What is the appropriate workup and treatment for a patient with bladder prolapse, considering their medical history, symptoms, and potential underlying conditions?

Bladder Prolapse Workup

Initial Clinical Assessment

The diagnosis of bladder prolapse (cystocele) is primarily clinical, requiring a focused history documenting specific symptoms and a thorough pelvic examination to determine the compartment(s) involved and severity of descent. 1, 2

History Taking

• Document whether the patient experiences a vaginal bulge or protrusion, pelvic pressure or heaviness, and the impact on daily activities 1, 2
• Assess for urinary symptoms including stress incontinence, urgency, frequency, incomplete emptying, or recurrent urinary tract infections 3
• Evaluate bowel symptoms such as constipation, difficulty with defecation, or fecal incontinence 3
• Inquire about sexual dysfunction related to the prolapse 2, 4
• Identify risk factors including prior pelvic surgeries, obstetric history, chronic constipation, chronic cough, and heavy lifting 5, 3

Physical Examination

• Perform examination with the patient in lithotomy position with straining to assess maximal descent of pelvic organs 1, 4
• Describe prolapse compartment by compartment: anterior vaginal wall (cystocele/urethrocele), apical (uterine/cervical or vaginal vault), and posterior vaginal wall (rectocele) 1, 5
• Grade the severity using POP-Q classification system, documenting the extent of externalization for each compartment 5, 3
• Assess for occult stress incontinence by reducing the prolapse and having the patient cough with a full bladder 3
• Evaluate pelvic floor muscle strength and identify any levator ani defects 3

Imaging Studies

When Imaging is Indicated

Imaging is NOT routinely required for diagnosis but should be obtained when clinical evaluation is inadequate, there is discrepancy between symptoms and examination findings, or when evaluating persistent/recurrent prolapse after treatment. 1, 3

Fluoroscopy Cystocolpoproctography (CCP)

• Dynamic CCP is one of the imaging tests of choice for evaluating vaginal bulge or clinically suspected pelvic organ prolapse, particularly for posterior compartment prolapse 1
• Performed with patient in physiologic upright sitting position on fluoroscopic commode during rest, Kegel contraction, strain, and defecation 1
• Demonstrates excellent sensitivity (96% for cystoceles, 94% for rectoceles) compared to physical examination 1
• Useful for identifying occult prolapse in compartments not apparent on physical examination and differentiating between cul-de-sac hernias and rectoceles 1

CT Pelvis

• CT is NOT recommended for routine evaluation of bladder prolapse, as there is no relevant literature supporting its use for this indication 1
• May be considered only if evaluating for associated complications or ruling out colorectal malignancy in specific clinical scenarios 1

Urodynamic and Functional Testing

Urinary Function Assessment

• Perform uroflowmetry with post-void residual measurement in all patients with voiding symptoms 3
• Obtain urinalysis to rule out infection 3
• Consider renal-bladder ultrasound if there are concerns about upper urinary tract involvement 3
• Urodynamic testing is indicated when voiding disorders are present but is NOT routinely recommended in asymptomatic patients without urinary complaints 3

Bowel Function Assessment

• Evaluate anorectal symptoms through detailed history and physical examination 3
• Additional anorectal testing (manometry, defecography) may be warranted if significant bowel symptoms persist that are not explained by the prolapse findings 3

Additional Workup Considerations

Rule Out Gynecologic Pathology

• Essential to exclude concurrent gynecologic conditions before proceeding with prolapse surgery 3
• Ensure cervical cancer screening is up to date 3
• Consider pelvic ultrasound if abnormal uterine bleeding or pelvic masses are suspected 3

Risk Stratification

• Identify high-grade prolapse (stage 3-4) as a risk factor for recurrence 3
• Document factors that may increase surgical complications: prior pelvic surgery, obesity, chronic cough, connective tissue disorders 3
• Assess for pelvic pain syndromes or hypersensitivity that may complicate surgical outcomes 3

Common Pitfalls to Avoid

• Do not assume all urinary or bowel symptoms are caused by the prolapse—many patients have coexisting conditions requiring separate evaluation 6
• Avoid treating asymptomatic prolapse—only patients with bothersome symptoms or medical indications should be offered treatment 5, 6
• Do not routinely order urodynamics in patients without urinary complaints, as this adds cost without changing management 3
• Recognize that physical examination may underestimate prolapse severity compared to dynamic imaging, particularly for posterior compartment defects 1