Initial Workup for Pelvic Organ Prolapse (Bladder Drop)
The initial workup for pelvic organ prolapse (POP) should begin with a thorough clinical evaluation, including a comprehensive assessment of bladder symptoms, physical examination with POP-Q staging, and urinalysis, before proceeding to any imaging studies. 1, 2
Clinical Assessment
History
- Document specific symptoms:
- Vaginal bulging or pressure
- Urinary symptoms (incontinence, frequency, urgency)
- Bowel symptoms (constipation, incomplete emptying)
- Sexual dysfunction
- Pelvic pain or pressure
- Assess impact on quality of life
- Identify risk factors:
- Vaginal childbirth history
- Previous pelvic surgeries
- Chronic straining/constipation
- Obesity
- Family history
Physical Examination
- Perform in lithotomy position, assessing at rest and with Valsalva maneuver
- Use split-speculum technique to evaluate each compartment separately:
- Anterior compartment (cystocele)
- Apical compartment (uterine/cervical or vaginal vault prolapse)
- Posterior compartment (rectocele, enterocele)
- Document degree of prolapse using POP-Q (Pelvic Organ Prolapse Quantification) system
- Evaluate pelvic floor muscle strength
- Assess for concurrent conditions (urinary incontinence, fecal incontinence)
Laboratory Testing
- Dipstick or microscopic urinalysis to exclude infection and hematuria 1
- Urine culture if urinalysis suggests infection
Additional Evaluation
For patients with complex presentations, additional testing may be indicated:
Post-Void Residual (PVR) Assessment
- Perform in all patients with POP to rule out voiding dysfunction 1
- Can be measured by bladder scan or catheterization
Specialized Testing (when indicated)
- Urodynamic testing: For patients with significant urinary symptoms, especially if considering surgical correction
- Defecography: For patients with significant posterior compartment symptoms or when physical examination findings are discordant with symptoms 1
Imaging Studies
Imaging is generally not required for initial diagnosis but may be indicated in specific circumstances:
- When clinical evaluation is difficult or inadequate
- When physical examination findings are discordant with symptoms
- For recurrent prolapse after surgical repair
- For complex multi-compartment prolapse
Imaging Options (when indicated)
MR Defecography: Provides comprehensive anatomic and functional evaluation of the entire pelvic floor 1, 2
- Excellent for detecting multi-compartment involvement
- Particularly useful for differentiating enteroceles from rectoceles
Transperineal Ultrasound (TPUS): Non-invasive alternative 1, 2
- Provides real-time dynamic assessment
- Most accurate for anterior compartment prolapse
- Limited utility for middle and posterior compartment assessment
Common Pitfalls to Avoid
- Relying solely on imaging for diagnosis without thorough clinical assessment
- Failing to assess all compartments (POP often involves multiple compartments)
- Not evaluating for concurrent conditions (urinary incontinence, bowel dysfunction)
- Treating asymptomatic prolapse (treatment should be guided by symptoms and their impact on quality of life)
- Overlooking modifiable risk factors (obesity, constipation)
Management Considerations
After completing the initial workup, management options should be discussed with the patient:
Conservative management (first-line therapy):
- Pelvic floor muscle training
- Vaginal pessaries
- Lifestyle modifications (weight loss, treating constipation)
Surgical management (when conservative measures fail or symptoms are disabling):
- Vaginal approaches with native tissue
- Abdominal approaches (laparoscopic/robotic)
- Obliterative procedures for elderly patients not sexually active
The American College of Radiology emphasizes that treatment should be guided by symptoms and their impact on quality of life, rather than relying solely on imaging findings 1, 2.