse with long periods of sitting and with bowel movements.

Practical rules for the first six weeks

• Nothing in the vagina: no tampons, no douching, no intercourse for six weeks or until you have been reviewed
• Keep the bowels soft from day one; take the laxative you are given before you need it, and do not strain
• Avoid lifting anything heavier than a full kettle for the first couple of weeks, then increase gradually, and avoid heavy or repeated lifting for around three months
• Walk a little every day from the start, building up distance, as this reduces clot risk and stiffness
• Shower rather than take long baths, and keep the area clean and dry
• Desk work is usually possible after two to three weeks; physically heavy work needs considerably longer and is best discussed before your operation
• Drive only once you could perform an emergency stop without hesitating, and check what your own insurance policy requires
• Restart pelvic floor exercises when your surgeon or physiotherapist says the tissues are ready, then continue them long term

Contact your doctor or attend hospital if you have heavy bleeding, a fever or feel generally unwell, develop an offensive discharge, cannot pass urine or can only dribble, have pain that is increasing rather than settling, or develop calf pain, chest pain or breathlessness. The recognised risks of this surgery, which should be discussed with you individually beforehand, include bleeding, infection, urinary infection, difficulty emptying the bladder, new urgency or stress leaking, narrowing or discomfort of the vagina affecting intercourse, and, uncommonly, injury to the bladder or ureter.

Recurrence: why prolapse can come back

It is important to understand that prolapse surgery repairs the damage but does not change the tissue that allowed the damage to happen. A cystocele can therefore recur, and some women do need further treatment at some point in their lives. Rather than quoting figures, which vary enormously with the operation performed, the starting severity and how recurrence is defined, it is far more useful to know what makes recurrence more or less likely in your own case.

Recurrence is more likely when the original prolapse was advanced, when there is levator avulsion so that the muscular floor has a permanent defect, when surgery is performed at a younger age and therefore has to last longer, when body weight is high, when the bowels remain constipated and straining continues, when a chronic cough goes untreated, when work or training involves regular heavy lifting, and when descent of the vaginal apex was not addressed at the first operation.

It also helps to separate anatomical recurrence from symptomatic recurrence. A degree of anterior wall descent can often be found again on examination years later in a woman who has no bulge sensation at all and is perfectly content. That is not a failure requiring treatment, and it does not mean the operation was wasted. What matters is whether the symptoms that led you to surgery have returned, and whether they are affecting you enough to want something done again.

Two measures specifically protect a repair: keep the pelvic floor programme going rather than stopping once the symptoms have settled, and, if you are postmenopausal, continue vaginal oestrogen if it has been prescribed, to keep the tissues in good condition. Beyond those, the lifestyle measures listed earlier in this article matter just as much after an operation as before one. It is also worth attending the follow-up you are offered, because a small recurrence noticed early can often be managed with a pessary or physiotherapy rather than with another operation.

If a cystocele does recur and is troublesome, the options are the same options you had the first time: physiotherapy, a pessary, or further surgery, with the surgical plan informed by what was done before and by why the first repair gave way.

Living with a mild cystocele, and when to seek help

Most mild cystoceles need no treatment at all, and if yours is not causing symptoms you care about, the right management is knowledge, sensible habits and review if things change. Prolapse does not reliably progress, and a great many women live for decades with a small anterior bulge that never becomes a problem. The lifestyle measures set out earlier, particularly bowel habit, lifting technique and a maintained pelvic floor routine, are the whole of day-to-day management for most of these women.

Three things are specific to living with a bulge rather than treating one. The first is timing. Because symptoms are mildest in the morning and build through the day, and because many women notice they are worse in the week before a period, it is often worth putting the demanding part of the day first: the long walk, the shopping, the gardening or the gym session in the morning rather than the evening. The second is sex. A lubricant helps if dryness is the problem, and different positions often reduce the awareness of the bulge; a mild prolapse is not a reason to stop being sexually active, and a short conversation with your partner about what feels comfortable is usually more useful than quietly avoiding it. The third is pregnancy. If you are planning one, say so early, because it changes the order of treatment rather than ruling anything out: surgical repair is normally deferred until you have finished having children, while physiotherapy and, if you need it, a pessary can be used throughout.

Seek medical advice promptly if you have

• Complete inability to pass urine, or passing only small dribbles with a full, uncomfortable bladder
• Pain in the side or lower back with fever, shivering or feeling very unwell, which may indicate a kidney infection
• A bulge that is bleeding, raw or ulcerated, or one that cannot be pushed back and is painful
• Visible blood in the urine, or repeated proven urinary infections
• Any vaginal bleeding after the menopause, which always needs assessment in its own right and should never be assumed to come from the prolapse
• A rapid change in the size of the bulge, or new difficulty opening the bowels

Outside those situations, the right time to book an appointment is simply when the cystocele has started to matter to you: when you are aware of a bulge most days, when your bladder does not empty properly, when infections keep coming back, when sex has become uncomfortable, or when you have changed what you do because of how your pelvis feels. Bring your questions, including the ones that feel awkward. This is an extremely common condition, there is a clear ladder of treatment running from physiotherapy through pessaries to surgery, and most women find a point on that ladder where they feel comfortable again.