Cystocele

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Cystocele
Other namesProlapsed bladder, dropped bladder, [1] anterior vaginal wall collapse [2]
Cystocele.jpg
A cystocele protruding through the vagina in a 73-year-old woman.
Pronunciation
Specialty Urology, gynecology [3]
Symptoms Trouble starting urination, incomplete urination, urinary incontinence, frequent urination [1]
Complications Urinary retention [1]
TypesGrade 1, 2, 3 [1]
Risk factors Childbirth, constipation, chronic cough, heavy lifting, being overweight [1]
Diagnostic method Based on symptoms and examination [1]
Differential diagnosis Bartholin cyst, nabothian cyst, urethral diverticulum [4]
TreatmentLifestyle changes, pelvic muscle exercises, vaginal pessary, surgery [1]
Frequency~33% of women > 50 years old [5]

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. [1] [5] Some may have no symptoms. [6] Others may have trouble starting urination, urinary incontinence, or frequent urination. [1] Complications may include recurrent urinary tract infections and urinary retention. [1] [7] Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. [8] Cystocele can negatively affect quality of life. [9] [10]

Contents

Causes include childbirth, constipation, chronic cough, heavy lifting, hysterectomy, genetics, and being overweight. [1] [2] [6] The underlying mechanism involves weakening of muscles and connective tissue between the bladder and vagina. [1] Diagnosis is often based on symptoms and examination. [1]

If the cystocele causes few symptoms, avoiding heavy lifting or straining may be all that is recommended. [1] In those with more significant symptoms a vaginal pessary, pelvic muscle exercises, or surgery may be recommended. [1] The type of surgery typically done is known as a colporrhaphy. [11] The condition becomes more common with age. [1] About a third of women over the age of 50 are affected to some degree. [5]

Signs and symptoms

The symptoms of a cystocele may include:

A bladder that has dropped from its normal position and into the vagina can cause some forms of incontinence and incomplete emptying of the bladder. [1]

Complications

Complications may include urinary retention, recurring urinary tract infections and incontinence. [1] [7] The anterior vaginal wall may actually protrude though the vaginal introitus (opening). This can interfere with sexual activity. [6] Recurrent urinary tract infections are common for those who have urinary retention. [15] In addition, though cystocele can be treated, some treatments may not alleviate troubling symptoms, and further treatment may need to be performed. Cystocele may affect the quality of life, women who have cystocele tend to avoid leaving their home and avoid social situations. The resulting incontinence puts women at risk of being placed in a nursing home or long-term care facility.[ medical citation needed ]

Cause

A cystocele occurs when the muscles, fascia, tendons and connective tissues between a woman's bladder and vagina weaken, or detach. [2] [16] The type of cystocele that can develop can be due to one, two or three vaginal wall attachment failures: the midline defect, the paravaginal defect, and the transverse defect. The midline defect is a cystocele caused by the overstretching of the vaginal wall; the paravaginal defect is the separation of the vaginal connective tissue at the arcus tendineus fascia pelvis; the transverse defect is when the pubocervical fascia becomes detached from the top (apex) of the vagina. [2] There is some pelvic prolapse in 40–60% of women who have given birth. [17] [18] Muscle injuries have been identified in women with cystocele. These injuries are more likely to occur in women who have given birth than those who have not. These muscular injuries result in less support to the anterior vaginal wall. [19]

Some women with connective tissue disorders are predisposed to developing anterior vaginal wall collapse. Up to one third of women with Marfan syndrome have a history of vaginal wall collapse. Ehlers-Danlos syndrome in women is associated with a rate of 3 out of 4. [6]

Risk factors

Risk factors for developing a cystocele are:

Connective tissue disorders predispose women to developing cystocele and other pelvic organ prolapse. The tissues tensile strength of the vaginal wall decreases when the structure of the collagen fibers change and become weaker. [6]

