How do I diagnose a prolapsed uterus?

Assessment of Uterine Prolapse

The diagnosis of pelvic organ prolapse, including uterine prolapse, is primarily clinical and should be performed using a systematic physical examination in the lithotomy position, assessing each compartment separately at rest and with Valsalva maneuver, and documenting the degree of prolapse using the POP-Q system. 1

Physical Examination Technique

1. Patient Positioning and Preparation:

   • Position the patient in lithotomy position
   • Ensure the patient has a comfortably full bladder for the stress test
   • Explain the procedure to reduce anxiety

2. Systematic Compartment Assessment:

   • Use a split-speculum technique to evaluate each compartment separately 1:
     • Anterior compartment (bladder/urethra)
     • Apical compartment (uterus/cervix or vaginal vault)
     • Posterior compartment (rectum)
   • Assess each compartment both at rest and with Valsalva maneuver

3. POP-Q System Documentation:

   • Document the degree of prolapse using the standardized Pelvic Organ Prolapse Quantification (POP-Q) system
   • This provides objective measurement of prolapse severity

Key Components of the Assessment

• Visual Inspection: Look for tissue protruding from the vaginal introitus, especially when the patient bears down 2

• Stress Test: Have the patient cough or perform Valsalva maneuver with a comfortably full bladder to observe for involuntary urine loss from the urethral meatus 1

• Pelvic Floor Muscle Strength: Evaluate pelvic floor muscle tone and strength during the examination 1

• Associated Conditions: Assess for commonly associated conditions such as:

  • Cystocele (anterior compartment)
  • Rectocele (posterior compartment)
  • Enterocele (apical compartment)
  • Perineal descent

Signs and Symptoms to Document

• Pelvic heaviness or fullness
• Low back pain that worsens with exertion and improves with rest
• Sensation of a "mass" protruding from the vagina
• Mucosal ulcerations or bleeding from tissue rubbing against clothing
• Difficulty voiding or recurrent urinary infections
• Need for "splinting" to defecate 3

Advanced Diagnostic Testing

While the diagnosis is primarily clinical, advanced imaging may be indicated in specific circumstances 1:

• MR Defecography: Provides comprehensive anatomic and functional evaluation of the entire pelvic floor; excellent for detecting multi-compartment involvement

• Dynamic Fluoroscopic Cystocolpoproctography (CCP): Allows functional evaluation in physiologic upright seated position; particularly useful for posterior compartment assessment

• Transperineal Ultrasound (TPUS): Non-invasive alternative providing real-time dynamic assessment; most accurate for anterior compartment prolapse 2, 1

Common Pitfalls to Avoid

1. Inadequate Examination: Failing to assess all compartments can miss multi-compartment involvement, as pelvic organ prolapse often affects multiple areas simultaneously 1

2. Overlooking Associated Conditions: Not evaluating for concurrent conditions such as urinary incontinence or bowel dysfunction can lead to incomplete management 1

3. Relying Solely on Imaging: Remember that treatment should be guided by symptoms and their impact on quality of life, rather than relying solely on imaging findings 1

4. Neglecting Patient Symptoms: The correlation between anatomical findings and patient symptoms is not always strong; focus on symptom relief rather than anatomical correction alone

By following this systematic approach to assessing uterine prolapse, clinicians can accurately diagnose the condition and develop appropriate management plans based on symptom severity and impact on quality of life.