Neurogenic Bladder in Hereditary Spastic Paraplegia: Treatment, Botox and Sacral Neuromodulation

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Hereditary Spastic Paraplegia (HSP) is best known for causing progressive stiffness, weakness and spasticity of the legs. However, the neurological pathways controlling the bladder travel through the same spinal cord neighbourhood, and bladder dysfunction can therefore become an important and sometimes underestimated part of HSP.

Studies of patients with HSP have reported lower urinary tract symptoms in a substantial proportion of patients, particularly urgency, urinary frequency, nocturia and urgency urinary incontinence. Difficulty emptying the bladder can also occur. Urodynamic studies frequently demonstrate neurogenic detrusor overactivity, sometimes accompanied by detrusor-sphincter dyssynergia.

The modern term for this problem is neurogenic lower urinary tract dysfunction (NLUTD) rather than simply “neurogenic bladder”, because the neurological condition may affect the bladder, bladder outlet and urinary sphincter in different ways.

For patients with HSP, treatment therefore needs to be individualised. The aim is not merely to reduce trips to the toilet. We want to achieve a bladder that stores urine safely, empties adequately, protects the kidneys and interferes as little as possible with everyday life.

How does HSP affect the bladder?

Normal bladder control requires remarkably complicated communication between the brain, spinal cord, bladder and urinary sphincter.

During filling, the bladder should remain relaxed while the urinary sphincter remains closed. When it is appropriate to urinate, the brain permits the bladder to contract while the sphincter relaxes.

HSP can disrupt these pathways.

The commonest urodynamic abnormality reported in HSP is detrusor overactivity, where involuntary bladder contractions occur during filling.

Patients may consequently experience:

  • urinary urgency and frequency;
  • waking repeatedly at night to urinate;
  • urgency urinary incontinence;
  • difficulty postponing urination;
  • hesitancy or a poor urinary stream;
  • incomplete bladder emptying;
  • recurrent urinary tract infections; and
  • occasionally significant urinary retention.

Importantly, symptoms do not always tell us exactly what the bladder is doing. Two patients saying, “I can’t hold on,” may have quite different underlying bladder physiology.

That is where urodynamic assessment can become particularly useful.

Investigating bladder dysfunction in HSP

Assessment should be tailored to the severity of symptoms and the patient’s neurological and urological risk.

It may include a detailed history, bladder diary, urinalysis, measurement of post-void residual urine, renal function assessment and ultrasound of the kidneys and bladder.

Urodynamic studies are particularly valuable when symptoms are significant, treatment has failed, bladder emptying is abnormal or invasive treatment such as Botox is being considered.

Urodynamics can identify:

Neurogenic detrusor overactivity (NDO)
The bladder contracts involuntarily while filling.

Poor bladder compliance
Bladder pressure increases excessively as the bladder fills. This is particularly important because sustained high storage pressures can potentially threaten the upper urinary tract.

Detrusor-sphincter dyssynergia (DSD)
Instead of relaxing during urination, the urinary sphincter contracts against the bladder.

Detrusor underactivity
The bladder contracts inadequately and therefore does not empty properly.

The EAU and AUA/SUFU guidelines emphasise risk-based evaluation and ongoing surveillance of patients with neurogenic lower urinary tract dysfunction rather than treating symptoms in isolation.

First-line treatment

Treatment depends upon whether the main problem is storage, emptying or a combination of both.

Lifestyle and bladder strategies

Some patients benefit from relatively simple measures such as:

  • adjusting fluid intake;
  • reducing excessive caffeine;
  • timed voiding;
  • managing constipation;
  • bladder retraining where appropriate;
  • pelvic-floor physiotherapy in selected patients; and
  • reviewing medications that may worsen bladder function.

Mobility is an important consideration in HSP. A bladder that gives somebody 20 seconds’ warning may be considerably more disabling when that person also has difficulty walking quickly to a toilet.

Treatment goals therefore need to reflect the patient’s mobility, hand function, independence and quality of life, something specifically emphasised by neuro-urology guidelines.

Medication

For predominantly overactive bladder symptoms, treatment commonly begins with an antimuscarinic medication and/or a beta-3 adrenergic agonist.

Antimuscarinic drugs can reduce involuntary bladder contractions but may cause dry mouth, constipation, blurred vision and cognitive adverse effects in susceptible patients.

Beta-3 agonists may provide an alternative or can sometimes be combined with an antimuscarinic.

Post-void residual urine should be considered, particularly when there is already evidence of impaired bladder emptying.

Intermittent catheterisation

When significant urinary retention or incomplete bladder emptying occurs, clean intermittent catheterisation (CIC) may be required.

This can sound intimidating when first discussed, but many patients become remarkably comfortable with the technique.

HSP creates an additional consideration: progressive lower-limb disability, hand function and mobility need to be considered when deciding whether intermittent catheterisation will remain practical.

Where possible, intermittent catheterisation is generally preferable to long-term indwelling catheterisation for bladder emptying in neuro-urological patients.

Botox injections into the bladder

For patients with persistent neurogenic detrusor overactivity despite medication, Botulinum toxin A (Botox) injected into the detrusor muscle can be extremely useful.

Botox temporarily reduces excessive acetylcholine-mediated contraction of the bladder muscle.

The result is essentially a bladder that becomes a little less excitable.

How is bladder Botox performed?

Using a cystoscope, multiple small injections of Botulinum toxin A are placed into the bladder wall.

It is usually performed as a short day procedure under local anaesthetic, sedation or general anaesthesia depending upon the patient and clinical circumstances.

The treatment is temporary and therefore generally needs to be repeated when its effect wears off.

How effective is Botox?

There is strong evidence for intradetrusor onabotulinumtoxinA in neurogenic detrusor overactivity associated with spinal cord injury and multiple sclerosis.

Randomised studies in these populations show:

  • fewer episodes of urinary incontinence;
  • increased bladder capacity;
  • reduced detrusor pressures;
  • improved urodynamic storage parameters; and
  • improved quality of life.