Diagnosis

There are two types of cystocele. The first is distension. This is thought to be due to the overstretching of the vaginal wall and is most often associated with aging, menopause and vaginal delivery. It can be observed when the rugae are less visible or even absent. The second type is displacement. Displacement is the detachment or abnormal elongation of supportive tissue. [25]

The initial assessment of cystocele can include a pelvic exam to evaluate leakage of urine when the women is asked to bear down or give a strong cough (Valsalva maneuver), and the anterior vaginal wall measured and evaluated for the appearance of a cystocele. [26] [27] If a woman has difficulty emptying her bladder, the clinician may measure the amount of urine left in the woman's bladder after she urinates called the postvoid residual. This is measured by ultrasound. A voiding cystourethrogram is a test that involves taking x-rays of the bladder during urination. This x-ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. [1] A urine culture and sensitivity test will assess the presence of a urinary tract infection that may be related to urinary retention. [12] Other tests may be needed to find or rule out problems in other parts of the urinary system. [1] Differential diagnosis will be improved by identifying possible inflammation of the Skene's glands and Bartholin glands. [28]

Grading

A number of scales exist to grade the severity of a cystocele.[ citation needed ]

The pelvic organ prolapse quantification (POP-Q) assessment, developed in 1996, quantifies the descent of the cystocele into the vagina. [6] [13] The POP-Q provides reliable description of the support of the anterior, posterior and apical vaginal wall. It uses objective and precise measurements to the reference point, the hymen. Cystocele and prolapse of the vagina from other causes is staged using POP-Q criteria can range from good support (no descent into the vagina) reported as a POP-Q stage 0 or I to a POP-Q score of IV which includes prolapse beyond the hymen. It also used to quantifies the movement of other structures into the vaginal lumen and their descent. [6] [13]

The Baden–Walker Halfway Scoring System is used as the second most used system and assigns the classifications as mild (grade 1) when the bladder droops only a short way into the vagina; (grade 2) cystocele, the bladder sinks far enough to reach the opening of the vagina; and (grade 3) when the bladder bulges out through the opening of the vagina. [1] [29]

Classifications

Cystocele can be further described as being apical, medial, or lateral. [30]

Apical cystocele is located upper third of the vagina. The structures involved are the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect. [16] [25]

Medial cystocele forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele. An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This defect can be assessed by MRI. [16] [25]

Lateral cystocele forms when both the pelviperineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a 'hammock-like' suspension and support for the lateral sides of the vagina. Defects in this lateral support system results in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between anterior vaginal wall and the arcus tendineus fasciae pelvis – the essential ligament structure. [16] [25]

Prevention

Cystocele may be mild enough not to result in symptoms that are troubling to a woman. In this case, steps to prevent it from worsening include:

Treatment

Treatment options range from no treatment for a mild cystocele to surgery for a more extensive cystocele. [1] If a cystocele is not bothersome, the clinician may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a pessary, a device placed in the vagina to hold the bladder in place and to block protrusion. [12] [23] Treatment can consist of a combination of non-surgical and surgical management. Treatment choice is also related to age, desire to have children, severity of impairment, desire to continue sexual intercourse and other diseases that a woman may have. [6]

Non-surgical

Cystocele is often treated by non-surgical means:

Surgery

The surgery to repair the anterior vaginal wall may be combined with other procedures that will repair the other points of pelvic organ support such as anterior-posterior repair and anterior colporrhaphy. [12] Treatment of cystocele often accompanies the more invasive hysterectomy. [32] Since the failure rate in cystocele repair remains high, additional surgery may be needed. [13] Women who have surgery to repair a cystocele have a 17% of needing another operation within the next ten years. [33]

