How do you diagnose cystocele and rectocele?

Diagnosing Cystocele and Rectocele

The diagnosis of cystocele and rectocele requires a systematic physical examination in the lithotomy position, assessing each compartment separately at rest and with Valsalva maneuver, complemented by appropriate imaging when necessary. 1

Physical Examination

Anterior Compartment (Cystocele)

• Perform visual inspection with the patient bearing down to look for tissue protruding from the anterior vaginal wall
• Use split-speculum technique to evaluate the anterior compartment separately
• Document the degree of prolapse using the POP-Q (Pelvic Organ Prolapse Quantification) system
• Assess for stress urinary incontinence with a stress test during coughing or Valsalva maneuver with a comfortably full bladder 1

Posterior Compartment (Rectocele)

• Examine the posterior vaginal wall for bulging during Valsalva maneuver
• Evaluate for incomplete evacuation symptoms which may indicate rectocele
• Digital examination can help identify the size and location of rectocele
• Check for concurrent enterocele which may be difficult to distinguish from high rectocele 2

Imaging Modalities

MR Defecography

• Provides comprehensive anatomic and functional evaluation of the entire pelvic floor
• Excellent for detecting multi-compartment involvement
• Best agreement with physical examination for anterior compartment prolapse (85%) 1
• Typically performed with rectal contrast and includes acquisition during active defecation 2
• Can detect clinically occult prolapse in other compartments
• Limitations: most centers lack open magnets for upright positioning; supine positioning may underestimate posterior compartment prolapse 2

Dynamic Fluoroscopic Cystocolpoproctography (CCP)

• Allows functional evaluation in physiologic upright seated position
• High sensitivity for detecting cystoceles (96%) and rectoceles (94%) 2
• Excellent for posterior compartment assessment
• Can detect contrast retention within rectoceles, indicating clinically relevant findings
• Limitations: requires contrast installation in bladder and vagina; lacks soft-tissue contrast resolution 2

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
• Can be used to define significant prolapse: descent of bladder ≥10 mm below symphysis pubis for cystocele and rectum ≥15 mm for rectocele 3

Diagnostic Criteria

Cystocele

• On physical exam: anterior vaginal wall bulge that increases with Valsalva
• On imaging:
  • MRI/CCP: bladder descent below the pubococcygeal line
  • VCUG: extension of opacified bladder below the level of pubic symphysis 2
  • Ultrasound: bladder descent ≥10 mm below symphysis pubis 3

Rectocele

• On physical exam: posterior vaginal wall bulge that increases with Valsalva
• On imaging:
  • MRI/CCP: anterior rectal wall bulge >2 cm from expected rectal position
  • Ultrasound: rectal descent ≥15 mm below symphysis pubis 3
  • Barium retention within rectocele on CCP suggests clinical relevance 2

Clinical Pearls and Pitfalls

• Physical examination alone may be insufficient to differentiate between cystocele, enterocele, and high rectocele 4
• Approximately one-third of patients with posterior vaginal wall bulging actually have enteroceles or sigmoidoceles rather than rectoceles 2
• The degree of concordance between imaging and physical examination varies by compartment - imaging may detect prolapse that is clinically occult 2
• Voiding dysfunction assessment (post-void residual) should be performed to evaluate for urinary retention with significant cystocele 1
• Consider multi-compartment involvement, as pelvic organ prolapse rarely affects a single compartment in isolation 1

By combining thorough physical examination with appropriate imaging when indicated, clinicians can accurately diagnose cystocele and rectocele, which is essential for planning appropriate management and improving patient outcomes.