The AUA/SUFU guideline gives this treatment a Grade A evidence recommendation in MS and spinal cord injury when oral treatment has failed.

The EAU likewise recommends detrusor Botulinum toxin A injections for neurogenic detrusor overactivity when antimuscarinic therapy is ineffective.

But what about HSP specifically?

This distinction is important.

HSP-specific clinical trials of intradetrusor Botox are very limited.

HSP therefore cannot simply inherit the strength of evidence available for MS and spinal cord injury. The AUA/SUFU guideline places Botox treatment for neurogenic disorders other than MS or spinal cord injury in a lower evidence category, although it states that treatment may be offered to appropriately selected patients whose symptoms have not responded adequately to oral medication.

In clinical practice, this makes the urodynamic diagnosis particularly important.

If an HSP patient has convincing neurogenic detrusor overactivity producing significant urgency, incontinence or unsafe bladder storage pressures despite conservative and medical treatment, intradetrusor Botox is a logical treatment option.

The evidence is therefore strongest for treating the urodynamic abnormality, rather than Botox having been proven specifically for the genetic diagnosis of HSP.

What are the disadvantages of Botox?

The most important adverse effect is incomplete bladder emptying or urinary retention.

A patient who previously urinated normally may need intermittent catheterisation after treatment.

The AUA/SUFU guideline therefore specifically recommends discussing the possibility of urinary retention and intermittent catheterisation before Botox is administered to a spontaneously voiding patient.

Other possible complications include urinary tract infection, haematuria, discomfort during urination and the need for repeated treatment.

This discussion is particularly important in HSP patients whose mobility or hand function might make self-catheterisation difficult.

Sacral neuromodulation

Another intriguing option is sacral neuromodulation (SNM).

Rather than temporarily weakening the bladder muscle, SNM attempts to modulate the neurological circuitry controlling bladder storage and emptying.

A small electrode is positioned close to a sacral nerve, usually the S3 nerve root, and connected to an electrical stimulator.

Think of it less as “shocking the bladder” and more as adjusting the electrical conversation between the bladder, spinal cord and brain.

A major advantage: it can be tested first

SNM generally begins with a trial or test phase.

A temporary or tined lead is placed near the sacral nerve and connected to an external stimulator.

Symptoms are then assessed.

A clinically meaningful improvement, commonly around 50% or greater, is generally required before proceeding to implantation of the permanent pulse generator.

That provides an important advantage: the patient effectively auditions the treatment before committing to the permanent implant.

Does sacral neuromodulation work in neurogenic bladder?

The evidence is promising but considerably less robust than the Botox evidence for MS and spinal cord injury.

The AUA/SUFU guideline states that SNM may be offered to selected patients with neurogenic lower urinary tract dysfunction who have urinary urgency, frequency and/or urgency incontinence, but rates the evidence as Grade C.

Studies involving mixed neurological populations have demonstrated improvements in:

  • urgency;
  • urinary frequency;
  • urgency incontinence;
  • voided volume;
  • bladder capacity; and
  • quality of life.

However, these studies include heterogeneous neurological diseases, making it difficult to predict outcomes for one particular condition.

The AUA/SUFU guideline specifically advises against SNM in neurogenic bladder caused by spinal cord injury or spina bifida, but HSP is not listed as an absolute contraindication.

What about sacral neuromodulation specifically for HSP?

Here we need to be particularly careful about claims of efficacy.

There is currently very limited direct evidence specifically studying SNM in patients with Hereditary Spastic Paraplegia.

Most of the evidence supporting SNM in neurological disease comes from mixed cohorts containing conditions such as multiple sclerosis, Parkinson’s disease, stroke, incomplete spinal cord disorders and other neurological conditions.

Consequently, it would be inappropriate to tell an HSP patient that sacral neuromodulation has a proven success rate specifically for HSP.

Instead, I would regard SNM as a potential treatment for carefully selected HSP patients, particularly those who:

  • continue to void spontaneously;
  • have troublesome urgency, frequency or urgency incontinence;
  • have failed conservative and pharmacological treatment;
  • do not have dangerous high-pressure bladder physiology requiring a different strategy; and
  • demonstrate a convincing response during the SNM test phase.

The test phase becomes particularly valuable when the evidence base for the underlying neurological disorder is limited.

Botox or sacral neuromodulation: which is better in HSP?

There is currently no good HSP-specific head-to-head trial demonstrating that one is superior to the other.

The choice should therefore be driven by the patient’s bladder physiology.

Botox may be particularly attractive when:

there is proven neurogenic detrusor overactivity, bladder pressures need to be reduced, medication has failed and the patient accepts the possibility of intermittent catheterisation and repeated injections.

Sacral neuromodulation may be attractive when:

urgency, frequency and urgency incontinence predominate, the patient continues to empty reasonably well, conservative and pharmacological therapy have failed, and there is no contraindication to implantation.

SNM also offers the considerable advantage of a test phase before permanent implantation.

The two therapies should therefore not necessarily be regarded as competitors. They act differently and may suit different neuro-urological phenotypes.

Why urodynamics matter before choosing treatment

For HSP, I believe one of the most useful questions is not simply:

“Does the patient have a neurogenic bladder?”

It is:

“What type of neurogenic bladder dysfunction does this particular patient have?”

An HSP patient with severe detrusor overactivity and high storage pressures is fundamentally different from an HSP patient with urgency but satisfactory storage pressures, and different again from somebody with detrusor underactivity and a large residual urine volume.

The treatment should follow the physiology.

This is particularly relevant because HSP studies confirm that detrusor overactivity is common, but voiding dysfunction and other urodynamic abnormalities also occur.

What happens when less-invasive treatments fail?

A small proportion of patients develop severe neurogenic lower urinary tract dysfunction that cannot be adequately controlled with medication, catheterisation, Botox or neuromodulation.

