Degrees of Cystocele and Rectocele
Cystocele Grading Systems
Cystoceles are graded using either the Baden-Walker classification (Grades I-IV) or the more standardized Pelvic Organ Prolapse Quantification (POP-Q) system (Stages 0-IV), with Grade/Stage III-IV representing high-grade prolapse where the bladder descends below the level of the pubic symphysis. 1
Baden-Walker Classification for Cystocele:
- Grade I: Bladder descends halfway down the vaginal canal 2
- Grade II: Bladder reaches the vaginal introitus (opening) 2
- Grade III: Bladder protrudes beyond the vaginal introitus 1
- Grade IV: Maximum protrusion with complete eversion of the vagina 1, 3
POP-Q System Correlation:
- Stage 0: No prolapse 1
- Stage I: Leading edge more than 1 cm above the hymen 1
- Stage II: Leading edge within 1 cm of the hymen (proximal or distal) 1
- Stage III: Leading edge more than 1 cm beyond the hymen but not completely everted 1
- Stage IV: Complete vaginal eversion 1
The POP-Q system is more precise and reproducible than Baden-Walker, using specific anatomical landmarks measured in centimeters relative to the hymenal ring. 4
Rectocele Grading
Rectoceles are also graded using the Baden-Walker/Beecham classification (Grades I-III) or the POP-Q system, measuring the posterior vaginal wall descent. 4, 5
Beecham/Baden-Walker Classification for Rectocele:
- Grade I: Rectum descends halfway down the vaginal canal 5
- Grade II: Rectum reaches the vaginal introitus 5
- Grade III: Rectum protrudes beyond the vaginal introitus 4, 6
Clinical Significance:
Symptomatic Grade 3-4 rectoceles that fail conservative management may require surgical intervention, though the correlation between anatomical grade and symptoms is often weak. 4, 6
Imaging Assessment
MR defecography and colpocystoproctography (CCP) provide superior assessment of prolapse severity compared to physical examination alone, with CCP showing 96% sensitivity for cystoceles and 94% for rectoceles. 4
Key Imaging Findings:
- Cystocele on imaging: Bladder descent measured relative to the pubococcygeal line or pubic symphysis 4
- Rectocele on imaging: Anterior rectal wall herniation into the posterior vaginal wall, with barium retention indicating clinically significant defects 4
- Functional assessment: Dynamic imaging during straining and defecation reveals prolapse that may not be apparent on static examination 4
Important Clinical Caveats
Physical examination may miss up to 17% of cystoceles and 23% of rectoceles detected on imaging, while imaging may detect clinically occult prolapse that doesn't require treatment. 4
High-grade cystoceles (Grade III-IV) are typically associated with multiple defects including central defects, lateral defects (paravaginal), and urethral hypermobility, requiring comprehensive surgical repair addressing all components. 1, 3
Asymptomatic Grade 1-2 prolapse does not require surgical intervention and should be managed conservatively with pelvic floor biofeedback therapy. 4, 6