The surgical treatment of cystocele will depend on the cause of the defect and whether it occurs at the top (apex), middle, or lower part of the anterior vaginal wall. The type of surgery will also depend on the type of damage that exists between supporting structures and the vaginal wall. [2] One of the most common surgical repairs is colporrhaphy. [32] This surgical procedure consists of making a longitudinal folding of the vaginal tissue, suturing it into place and creating a stronger point of resistance to the intruding bladder wall. Surgical mesh is sometimes used to strengthen the anterior vaginal wall. [6] It has a 10–50% failure rate. [34] [32] In some cases a surgeon may choose to use surgical mesh to strengthen the repair. [32]

During surgery, the repair of the vaginal wall consists of folding over and then suturing the existing tissue between the vagina and bladder to strengthen it. [1] [11] This tightens the layers of tissue to promote the replacement of the pelvic organs into their normal place. The surgery also provides more support for the bladder. This surgery is done by a surgeon specializing in gynecology and is performed in a hospital. Anesthesia varies according to the needs of each woman. Recovery may take four to six weeks. [1] Other surgical treatment may be performed to treat cystocele. Support for the vaginal wall is accomplished with the paravaginal defect repair. This is a surgery, usually laproscopic, that is done to the ligaments and fascia through the abdomen. The lateral ligaments and supportive structures are repaired, sometimes shortened to provide additional support to the vaginal wall. [32]

Sacrocolpopexy is a procedure that stabilizes the vaginal vault (the uppermost portion of the vagina) and is often chosen as the treatment for cystocele, especially if previous surgeries were not successful. The procedure consists of attaching the vaginal vault to the sacrum. It has a success rate of 90%. [32] Some women choose not to have surgery to close the vagina. This surgery, called colpocleisis, treats cystocele by closing the vaginal opening. This can be an option for women who no longer want to have vaginal intercourse. [22]

If an enterocele/sigmoidocele, or prolapse of the rectum/colon, is also present, the surgical treatment will take this concurrent condition into account while planning and performing the repairs. [2] Estrogen that is administered vaginally before surgical repair can strengthen the vaginal tissue providing a more successful outcome when mesh or sutures are used for the repair. Vaginal thickness increases after estrogen therapy. [33] Another review on the surgical management of cystocele describes a more successful treatment that more strongly attaches the ligaments and fascia to the vagina to lift and stabilize it. [35]

Post surgical complications can develop. The complications following surgical treatment of cystocele are:

  • side effects or reactions to anesthesia
  • bleeding
  • infection
  • painful intercourse
  • Urinary incontinence
  • constipation [34]
  • bladder injuries
  • urethral injuries
  • urinary tract infection. [32] [7]
  • vaginal erosion due to mesh [12]

After surgery, a woman is instructed to restrict her activities and monitor herself for signs of infection such as an elevated temperature, discharge with a foul odor and consistent pain. Clinicians may recommend that sneezing, coughing, and constipation are to be avoided. Splinting the abdomen while coughing provides support to an incised area and decreases pain on coughing. [12] This is accomplished by applying gentle pressure to the surgical site for bracing during a cough. [36] [37]

Recurrent surgery on the pelvic organs may not be due to a failure of the surgery to correct the cystocele. Subsequent surgeries can be directly or indirectly relating to the primary surgery. [13] Prolapse can occur at a different site in the vagina. Further surgery after the initial repair can be to treat complications of mesh displacement, pain, or bleeding. Further surgery may be needed to treat incontinence. [13]

One goal of surgical treatment is to restore the vagina and other pelvic organs to their anatomically normal positions. This may not be the outcome that is most important to the woman being treated who may only want relief of symptoms and an improvement in her quality of life. The International Urogynecological Association (IUGA) has recommended that the data collected regarding the success of cystocele and pelvic organ repairs include the presence or absence of symptoms, satisfaction and Quality of Life. Other measures of a successful outcome should include perioperative data, such as operative time and hospital stay. Standardized Healthcare Quality of Life should be part of the measure of a successful resolution of cystocele. Data regarding short- and long-term complications is included in the recommendations of the IUGA to better assess the risk–benefit ratio of each procedure. [13] Current investigations into the superiority of using biological grafting versus native tissue or surgical mesh indicates that using grafts provides better results. [38]