More invasive options can include bladder augmentation or urinary diversion, depending upon bladder pressures, continence, renal risk, mobility and the patient’s ability to catheterise.

Fortunately, these procedures are required far less commonly than the conservative, pharmacological and minimally invasive treatments discussed above.

Follow-up is important

HSP is a neurological condition that can evolve over time. Bladder function can evolve with it.

A treatment that worked well several years ago may therefore need reassessment if symptoms change.

Patients should seek review if they develop:

  • worsening urinary incontinence;
  • increasing difficulty emptying;
  • recurrent urinary infections;
  • new urinary retention;
  • haematuria;
  • flank pain; or
  • a significant change in their usual bladder pattern.

Depending upon risk, follow-up may include post-void residual measurement, renal function, renal tract imaging and repeat urodynamics.

Current EAU guidance emphasises ongoing surveillance and reassessment in neuro-urological patients, with the intensity of follow-up determined by individual risk. The 2026 EAU Neuro-Urology Guidelines have also updated recommendations regarding diagnosis, treatment, Botulinum toxin A and follow-up.

The bottom line

Bladder dysfunction is a genuine and sometimes overlooked component of Hereditary Spastic Paraplegia.

The commonest problem is neurogenic detrusor overactivity, producing urgency, frequency, nocturia and urgency incontinence, although impaired emptying and detrusor-sphincter dysfunction can also occur.

Treatment usually progresses from conservative measures and medication to intermittent catheterisation where necessary, followed by more advanced therapies in appropriately selected patients.

Intradetrusor Botox is an effective established treatment for neurogenic detrusor overactivity, although the highest-quality evidence comes from MS and spinal cord injury rather than HSP itself. Its principal trade-off is the possibility of urinary retention and the need for intermittent catheterisation.

Sacral neuromodulation is another potential option for selected HSP patients, especially those with refractory urgency, frequency and urgency incontinence who continue to void spontaneously. However, the evidence specifically for HSP remains limited, so the temporary test phase is particularly useful in determining whether an individual patient is likely to benefit.

Most importantly, treatment should be based on the patient’s symptoms, urodynamic findings, bladder-emptying ability, mobility and individual goals rather than the diagnosis of HSP alone.

So, If this is you, come have a chat to your local Brisbane functional urologist, Dr Jo Schoeman to discuss this further

References and further reading

  1. Fourtassi M, Jacquin-Courtois S, Scheiber-Nogueira MC, et al. Bladder dysfunction in hereditary spastic paraplegia: a clinical and urodynamic evaluation. Spinal Cord. 2012;50:558–562.
  2. Braschinsky M, Zopp I, Kals M, Haldre S, Gross-Paju K. Bladder dysfunction in hereditary spastic paraplegia: what to expect? J Neurol Neurosurg Psychiatry. 2010;81:263–266.
  3. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up. J Urol. 2021;206:1106–1113.
  4. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. J Urol. 2021.
  5. European Association of Urology. EAU Guidelines on Neuro-Urology, 2026.
  6. European Association of Urology. Neuro-Urology: Botulinum toxin A injections. The guideline recommends detrusor Botulinum toxin A for neurogenic detrusor overactivity when antimuscarinic therapy is ineffective.

Important note

This information is intended for general patient education and does not replace individual medical assessment. Hereditary Spastic Paraplegia encompasses multiple genetic and clinical phenotypes, and bladder treatment should be individualised following appropriate neurological and urological assessment.

Anterior Vaginal Prolapse (Cystocele): When the Bladder Bulges into the Vagina

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An anterior vaginal prolapse, often called a cystocele, develops when the tissues supporting the bladder and the front wall of the vagina weaken. The bladder then descends and pushes into the vaginal wall, sometimes producing a noticeable vaginal bulge.

A cystocele is not cancerous and is not usually dangerous. However, it can cause pressure, discomfort, difficulty emptying the bladder, urinary leakage and recurrent urinary tract infections. Treatment depends on the severity of the prolapse and, more importantly, how much it affects daily life.

What normally supports the bladder?

The bladder rests above the front wall of the vagina. It is supported by:

  • Pelvic-floor muscles
  • Connective tissue and fascia between the bladder and vagina
  • Ligaments supporting the uterus and top of the vagina
  • The normal attachments of the vagina to the pelvic sidewalls

These structures work together rather like the ropes, fabric and anchor points of a hammock. When the supporting tissue stretches, tears or detaches, the front vaginal wall can descend and the bladder follows it.

Although commonly called a “fallen bladder,” the bladder has not become detached. It has lost some of its normal support.

How does a cystocele develop?

Usually, several factors contribute over time.

Pregnancy and vaginal childbirth

Pregnancy stretches the pelvic floor, while vaginal delivery can injure muscles, nerves and connective tissue. The risk may be higher after:

  • Multiple vaginal births
  • Forceps-assisted delivery
  • A prolonged second stage of labour
  • Delivery of a larger baby
  • Significant perineal injury

A prolapse may become apparent soon after childbirth or many years later.

Menopause and ageing

After menopause, falling oestrogen levels can make vaginal and supporting tissues thinner and less elastic. Ageing also changes collagen strength and muscle function.

Chronic pressure on the pelvic floor

Repeated increases in abdominal pressure may contribute, including:

  • Chronic constipation and straining
  • Persistent coughing
  • Heavy lifting
  • Obesity
  • High-impact activity in susceptible women

Previous pelvic surgery

A cystocele can occur after hysterectomy or previous prolapse surgery, particularly if the upper vaginal or apical support is weakened.

Inherited tissue characteristics

Some women naturally have more flexible connective tissue. Family history, joint hypermobility and certain connective-tissue disorders may increase susceptibility.

What does an anterior prolapse feel like?

