How to assess pelvic organ prolapse in a patient?

Assessment of Pelvic Organ Prolapse

Begin with a standardized physical examination using the POP-Q or S-POP classification system to describe and quantify prolapse in each compartment, reserving imaging for cases where physical examination is inadequate, findings are equivocal, or when evaluating severe/recurrent prolapse. 1, 2

Initial Clinical Assessment

History Taking

• Document specific symptoms: sensation of vaginal bulging or protrusion, pelvic pressure, urinary incontinence, defecatory dysfunction, urinary retention, and constipation 1, 3, 4
• Assess impact on quality of life and daily activities 3
• Identify risk factors: vaginal multiparity, advanced age, menopause, obesity, chronic straining, heavy lifting, chronic respiratory conditions 1, 5
• Rule out other pelvic pathologies that may explain symptoms 3

Physical Examination Technique

• Perform examination with empty bladder 2
• Position patient supine initially, but examine upright if prolapse cannot be reproduced in supine position 2
• Use the POP-Q (Pelvic Organ Prolapse Quantification) system or S-POP (Simplified POP-Q) system as these are the only methods with sufficient reproducibility for standardized documentation 2
• Examine each compartment separately: anterior (bladder/cystocele), apical (uterus/vaginal vault), and posterior (rectum/rectocele) 1, 6, 3
• Document the extent of externalization for each compartment 3

Critical caveat: Physical examination may be limited in depicting multicompartment involvement, particularly for enteroceles and occult defects 1

Assessment of Associated Pelvic Floor Dysfunction

Urinary Tract Evaluation

• Perform cough stress test with bladder volume ≥200 ml and prolapse reduced (using speculum or pessary) to assess for stress urinary incontinence 2
• Measure post-void residual urine volume; >100 ml suggests voiding difficulty 2
• Consider prolapse reduction during examination to predict postoperative voiding difficulty 2
• Urodynamic testing is NOT routinely beneficial for detrusor overactivity assessment as it does not change management, except when both SUI and voiding dysfunction coexist 2

Important note: Absence of preoperative occult SUI has 91% negative predictive value for de novo SUI postoperatively, making this assessment clinically valuable 2

Gastrointestinal Evaluation

• Clinical examination remains primary assessment tool for bowel symptoms 2
• Routine radiographic or physiological GI testing adds no value to physical examination alone 2
• Reserve additional GI imaging for specific indications: when symptoms are not explained by observed prolapse or to detect enteroceles, sigmoidoceles, and intussusception 1, 2

Indications for Imaging

When to Order Imaging Studies

Imaging is reserved for specific clinical scenarios, not routine assessment 1, 3:

• Severe or recurrent prolapse 1
• Physical examination findings discordant from patient symptoms 1
• Patient unable to tolerate adequate physical examination 1
• Equivocal findings on clinical examination 1, 7
• Persistent symptoms after treatment 6
• Need to evaluate for occult pelvic floor disorders in compartments not apparent on physical examination 6

Imaging Modality Selection

For anterior compartment (bladder) prolapse:

• Transperineal ultrasound (TPUS) is the preferred first-line imaging as it is non-invasive, less expensive, and shows significant correlation with physical examination 8
• TPUS can detect levator muscle avulsion, which predicts prolapse recurrence 8
• Perform TPUS during rest, strain, and Kegel maneuvers 8

For multicompartment evaluation:

• MR defecography provides comprehensive anatomic and functional evaluation of the entire pelvic floor with 85% agreement with physical examination for anterior compartment prolapse 8
• MR imaging directly visualizes intrapelvic contents and soft tissues without requiring bladder, vaginal, or small bowel contrast 1
• Use rectal contrast (US gel or sterile lubricating jelly) for MR defecography as it facilitates defecation and improves detection of prolapse compared to dynamic pelvic floor MRI without rectal contrast 1
• MR imaging is best for detecting levator muscle defects and associated pelvic floor abnormalities in multiple compartments 8

Limited utility modalities:

• Voiding cystourethrography (VCUG) has limited utility as it focuses only on anterior compartment and has lower detection rates compared to MR defecography 8
• CT may be considered only when patient cannot tolerate MRI and multiplanar visualization is clinically desired 9

Common Pitfalls to Avoid

• Do not rely on imaging alone to replace clinical examination for POP assessment 2
• Do not perform routine urodynamic testing unless both SUI and voiding dysfunction coexist 2
• Do not order routine GI radiographic testing without specific clinical indication 2
• Remember that patients often have multicompartment involvement even when presenting with predominant single-compartment symptoms 1, 6
• Document all compartments preoperatively as this influences surgical planning, particularly since procedures for stress incontinence and prolapse may be performed concomitantly 6