Epidemiology

A large study found a rate of 29% over the lifetime of a woman. Other studies indicate a recurrence rate as low as 3%. [13]

In the US, greater than 200,000 surgeries are performed each year for pelvic organ prolapse and 81% of these are to correct cystocele. [14] [11] Cystocele occurs most frequently compared to the prolapse of other pelvic organs and structure. [13] [14] Cystocele is found to be three times as common as vaginal vault prolapse and twice as often as posterior vaginal wall defects. The incidence of cystocele is around 9 per 100 women-years. The highest incidence of symptoms occurs between ages of 70 and 79 years. Based on population growth statistics, the number of women with prolapse will increase by a minimum of 46% by the year 2050 in the US. Surgery to correct prolapse after hysterectomy is 3.6 per 1,000 women-years. [13]

History

The ancient Greek method for treating cystocele Hippocrates treatment for prolapse.png
The ancient Greek method for treating cystocele

Notable is the mention of cystocele in many older cultures and locations. [39] In 1500 B.C. Egyptians wrote about the "falling of the womb". In 400 B.C. a Greek physician documented his observations and treatments:

"After the patient had been tied to a ladder-like frame, she was tipped upward so that her head was toward the bottom of the frame. The frame was then moved upward and downward more or less rapidly for approximately 3–5 min. As the patient was in an inverted position, it was thought that the prolapsing organs of the genital tract would be returned to their normal position by the force of gravity and the shaking motion." [39]

Hippocrates had his own theories regarding the cause of prolapse. He thought that recent childbirth, wet feet, 'sexual excesses', exertion, and fatigue may have contributed to the condition. Polybus, Hippocrates's son-in-law, wrote: "a prolapsed uterus was treated by using local astringent lotions, a natural sponge packed into the vagina, or placement of half a pomegranate in the vagina." In 350 A.D., another practitioner named Soranus described his treatments which stated that the pomegranate should be dipped into vinegar before insertion. Success could be enhanced if the woman was on bed rest and reduced intake of fluid and food. If the treatment was still not successful, the woman's legs were tied together for three days. [39]

In 1521, Berengario da Carpi performed the first surgical treatment for prolapse. This was to tie a rope around the prolapse, tighten it for two days until it was no longer viable and cut it off. Wine, aloe, and honey were then applied to the stump. [39]

In the 1700s, a Swiss gynecologist, Peyer, published a description of a cystocele. He was able to describe and document both cystocele and uterine prolapse. In 1730, Halder associated cystocele with childbirth. During this same time, efforts began to standardize the terminology that is still familiar today. In the 1800s, the surgical advancements of anesthesia, suturing, suturing materials and acceptance of Joseph Lister's theories of antisepsis improved outcomes for women with cystocele. The first surgical techniques were practiced on female cadavers. In 1823, Geradin proposed that an incision and resection may provide treatment. In 1830, the first dissection of the vagina was performed by Dieffenbach on a living woman. In 1834, Mendé proposed that dissecting and repair of the edges of the tissues could be done. In 1859, Huguier proposed the amputation of the cervix was going to solve the problem for elongation. [39]

In 1866, a method of correcting a cystocele was proposed that resembled current procedures. Sim subsequently developed another procedure that did not require the full-thickness dissection of the vaginal wall. In 1888, another method of treating anterior vaginal wall Manchester combined an anterior vaginal wall repair with an amputation of the cervix and a perineorrhaphy. In 1909, White noted the high rate of recurrence of cystocele repair. At this time it was proposed that reattaching the vagina to support structures was more successful and resulted in less recurrence. This same proposal was proposed again in 1976 but further studies indicated that the recurrence rate was not better. [39]