A mild cystocele may cause no symptoms and may only be detected during an examination. More advanced prolapse can cause:

  • A vaginal bulge or lump
  • A sensation that “something is coming down”
  • Pelvic heaviness, dragging or pressure
  • Symptoms that worsen later in the day
  • Discomfort after prolonged standing or activity
  • Difficulty inserting a tampon
  • Discomfort or altered sensation during intercourse
  • Vaginal irritation, discharge or spotting when exposed tissue rubs on clothing

Some women describe the bulge as feeling like a small egg, golf ball or soft balloon at the vaginal opening.

The size seen during an examination does not always match symptom severity. A modest prolapse can be very troublesome, while a larger prolapse may cause surprisingly few symptoms.

How can a cystocele affect the bladder?

Because the bladder and urethra depend on coordinated pelvic support, a cystocele can produce several different and sometimes apparently contradictory urinary symptoms.

These may include:

  • A slow or intermittent urinary stream
  • Hesitancy before urine starts
  • The need to strain to urinate
  • A feeling that the bladder has not emptied
  • Needing to change position to finish urinating
  • Urinary urgency and frequency
  • Waking at night to urinate
  • Stress incontinence with coughing, laughing or exercise
  • Urge incontinence
  • Leakage after standing up from the toilet

Some women need to press the vaginal bulge backwards with a finger to empty the bladder. This is known as splinting or manual reduction.

Interestingly, a larger prolapse can sometimes kink or compress the urethra and temporarily hide stress incontinence. Once the prolapse is reduced with a pessary or repaired surgically, previously hidden leakage may become apparent. This is called occult stress urinary incontinence.

Can a cystocele cause urinary retention?

Yes. A significant prolapse may alter the angle between the bladder and urethra, obstruct urine flow or prevent the bladder muscle from emptying efficiently.

Possible consequences include:

  • Persistent residual urine after voiding
  • Recurrent urinary infections
  • Overflow leakage
  • Increasing difficulty passing urine
  • Bladder stones in uncommon cases
  • Upper urinary-tract obstruction or kidney problems in severe, longstanding prolapse

Complete acute retention is uncommon but requires urgent medical attention.

The amount remaining in the bladder can be assessed with a bladder ultrasound or catheter measurement. The prolapse may be reduced during testing to determine whether bladder emptying improves.

Why may urinary infections become more frequent?

A prolapse does not automatically cause infection. However, urine left in the bladder after voiding may provide an environment in which bacteria can multiply.

Menopause-related vaginal atrophy can add to this risk by changing the protective vaginal bacterial population and weakening the tissues around the urethra.

Not every episode of urgency, frequency or burning is an infection. Whenever practical, suspected recurrent UTIs should be confirmed with a midstream urine culture before antibiotics are prescribed.

Management may include:

  • Improving bladder emptying
  • Treating constipation
  • Using a pessary to reduce the prolapse
  • Low-dose topical vaginal oestrogen when appropriate
  • Culture-directed antibiotics for proven infection
  • Additional UTI-prevention measures in selected women

How is a cystocele assessed?

Assessment usually includes:

  • A detailed history of the bulge and urinary symptoms
  • Pelvic examination while lying down and sometimes standing
  • Asking the patient to cough or strain
  • Assessment of the front, back and top of the vagina
  • Evaluation of uterine or vaginal-vault support
  • Urine testing
  • Measurement of residual urine after voiding
  • Assessment for vaginal atrophy
  • Pelvic-floor muscle assessment

Clinicians commonly describe prolapse using the Pelvic Organ Prolapse Quantification system, known as POP-Q.

A bladder diary, kidney ultrasound, cystoscopy or urodynamic study may be appropriate when there is significant retention, recurrent infection, complex incontinence, previous pelvic surgery or uncertainty about bladder function.

Does every cystocele need treatment?

No. Treatment is generally based on symptoms, not examination findings alone.

A mild or moderate prolapse that is not bothersome can often be observed. Prolapse is not inevitably progressive, and delaying treatment does not usually make later surgery impossible.

Treatment becomes more appropriate when the prolapse causes:

  • A troublesome bulge
  • Difficulty emptying the bladder
  • Recurrent infections associated with residual urine
  • Vaginal ulceration or bleeding
  • Limitations on exercise, work or sexual activity
  • A significant effect on quality of life

Can the prolapse be reduced?

A prolapse may be gently pushed back into the vagina. This does not permanently repair the weakened support, but it can temporarily restore the anatomy and improve comfort or bladder emptying.

Some women manually reduce the prolapse before passing urine. If this is frequently necessary, medical assessment is advisable.

A clinician may also reduce the prolapse during an examination, bladder-emptying test or urodynamic study. A vaginal pessary provides more sustained non-surgical reduction.

If a prolapse suddenly becomes very painful, cannot be reduced, causes heavy bleeding or is associated with an inability to urinate, urgent assessment is required.

Conservative management

Observation

When symptoms are mild, reassurance and periodic review may be all that is required.

Pelvic-floor physiotherapy

A pelvic-floor physiotherapist can assess muscle strength, coordination and relaxation. An individualised program may:

  • Improve mild prolapse symptoms
  • Reduce the sensation of heaviness
  • Improve stress or urge incontinence
  • Teach safer lifting and pressure-management techniques
  • Assist bowel emptying without excessive straining

Exercises cannot reliably “pull back” a large prolapse permanently, but they can improve symptoms and support bladder control.

Addressing contributing factors

Helpful measures may include:

  • Treating constipation
  • Avoiding repeated straining
  • Managing chronic cough
  • Gradual weight reduction where appropriate
  • Modifying heavy lifting
  • Using good lifting and breathing techniques
  • Maintaining regular, low-impact physical activity

Women should not be frightened away from exercise. The aim is sensible modification rather than unnecessary restriction.

Vaginal pessary

A pessary is a removable silicone device placed inside the vagina to support the prolapse. Common designs include ring pessaries and space-filling pessaries.

