How do you assess for bladder prolapse?

Assessment of Bladder Prolapse (Cystocele)

Physical examination with the Pelvic Organ Prolapse Quantification (POP-Q) system is the primary method for diagnosing bladder prolapse, performed with an empty bladder in the standing position to avoid underestimating the extent of prolapse. 1, 2

Clinical Examination Technique

Patient Positioning and Preparation

• Examine with an empty bladder to maximize visualization of the full extent of prolapse 3, 2
• Start in the standing position if possible, as this reveals significantly more prolapse than supine examination 3, 2
  • Standing with empty bladder shows mean descent 2.7 cm beyond hymen versus only 0.39 cm when supine with full bladder 3
  • Examining supine with full bladder can miss up to 2 stages of prolapse severity 3
• If prolapse cannot be reproduced supine, the patient must be examined upright 2

Standardized Measurement System

• Use the POP-Q system or Simplified POP-Q (S-POP) as these are the only methods with sufficient reproducibility for clinical use 2
• Describe prolapse compartment by compartment, indicating the extent of externalization for each 4
• Bladder prolapse (cystocele) specifically involves descent of the anterior vaginal wall 5, 6

When to Consider Imaging

Clinical Diagnosis is Primary

• Diagnosis of bladder prolapse is clinical and does not require imaging 1, 4
• Reserve imaging for cases where clinical evaluation is difficult or inadequate 1

Imaging Modalities When Indicated

For anterior compartment (bladder) prolapse specifically:

• Transperineal ultrasound (TPUS) is the preferred first-line imaging when needed 7, 1

  • Non-invasive and less expensive 7
  • Shows significant correlation with physical examination, particularly for anterior compartment prolapse 7, 1
  • Can detect levator muscle avulsion, which predicts prolapse recurrence 7, 1
  • Performed during rest, strain, and Kegel maneuvers 7

• MR defecography provides comprehensive multicompartment evaluation 7, 1

  • Shows 85% agreement with physical examination for anterior compartment prolapse 7
  • Best for detecting associated pelvic floor abnormalities in multiple compartments 7
  • Requires repeated strain/defecation maneuvers to maximize prolapse visualization 7
  • Can detect and quantify levator muscle defects with high interobserver reliability 7, 1

• Voiding cystourethrography (VCUG) has limited utility 7, 1

  • Focuses only on anterior compartment (bladder and urethra) 7, 1
  • Defines cystocele as bladder extension below pubic symphysis 7, 1
  • Rarely used for initial evaluation due to narrow focus and recent studies showing lower detection rates compared to MR defecography 7
  • Reserve for patients with suspected concomitant urinary dysfunction requiring specific urethral assessment 7

Associated Functional Assessment

Urinary Symptoms Evaluation

• Perform cough stress test with bladder volume ≥200 ml and prolapse reduced (with speculum or pessary) to assess for occult stress urinary incontinence 2
• Measure post-void residual urine volume (>100 ml commonly used threshold for voiding difficulty) 2
• Prolapse reduction during examination can predict postoperative persistence of voiding difficulty 2

When Urodynamic Testing is NOT Needed

• No benefit for assessing detrusor overactivity as it does not change management 2
• Only changes management when stress incontinence and voiding dysfunction co-exist 2

Critical Pitfalls to Avoid

• Never examine with a full bladder in supine position only - this combination misses the most prolapse and can underestimate severity by 2 full stages 3
• Do not rely on imaging alone - imaging studies cannot replace clinical examination for POP assessment 2
• Avoid routine imaging - only symptomatic prolapse detected on clinical examination warrants treatment consideration 4, 6
• Do not assume all urinary/bowel symptoms are caused by the prolapse - these require separate evaluation and may not correlate with prolapse severity 6, 2