What is the initial workup for pelvic organ prolapse?

Initial Workup for Pelvic Organ Prolapse

The initial evaluation of pelvic organ prolapse (POP) is primarily clinical and begins with a thorough physical examination, which should be performed before proceeding to any imaging studies. 1

Clinical Assessment

History

• Document specific symptoms:
  • Vaginal bulging or pressure (most specific symptom)
  • Urinary symptoms (incontinence, frequency, urgency, straining to void)
  • Bowel symptoms (constipation, incomplete evacuation, digital assistance)
  • Sexual dysfunction
  • Pelvic pain or pressure

Physical Examination

• Perform in lithotomy position
• Assess at rest and with Valsalva maneuver
• Use a split-speculum technique to evaluate each compartment separately:
  • Anterior compartment (bladder/urethra)
  • Apical compartment (uterus/cervix or vaginal cuff)
  • Posterior compartment (rectum/rectovaginal space)
• Document the degree of prolapse using the POP-Q (Pelvic Organ Prolapse Quantification) system
• Evaluate pelvic floor muscle strength
• Assess for concurrent conditions (urethral hypermobility, stress incontinence)

When to Consider Imaging

Imaging is generally not required for initial diagnosis of POP but may be indicated in specific circumstances 1, 2:

• When clinical evaluation is difficult or inadequate
• For persistent or recurrent symptoms after treatment
• When physical examination findings are discordant with symptoms
• To differentiate between types of posterior compartment prolapse (rectocele vs. enterocele)
• To evaluate for multi-compartment involvement not apparent on examination

Appropriate Imaging Studies

When imaging is indicated, options include:

1. MR Defecography:

   • Provides comprehensive anatomic and functional evaluation of the entire pelvic floor
   • Excellent for detecting multi-compartment involvement
   • Particularly useful for differentiating enteroceles from rectoceles 1

2. Dynamic Fluoroscopic Cystocolpoproctography (CCP):

   • Allows functional evaluation in physiologic upright seated position
   • High sensitivity for detecting internal rectal prolapse (88%) and peritoneocele (83%)
   • Particularly useful for posterior compartment assessment 1

3. Transperineal Ultrasound (TPUS):

   • Non-invasive and less expensive alternative
   • Provides real-time dynamic assessment
   • Most accurate for anterior compartment prolapse
   • Limited utility for middle and posterior compartment assessment 1

Management Considerations

Based on the initial workup:

• Conservative management should be offered as first-line therapy 3, 4:

  • Pelvic floor muscle training
  • Vaginal pessaries
  • Lifestyle modifications (weight loss, treating constipation)

• Surgical management may be considered when:

  • Conservative measures fail
  • Symptoms are disabling
  • Prolapse is stage 2 or greater on POP-Q classification 4

Common Pitfalls to Avoid

1. Relying solely on imaging for diagnosis

   • POP diagnosis is primarily clinical 2, 4
   • Imaging should complement, not replace, physical examination

2. Failing to assess all compartments

   • POP often involves multiple compartments 1
   • Isolated assessment may miss concurrent defects

3. Treating asymptomatic prolapse

   • Many women with anatomic prolapse are asymptomatic 2
   • Treatment should be guided by symptoms and their impact on quality of life

4. Age-based treatment limitations

   • Advanced age alone should not limit treatment options 5
   • Individual assessment of health status and expectations is more important than chronological age

5. Missing concurrent conditions

   • Urinary incontinence often coexists with POP
   • Bowel dysfunction may require separate evaluation

By following this systematic approach to the initial workup of POP, clinicians can accurately diagnose the condition, determine its severity and impact, and develop an appropriate management plan tailored to the patient's specific needs.