Advantages include:

  • Avoiding or postponing surgery
  • Rapid improvement in bulge symptoms
  • Possible improvement in bladder emptying
  • Suitability for women planning future pregnancy
  • Use in women who are not medically fit for surgery
  • The ability to assess whether prolapse reduction reveals stress incontinence

Finding the correct size sometimes requires more than one fitting. Follow-up is important to check comfort, bladder emptying and vaginal health.

Possible problems include discharge, spotting, odour, difficulty removing the device and vaginal ulceration. These risks are reduced by appropriate fitting, regular review and, in suitable postmenopausal women, topical vaginal oestrogen.

When is surgery considered?

Surgery may be considered when:

  • Conservative treatment has not provided adequate relief
  • The prolapse extends to or beyond the vaginal opening
  • Bladder emptying is significantly impaired
  • The patient does not want or cannot manage a pessary
  • Symptoms substantially affect quality of life

The goal is to improve symptoms and function, not simply to make the examination look anatomically perfect.

Before surgery, the surgeon should discuss:

  • The patient’s most troublesome symptoms
  • Sexual activity and future preferences
  • Whether the uterus is present
  • Previous pelvic surgery
  • The strength of apical or upper-vaginal support
  • Existing or occult urinary incontinence
  • The possibility of recurrence
  • The benefits and complications of each surgical route

Native-tissue anterior vaginal repair

The most established vaginal operation for a cystocele is an anterior colporrhaphy, also called an anterior vaginal repair.

Through an incision in the front vaginal wall, the bladder is carefully separated from the vagina. The patient’s own supporting tissue is then folded, tightened or reattached, and the vaginal incision is closed with dissolving sutures.

This is a native-tissue repair, meaning no permanent synthetic mesh is placed through the vagina.

Possible complications include:

  • Bleeding or infection
  • Temporary difficulty emptying the bladder
  • Urinary tract infection
  • Injury to the bladder or ureters
  • New or persistent urinary urgency
  • New or unmasked stress incontinence
  • Pain during intercourse
  • Vaginal narrowing
  • Recurrence of the prolapse
  • Need for further prolapse or continence surgery

A catheter may be required temporarily until bladder emptying is satisfactory.

Why apical support matters

A cystocele is not always an isolated defect. Weakness at the top of the vagina or uterus can pull the front wall down.

Repairing only the visible cystocele without addressing significant upper-vaginal weakness may increase the likelihood of recurrence. Surgery may therefore include an apical suspension procedure, with or without hysterectomy, depending on the anatomy and the patient’s preferences.

Options may include:

  • Uterosacral ligament suspension
  • Sacrospinous fixation
  • Uterine-preserving hysteropexy
  • Abdominal or laparoscopic sacrocolpopexy

Sacrocolpopexy and abdominal mesh

Sacrocolpopexy is usually performed laparoscopically or robotically. Surgical mesh is attached to the vagina and then secured to the sacrum to restore upper-vaginal support.

This is different from placing a mesh sheet through a vaginal incision to repair a cystocele. Abdominally placed mesh remains available in Australia for selected prolapse operations.

It has its own risks, including mesh exposure or erosion, infection, pain, bowel or urinary injury and the possibility of further surgery. The benefits and risks should be discussed carefully.

Transvaginal synthetic mesh in Australia

Permanent synthetic mesh kits previously used through a vaginal incision for pelvic organ prolapse caused significant concern because of complications such as:

  • Mesh exposure through the vaginal wall
  • Chronic pelvic or vaginal pain
  • Painful intercourse
  • Infection
  • Bladder or urethral erosion
  • Urinary problems
  • Difficult or incomplete mesh removal

Following a review of safety and effectiveness, the Australian Therapeutic Goods Administration removed transvaginal mesh products intended solely for treating pelvic organ prolapse from the Australian Register of Therapeutic Goods. TGA information about urogynaecological mesh

This restriction does not mean that all uses of surgical mesh are identical. It is important to distinguish:

  • Transvaginal mesh sheets used to treat prolapse
  • Small mid-urethral slings used for stress urinary incontinence
  • Mesh placed abdominally during sacrocolpopexy
  • Biological grafts or allografts

Each involves different materials, surgical approaches, benefits and risks.

What is the role of an allograft?

An allograft is processed human donor tissue. Examples include donor fascia lata obtained from the strong tissue of the thigh.

A biological graft may be placed to reinforce weakened vaginal support. It is not the same as permanent polypropylene mesh. The material acts as a scaffold and is gradually remodelled or absorbed to varying degrees.

The proposed advantages include:

  • Avoiding permanent synthetic mesh
  • Providing reinforcement where native tissue is weak
  • Potentially reducing permanent foreign-body complications
  • Offering an option in selected reconstructive or repeat operations

However, these theoretical advantages do not mean that an allograft is routinely better than native-tissue repair.

Limitations of allograft repair

Available evidence has not established that biological graft reinforcement consistently provides better long-term outcomes than a well-performed native-tissue anterior repair. Some grafts may stretch or lose strength as they remodel, and prolapse can recur.

Potential limitations and complications include:

  • Graft failure or absorption
  • Recurrent prolapse
  • Infection
  • Inflammatory or wound-healing problems
  • Vaginal exposure, although generally less characteristic than with permanent synthetic mesh
  • Additional cost
  • Limited long-term product-specific evidence
  • An extremely low theoretical risk of disease transmission despite donor screening and processing

A major Cochrane review concluded that evidence does not support routine use of biological grafts over native-tissue repair for vaginal prolapse. Cochrane review of transvaginal mesh, grafts and native-tissue repair

For most women undergoing a first anterior repair, native tissue remains the usual vaginal surgical approach. An allograft may be considered selectively, for example, in complex reconstruction, poor-quality tissue or recurrent prolapse, but this should involve careful informed consent and discussion of the uncertainty in long-term benefit.

Women should ask:

  • What exact graft product is proposed?
  • Is it included on the Australian Register of Therapeutic Goods?
  • Why is it preferable in my particular case?
  • What evidence supports its use for anterior prolapse?
  • What are the surgeon’s results and complication rates?
  • What alternatives are available without graft material?

