How do I examine a woman for vaginal and bladder prolapse?

How to Examine for Vaginal and Bladder Prolapse

Physical examination is the cornerstone of diagnosis for vaginal and bladder prolapse, with imaging reserved only for cases where clinical evaluation is inadequate or symptoms persist despite treatment. 1, 2

Essential Components of Physical Examination

Patient Positioning

• Examine the patient in dorsal lithotomy position initially, but consider upright examination (45-degree angle in birthing chair) for more accurate assessment, as 36% of patients with stage 0-I prolapse in lithotomy position demonstrate stage II or greater prolapse when examined upright 3
• Upright positioning increases prolapse measurements by 2 cm or more in 48% of patients 3

Systematic Examination Technique

External genital assessment:

• Inspect for visible lesions, trauma, or infection 4
• Observe for obvious vaginal bulging or protrusion at rest 1, 5

Speculum examination to visualize each compartment separately: 2, 4

• Anterior vaginal wall (bladder/cystocele): Use the posterior blade of the speculum to depress the posterior wall while asking the patient to strain or perform Valsalva maneuver; observe for anterior wall descent below the hymen 6
• Apical compartment (uterus/cervix or vaginal cuff): Assess descent of the cervix or vaginal apex during straining 6
• Posterior vaginal wall (rectocele/enterocele): Use the anterior blade to depress the anterior wall while observing posterior wall descent during straining 6
• Lateral vaginal wall defects: Assess for paravaginal defects, which commonly coexist with apical or posterior prolapse 4

Levator muscle integrity assessment:

• Palpate the levator ani muscles bilaterally to detect defects or avulsion, as these predict surgical recurrence and influence treatment planning 2, 4
• Assess muscle tone and voluntary contraction strength 6

What You Will Feel and See

Cystocele (bladder prolapse):

• A soft, smooth bulge of the anterior vaginal wall that descends during straining 1, 5
• The bulge may be reducible with gentle pressure 5

Uterine/apical prolapse:

• Descent of the cervix or vaginal cuff toward or beyond the hymen 5, 6
• In advanced cases, the cervix or vaginal apex protrudes outside the vaginal opening 5

Rectocele:

• A posterior vaginal wall bulge that may be confirmed by rectal examination 5, 6

Key Symptoms to Query

Document the following symptoms to correlate with examination findings: 1, 2

• Sensation of vaginal bulging or protrusion
• Pelvic pressure or heaviness
• Urinary incontinence, frequency, urgency, incomplete voiding, or need for splinting/digital maneuvers to void
• Bowel dysfunction or constipation requiring digital manipulation
• Sexual dysfunction or dyspareunia

When Imaging Is Indicated

Imaging should only be ordered when: 1, 2, 4

• Clinical examination is difficult or inadequate
• Symptoms persist or recur after treatment
• Multicompartment involvement is suspected and requires comprehensive assessment
• Surgical planning requires detailed anatomic evaluation of pelvic floor muscles and fascia

If imaging is needed, transperineal ultrasound (TPUS) is the preferred first-line modality, as it is non-invasive, less expensive, provides real-time dynamic assessment, and shows 59.6% prediction rate for anterior compartment prolapse with significant correlation to physical examination 7, 1

Critical Pitfalls to Avoid

• Do not fail to assess all compartments, as multicompartment involvement is common and lateral vaginal wall defects often coexist with other prolapse 2, 4
• Do not overlook levator muscle defects, which predict surgical recurrence rates up to 29% and must influence treatment planning 7, 2, 4
• Do not examine only in lithotomy position if prolapse is not evident, as upright examination significantly increases detection rates 3
• Do not order imaging for straightforward cases, as clinical examination is adequate for most diagnoses 1