In 1888, treatments were tried that entered the abdomen to make reattachments. Some did not agree with this and suggested an approach through the inguinal canal. In 1898, further abdominal approaches were proposed. No further advances have been noted until 1961 when reattachment of the anterior vaginal wall to Cooper's ligament began to be used. Unfortunately, posterior vaginal wall prolapse occurred in some patients even though the anterior repair was successful. [39]

In 1955, using mesh to support pelvic structures came into use. In 1970, tissue from pigs began to be used to strengthen the anterior vaginal wall in surgery. Beginning in 1976, improvement in suturing began along with the surgical removal of the vagina being used to treat prolapse of the bladder. In 1991, assumptions about the detailed anatomy of the pelvic support structures began to be questioned regarding the existence of some pelvic structures and the non-existence of others. More recently, the use of stem cells, robot-assisted laparoscopic surgery are being used to treat cystocele. [39]

See also

Related Research Articles

In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place", from the Latin prolabi meaning "to fall out".

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

<span class="mw-page-title-main">Pelvic floor dysfunction</span> Medical condition

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma.

<span class="mw-page-title-main">Pelvic organ prolapse</span> Descent of the pelvic organs from their normal positions

Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.

<span class="mw-page-title-main">Stress incontinence</span> Form of urinary incontinence from an inadequate closure of the bladder

Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

A urethrocele is the prolapse of the female urethra into the vagina. Weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles. In this case, the term used is cystourethrocele.

Colporrhaphy is a surgical procedure in women that repairs a defect in the wall of the vagina. It is the surgical intervention for both cystocele and rectocele.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

Descending perineum syndrome refers to a condition where the perineum "balloons" several centimeters below the bony outlet of the pelvis during strain, although this descent may happen without straining. The syndrome was first described in 1966 by Parks et al.

Urethral hypermobility is a condition of excessive movement of the female urethra due to a weakened urogenital diaphragm. It describes the instability of the urethra in relation to the pelvic floor muscles. A weakened pelvic floor muscle fails to adequately close the urethra and hence can cause stress urinary incontinence. This condition may be diagnosed by primary care providers or urologists. Treatment may include pelvic floor muscle exercises, surgery, or minimally invasive procedures.

The Pelvic Organ Prolapse Quantifications System (POP-Q) is a system for assessing the degree of prolapse of pelvic organs to help standardize diagnosing, comparing, documenting, and sharing of clinical findings. This assessment is the most frequently used among research publications related to pelvic organ prolapse.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

<span class="mw-page-title-main">Vaginal support structures</span> Structures that maintain the position of the vagina within the pelvic cavity

The vaginal support structures are those muscles, bones, ligaments, tendons, membranes and fascia, of the pelvic floor that maintain the position of the vagina within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to pelvic organ prolapse. Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to incontinence and urinary retention.

Vaginal rugae are structures of the vagina that are transverse ridges formed out of the supporting tissues and vaginal epithelium in females. Some conditions can cause the disappearance of vaginal rugae and are usually associated with childbirth and prolapse of pelvic structures. The rugae contribute to the resiliency and elasticity of the vagina and its ability to distend and return to its previous state. These structures not only allow expansions and an increase in surface area of the vaginal epithelium, they provide the space necessary for the vaginal microbiota. The shape and structure of the rugae are supported and maintained by the lamina propria of the vagina and the anterior and posterior rugae.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

<span class="mw-page-title-main">Vaginal introital laxity</span> Medical condition

Vaginal introital laxity is a symptom of pelvic floor dysfunction characterised by a sensation of looseness at vaginal external opening, also known as the vaginal introitus. Possible causes include pelvic organ prolapse (POP), post-pregnancy and vaginal delivery and menopause. Consequences may include experiencing sexual dysfunction, ranging from dyspareunia, increased vaginal “wind” to overactive bladder (OAB). These consequences may lead to adverse significant impacts on women’s sexual health, body image and quality of life. Vaginal laxity is often underreported, with approximately 80% of women not seeking treatment or discussing their concerns.

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