UGSA and USANZ guidance

The Urogynaecological Society of Australasia (UGSA) supports specialist training, credentialing and appropriate governance for clinicians implanting or removing transvaginal mesh. Its published position material emphasises that mesh procedures and mesh-complication surgery require suitable training, experience, consent and clinical oversight. UGSA position statements

The Urological Society of Australia and New Zealand (USANZ) represents urologists involved in treating urinary dysfunction, retention, recurrent infection and pelvic-floor disorders.

There is no joint UGSA–USANZ statement recommending allograft reinforcement for routine anterior prolapse repair. It would therefore be inaccurate to suggest that either organisation endorses routine allograft use.

The practical Australian approach is individualised and evidence-based:

  • Treat symptoms rather than the examination alone
  • Offer observation, pelvic-floor physiotherapy and pessary management where appropriate
  • Assess bladder emptying and culture suspected recurrent infections
  • Use native-tissue repair as the usual vaginal surgical option
  • Evaluate and restore apical support where necessary
  • Avoid routine transvaginal permanent synthetic mesh for prolapse
  • Reserve biological grafts or other specialised reconstruction for carefully selected patients
  • Provide clear consent regarding alternatives, uncertainty, recurrence and complications

Recovery after anterior prolapse surgery

Recovery varies according to the procedure. Patients can generally expect:

  • A temporary urinary catheter
  • A bladder-emptying assessment before discharge
  • Light vaginal bleeding or discharge
  • Pelvic discomfort for several days
  • Avoidance of constipation and straining
  • Gradual return to walking and daily activities
  • Temporary restrictions on heavy lifting and vaginal intercourse

Urgent advice should be sought for fever, heavy bleeding, worsening pain, inability to urinate, offensive discharge, calf swelling, chest pain or shortness of breath.

Can a cystocele return?

Yes. Surgery repairs the current weakness but cannot permanently reverse ageing, tissue quality or every future pressure placed on the pelvic floor.

Recurrence does not always require another operation. A recurrent prolapse may be mild and successfully managed with observation, physiotherapy or a pessary.

Reducing constipation, treating chronic cough, maintaining a healthy weight and using sensible lifting techniques may help protect the repair.

The take-home message

An anterior vaginal prolapse occurs when weakened support allows the bladder to bulge into the front wall of the vagina. It can cause pressure, urinary leakage, incomplete emptying, retention and recurrent infections, but treatment is only necessary when symptoms are troublesome or bladder function is affected.

Conservative measures, particularly pelvic-floor physiotherapy and a vaginal pessary, are effective options for many women. When surgery is needed, native-tissue anterior repair remains the usual vaginal procedure in Australia, often combined with restoration of upper-vaginal support.

Processed human-tissue allografts are different from permanent synthetic mesh, but current evidence does not support their routine use for every cystocele. Their role is selective and should be discussed with a surgeon experienced in female pelvic-floor reconstruction.

So, if you can feel a bulge and it is affecting your waterworks, come see your local urogynaecologist or local Brisbane urologist specialising in this field.

This article provides general information and does not replace individual medical advice. Treatment should be selected after assessment by an appropriately trained urologist, urogynaecologist or gynaecologist.

Vaginal Atrophy: How Menopause Can Affect the Bladder, Infections and Incontinence

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Vaginal dryness after menopause is common, but it is not “just part of getting older” and does not need to be silently tolerated.

The modern medical term is genitourinary syndrome of menopause (GSM). This recognises that falling oestrogen levels affect not only the vagina and vulva, but also the urethra, bladder and pelvic floor. Symptoms may therefore include dryness or painful intercourse as well as urinary urgency, recurrent urinary tract infections and leakage.

GSM is usually a chronic condition. Unlike hot flushes, it often persists or gradually worsens without treatment. Fortunately, several effective management options are available.

What causes vaginal atrophy?

Before menopause, oestrogen helps keep the vaginal and lower urinary-tract tissues:

  • Thick, elastic and well lubricated
  • Well supplied with blood
  • Naturally acidic
  • Populated by protective Lactobacillus bacteria
  • More resistant to irritation and infection

When oestrogen levels fall, most commonly during perimenopause and after menopause, the vaginal lining becomes thinner, drier and less elastic. The vaginal pH rises and the protective bacterial balance changes.

Similar changes can occur after removal of the ovaries, during breastfeeding, or following some treatments for breast or gynaecological cancer.

What symptoms can vaginal atrophy cause?

Symptoms vary considerably and may include:

Vaginal and vulval symptoms

  • Dryness, burning or irritation
  • Itching or tenderness
  • Discomfort when sitting, walking or exercising
  • Pain during or after intercourse
  • Light bleeding following intercourse
  • Reduced lubrication or altered sexual sensation

Bladder and urinary symptoms

  • Urinary urgency
  • Passing urine more frequently
  • Waking at night to urinate
  • Burning or stinging when passing urine
  • Recurrent urinary tract infections
  • Urge incontinence
  • Worsening stress urinary incontinence in some women

These symptoms can overlap with infection, overactive bladder, pelvic-floor dysfunction, skin disorders and, occasionally, more serious conditions. Persistent or recurrent symptoms should therefore be properly assessed rather than repeatedly treated with antibiotics without confirmation.

Why can vaginal atrophy increase urinary infections?

The vagina, urethra and bladder are closely connected anatomically and hormonally.

After menopause, loss of protective vaginal bacteria and an increase in vaginal pH may make it easier for bowel bacteria, particularly E. coli, to colonise the vaginal opening and enter the urinary tract. Thinning around the urethra may further reduce its natural defence against infection.

Low-dose vaginal oestrogen can help restore healthier tissue and a more protective vaginal environment. For appropriately selected peri- and postmenopausal women with recurrent urinary tract infections, it can reduce the likelihood of further infections.

However, not every episode of burning or urgency is a UTI. Whenever practical, recurrent episodes should be confirmed with a midstream urine culture before antibiotics are prescribed.

