A 78-year-old woman presents with difficulty initiating urination and a bulge at the anterior vaginal wall. What is the most likely diagnosis?

The presentation of a 78-year-old woman with difficulty initiating urination and a bulge at the anterior vaginal wall strongly suggests a cystocele. A cystocele occurs when there is a weakening of the pelvic support structures, leading to the bladder protruding into the anterior wall of the vagina. This anatomical change can create a bulge that may be visible or palpable during a physical examination, particularly when the woman is in a standing position or performing tasks that increase intra-abdominal pressure.

The symptom of difficulty initiating urination can also be explained by the presence of a cystocele because the bulging bladder may obstruct the urethra or compress the urinary passage, making it challenging for her to start urination. This is a common issue in postmenopausal women due to decreased estrogen levels, which can contribute to the weakening of pelvic support tissues.

In this case, identifying a cystocele is crucial for proper management, which may include pelvic floor exercises, pessaries, or surgical interventions, depending on the severity of the symptoms and the patient’s overall health.

Understanding this clinical scenario also helps clarify why other diagnoses are less likely. For instance, a urethral stricture typically would not present with a bulge, and the main