What should be assessed when a bulge is identified in the vagina?

Assessment of Vaginal Bulge

When a bulge is identified in the vagina, a thorough clinical examination should be performed first, followed by appropriate imaging studies when clinical evaluation is difficult, inadequate, or when patients present with persistent or recurrent symptoms after treatment.

Initial Clinical Assessment

• The initial evaluation of a vaginal bulge begins with a comprehensive physical examination to identify the type and extent of pelvic organ prolapse (POP) 1
• POP may involve various compartments of the pelvic floor, including:
  • Anterior compartment (cystocele and/or urethrocele)
  • Apical compartment (uterine/cervical and/or vaginal prolapse)
  • Posterior compartment (rectocele) 1
• Additionally, pelvic contents at the posterior cul-de-sac may herniate into the rectovaginal space, containing:
  • Peritoneal fat (peritoneocele)
  • Small bowel (enterocele)
  • Sigmoid colon (sigmoidocele) 1

Physical Examination Components

• External genital examination to assess:
  • Presence of any lesions, including papules, vesicles, pustules, ulcers, fissures, and warts 1
  • Signs of trauma or laceration 1
  • Bartholin glands (located at 4 and 8 o'clock positions) and Skene glands (lateral to urethra) for signs of infection 1
  • Perianal area for evidence of trauma, discharge, or warts 1
• Speculum examination to:
  • Inspect vaginal walls for discharge and lesions 1
  • Visualize the cervix completely to note presence of any lesions 1
  • Assess for bluish hue (Chadwick sign) which may indicate pregnancy 1
• Assessment of the degree of prolapse:
  • Document the extent of descent in relation to the hymen (optimal cutoff for defining prolapse associated with vaginal bulge symptoms) 2
  • Note that the level of vaginal descent may not predict bulge symptoms as accurately in younger patients 2

Differential Diagnosis

• It's important to recognize that not all vaginal bulges are due to prolapse 3
• Consider other causes such as:
  • Vaginal cysts (Müllerian, Gartner's, Skene duct, Bartholin gland, epidermal inclusion)
  • Endometriotic cysts
  • Urethral diverticulum 3

Imaging Studies

When clinical evaluation is difficult or inadequate, or for patients with persistent symptoms after treatment, imaging studies should be considered 1:

Dynamic Cystocolpoproctography (CCP)

• One of the imaging tests of choice for evaluation of vaginal bulge or suspected POP 1
• Involves fluoroscopic imaging during defecation with patient sitting in upright position 1
• Images obtained during rest, Kegel (contraction), strain, and defecation 1
• Shows good agreement with surgical findings for detection of:
  • Full-thickness rectal prolapse
  • Posterior colpocele
  • Rectocele
  • Peritoneocele 1, 4
• Sensitivities for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively 1
• Allows for functional evaluation in physiologic upright seated positioning 1

MR Defecography

• Provides high soft-tissue contrast resolution for direct visualization of pelvic organs and floor muscles 4
• Allows for assessment of:
  • Pelvic floor muscles and fascia
  • Postsurgical changes in the pelvic floor 1
• Routine T2-weighted images at rest can detect and quantify levator muscle defects 1
• Muscle defects seen on MRI correlate with symptoms of POP 1

Transperineal Ultrasound (TPUS)

• Can be used for anatomic and functional evaluation of the pelvic floor 1
• Images obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers 1
• Can detect levator muscle avulsion, a predictor of prolapse recurrence after surgical repair 1
• Shows moderate-to-good agreement with MRI for detection of levator ani defects 1
• Main advantage: noninvasive, less expensive technique with dynamic real-time functional assessment 1

Important Considerations

• Age and vaginal parity are independently associated with vaginal bulge symptoms 2
• Women in the United States have a 13% lifetime risk of undergoing surgery for POP 5, 6
• Peak incidence of POP symptoms is in women aged 70-79 years 5, 6
• By 2050, the number of women experiencing POP is anticipated to increase by approximately 50% due to the aging population 5, 6

Clinical Pitfalls to Avoid

• Not differentiating between cul-de-sac hernias and anterior rectoceles, both of which can present with posterior vaginal bulge 1
• Failing to evaluate for occult pelvic floor disorders in compartments other than those apparent on physical examination 1
• Overlooking non-prolapse causes of vaginal bulge such as cysts or urethral diverticulum 3
• Not recognizing that the level of vaginal descent does not predict bulge symptoms as accurately in younger patients 2