How does vaginal atrophy affect continence?

Oestrogen-sensitive tissue is present around the urethra, bladder neck, vagina and pelvic floor. Oestrogen deficiency may contribute to:

  • Increased bladder sensitivity
  • Sudden urgency
  • Increased urinary frequency
  • Urge-related leakage
  • Urethral irritation
  • Reduced tissue support around the urethra

Treating GSM may improve urgency, frequency, discomfort and recurrent infection. Some women also report improved continence.

Vaginal oestrogen is not, however, a complete treatment for all urinary leakage. Stress incontinence: leakage with coughing, laughing, exercise or lifting, often requires pelvic-floor physiotherapy and sometimes additional medical or surgical management.

How is GSM assessed?

Assessment may include:

  • A careful symptom and medical history
  • Medication review
  • Pelvic examination
  • Urine testing and culture
  • Bladder diary
  • Assessment of pelvic-floor function
  • Measurement of residual urine after voiding
  • Evaluation for prolapse, skin conditions or urethral abnormalities

Further tests such as ultrasound, cystoscopy or urodynamic studies are not required for every woman. They may be recommended when symptoms are complicated, recurrent, associated with blood in the urine, or not responding as expected.

Any postmenopausal bleeding, unexplained blood-stained discharge, visible blood in the urine, pelvic mass, ulcer or persistent vulval lesion requires prompt assessment.

Management options

Treatment should be individualised according to the symptoms, examination findings, medical history and personal preferences.

Vaginal moisturisers

A vaginal moisturiser is used regularly, often several times per week, to improve ongoing hydration. It is different from a lubricant and may be sufficient for mild symptoms.

Avoid perfumed products, douches and harsh soaps, which can worsen irritation.

Lubricants

Water- or silicone-based lubricants can reduce friction during sexual activity. These provide short-term relief but do not reverse the underlying tissue changes.

Pelvic-floor physiotherapy

Pelvic-floor physiotherapy may assist women with:

  • Stress or urge incontinence
  • Pelvic-floor weakness
  • Pelvic-floor overactivity or pain
  • Painful intercourse
  • Difficulty coordinating bladder control

Importantly, more squeezing is not always better. Some women have an overactive or painful pelvic floor and need relaxation and coordination work rather than simply stronger contractions.

Bladder-directed treatment

Persistent overactive-bladder symptoms may require bladder training, fluid and caffeine modification, medication, intravesical Botox or sacral neuromodulation. Stress incontinence may require additional treatments ranging from supervised physiotherapy to bulking injections or surgery.

Topical vaginal oestrogen: what role does it play?

Low-dose vaginal oestrogen is one of the most effective treatments for moderate or persistent GSM. It is available in different preparations, including vaginal cream, tablets or pessaries.

It acts mainly within the vagina and surrounding urinary tissues. Treatment may:

  • Improve dryness, burning and irritation
  • Restore tissue thickness and elasticity
  • Reduce pain during intercourse
  • Improve urethral discomfort
  • Reduce urinary urgency and frequency in some women
  • Lower the risk of recurrent UTIs
  • Complement other treatments for bladder symptoms

Treatment commonly begins with a short loading phase followed by a lower-frequency maintenance schedule. The exact regimen depends on the product prescribed. Improvement may begin within several weeks, but the full benefit can take several months.

Because GSM is usually ongoing, symptoms commonly return when treatment is stopped.

Is topical vaginal oestrogen safe?

For most women, low-dose vaginal oestrogen has minimal absorption into the bloodstream and has a substantially different risk profile from systemic menopausal hormone therapy.

At standard low doses:

  • A progestogen is generally not required solely to protect the uterus.
  • It has not been shown to carry the same blood-clot risk as oral systemic oestrogen.
  • Long-term treatment can be considered when symptoms persist, with periodic clinical review.

Possible adverse effects include local irritation, discharge, breast tenderness or spotting, although these are uncommon.

Unexpected postmenopausal bleeding should never simply be attributed to the oestrogen. It requires investigation.

What if I have had breast cancer?

This requires an individual discussion.

Non-hormonal treatments are usually considered first. If symptoms remain troublesome, low-dose vaginal oestrogen may sometimes be considered after shared decision-making with the patient’s treating team. Particular caution is required for women taking an aromatase inhibitor, because even small changes in circulating oestrogen may be clinically important.

Women should not stop cancer medication or commence vaginal hormones without discussing this with their oncologist, breast surgeon, GP or menopause specialist. Current specialist guidance recognises that low-dose vaginal oestrogen may be reasonable for selected women when non-hormonal measures have failed, but the decision must be personalised.

MonaLisa Touch laser therapy—and why it remains controversial

MonaLisa Touch is a branded fractional carbon-dioxide laser treatment applied inside the vagina. The laser delivers controlled thermal energy to the vaginal lining with the aim of stimulating healing, collagen formation and tissue remodelling.

It is commonly promoted as a “non-hormonal” treatment for vaginal dryness, burning, painful intercourse and some urinary symptoms. A course generally involves several treatments followed by possible maintenance sessions.

Although some women report improvement, vaginal laser therapy remains controversial.

Why has it become popular?

Vaginal laser treatment may appeal to women who:

  • Prefer not to use vaginal oestrogen
  • Have not improved with moisturisers or lubricants
  • Have concerns about hormone treatment
  • Have experienced symptoms following breast-cancer treatment
  • Prefer a procedure rather than ongoing medication

Early uncontrolled studies reported encouraging improvements. However, uncontrolled studies cannot reliably separate the true treatment effect from placebo response, increased clinical attention, lubricants used during treatment or natural variation in symptoms.

The gap between marketing and evidence

The greatest controversy is the difference between strong commercial claims and the quality of the supporting clinical evidence.

Some clinics advertise vaginal laser therapy as “rejuvenation” or suggest it can restore vaginal tissue, improve sexual function, prevent infections and treat urinary incontinence. These claims are broader than the available evidence supports.

