Differentiating Cystocele from Rectocele on Physical Examination
To distinguish between a cystocele and rectocele on exam, assess which vaginal wall is bulging: a cystocele presents as an anterior vaginal wall bulge (bladder herniation), while a rectocele presents as a posterior vaginal wall bulge (rectal herniation). 1, 2
Examination Technique for Cystocele (Anterior Compartment)
- Position the patient supine and perform a speculum examination or use the posterior blade of a speculum to depress the posterior vaginal wall while asking the patient to perform a Valsalva maneuver 1
- Observe for anterior vaginal wall descent below the hymenal ring, which indicates bladder prolapse through the anterior vaginal wall 1
- Look for an anterior vaginal wall groove on examination, which can help distinguish cystourethrocele (Green type II) from isolated cystocele (Green type III) 3
- Palpate the anterior vaginal wall to feel the bladder bulging forward into the vaginal canal 1
Examination Technique for Rectocele (Posterior Compartment)
- Position the patient in left lateral decubitus position with buttocks separated, which is the recommended position by the American College of Radiology for optimal assessment 2
- Perform a digital rectal examination while specifically observing for perineal descent during simulated defecation 2
- Palpate for posterior vaginal wall bulging during the rectal examination, which is the hallmark finding of rectocele 2
- Instruct the patient to "expel my finger" to assess expulsionary forces and observe for posterior vaginal wall protrusion 2
- Assess resting sphincter tone and puborectalis muscle contraction during squeeze maneuvers 2
Key Distinguishing Features
- Anatomic location is the primary differentiator: cystocele involves the anterior vaginal wall (bladder side), while rectocele involves the posterior vaginal wall (rectal side) 1, 2
- Associated symptoms differ: cystocele patients typically report urinary symptoms including stress incontinence or overflow incontinence with large cystoceles, while rectocele patients report obstructive defecation symptoms, incomplete evacuation, and may require digital disimpaction maneuvers 2, 4, 5
- Both conditions commonly coexist in postmenopausal women with vaginal childbirth history, so examine all compartments systematically 6, 5
Critical Clinical Caveat
- Physical examination alone has significant limitations: clinical exam detects only 7% of rectoceles compared to imaging studies, and a normal digital rectal examination does not exclude rectocele 2
- If symptoms persist despite negative examination findings, or if multicompartment involvement is suspected, consider imaging with MR defecography (comprehensive evaluation) or transperineal ultrasound for anterior compartment assessment 1, 2, 6
- Always assess for occult prolapse in other compartments, as surgical planning may require addressing multiple compartments simultaneously 6