More rigorous randomised studies, particularly those comparing laser treatment with a sham procedure, have not consistently shown a clinically meaningful benefit. The 2025 joint AUA/SUFU/AUGS guideline concluded that fractional CO₂ laser may produce little or no difference in several GSM symptoms compared with sham treatment or vaginal oestrogen. AUA/SUFU/AUGS guideline

The RACGP also notes that the long-term effectiveness and safety of vaginal laser therapy have not been established.

Regulatory concerns

Regulators have raised concerns about energy-based vaginal treatments being promoted for indications that have not been adequately supported by clinical evidence.

A device being legally supplied or registered for a particular use does not necessarily mean that every advertised claim, such as treating incontinence, preventing UTIs or providing “vaginal rejuvenation”, has been independently proven.

Regulatory reviews in Australia and warnings internationally have focused on:

  • Insufficient high-quality evidence of effectiveness
  • Lack of reliable long-term safety information
  • Promotion extending beyond authorised indications
  • The possibility of women being exposed to an expensive procedure before established treatments have been tried

Patients should be cautious about phrases such as “TGA approved.” Inclusion of a device on the Australian Register of Therapeutic Goods does not amount to endorsement of every clinical or advertising claim.

Possible complications

Vaginal laser is often described as painless or risk-free, but possible adverse effects include:

  • Burning or prolonged irritation
  • Vaginal pain
  • Bleeding or discharge
  • Infection
  • Pain during intercourse
  • Urinary discomfort
  • Tissue burns
  • Scarring or narrowing of the vagina
  • Persistence or worsening of the original symptoms

The true frequency of uncommon or delayed complications is uncertain because long-term data remain limited.

Does it treat urinary incontinence or prevent UTIs?

Evidence that vaginal laser reliably treats urinary incontinence is insufficient. Small studies have reported improvements, but many lacked sham controls, had short follow-up or used subjective outcomes.

It should not be presented as an established treatment for stress urinary incontinence, overactive bladder or recurrent UTIs. These conditions require an accurate diagnosis and may respond to better-supported treatments such as:

  • Pelvic-floor physiotherapy
  • Bladder training
  • Low-dose vaginal oestrogen
  • Overactive-bladder medication
  • Continence procedures or surgery
  • UTI-prevention strategies based on urine-culture results

What about women who cannot use oestrogen?

Vaginal laser is sometimes marketed directly to breast-cancer survivors. This is particularly controversial because these women may be vulnerable to claims that a costly procedure is their only non-hormonal option.

Non-hormonal moisturisers, lubricants, pelvic-floor therapy and multidisciplinary care should be considered first. Selected women with a history of breast cancer may also be able to use low-dose vaginal oestrogen after shared decision-making with their oncologist and treating specialists.

Laser should not automatically be assumed to be safer simply because it is “non-hormonal.” Hormonal exposure is avoided, but procedural risks and uncertainty about long-term effects remain.

Cost and conflicts of interest

Vaginal laser therapy is generally privately funded and may require an initial treatment course followed by maintenance sessions. Patients should be told the total likely cost and the possibility that any improvement may be temporary.

Some published studies have had small sample sizes, limited follow-up or connections with device manufacturers. This does not automatically invalidate the findings, but it reinforces the need for independent, sham-controlled and long-term research.

The UGSA and USANZ perspective

The Urogynaecological Society of Australasia (UGSA) and the Urological Society of Australia and New Zealand (USANZ) support evidence-based assessment and management of pelvic-floor and urinary disorders.

At the time of writing, publicly accessible UGSA or USANZ guideline specifically endorsing MonaLisa Touch for GSM, recurrent UTIs or urinary incontinence could not be found. The treatment should therefore not be described as endorsed by either organisation.

A balanced conclusion

Some women report meaningful improvement after MonaLisa Touch treatment, and research into vaginal energy-based therapy is continuing. These experiences should not be dismissed. However, individual improvement does not establish that the treatment is consistently effective, superior to placebo or safe over many years.

At present, MonaLisa Touch should not be considered first-line treatment for GSM, urinary incontinence or recurrent UTIs. If it is being considered, patients should receive balanced counselling that includes:

  • The limited and conflicting evidence
  • The absence of reliable long-term safety data
  • Possible adverse effects
  • Treatment costs and likely maintenance requirements
  • Established alternatives, particularly low-dose vaginal oestrogen
  • The clinician’s experience and any financial relationship with the device provider

Ideally, treatment should be provided by an appropriately trained medical practitioner following a proper pelvic and urinary assessment, with clear consent and structured follow-up. Participation in a well-designed clinical trial is preferable where available.

When should you seek medical advice?

Please arrange an assessment if you have:

  • Recurrent or persistent UTI symptoms
  • Blood in the urine
  • Postmenopausal vaginal bleeding
  • New or worsening urinary leakage
  • Difficulty emptying the bladder
  • Persistent vaginal, vulval or pelvic pain
  • Pain during intercourse
  • A lump, ulcer or skin change
  • Symptoms that have not improved with simple measures

The take-home message

Vaginal atrophy is better understood as genitourinary syndrome of menopause because it can affect the vagina, urethra, bladder, continence and susceptibility to infection.

Low-dose vaginal oestrogen is an effective and generally safe treatment for most women and can be particularly valuable for recurrent UTIs and urinary symptoms associated with menopause. Women with previous hormone-sensitive cancer require individualised advice.

MonaLisa Touch and similar vaginal laser therapies remain less well supported. Their long-term benefits and safety are uncertain, and they should not replace proper assessment or established treatments.

This information is general and does not replace individual medical advice. Treatment should be selected after discussion with your GP, urologist, urogynaecologist, gynaecologist or menopause specialist.

So, if your menopause is driving your bladder symptoms, ask for a review with your local urogynaecologist or come chat to your functional urologist in Brisbane, Dr Jo Schoeman