How do you differentiate cystocele, rectocele, and uterine (or vaginal vault) prolapse on pelvic examination?

Differentiating Cystocele, Rectocele, and Uterine Prolapse on Pelvic Examination

To distinguish these three types of pelvic organ prolapse on examination, use a speculum to isolate and visualize each vaginal wall compartment separately: anterior wall bulging indicates cystocele, posterior wall bulging indicates rectocele, and descent of the cervix (or vaginal apex if post-hysterectomy) indicates uterine/vault prolapse. 1

Systematic Examination Technique

Patient Positioning and Preparation

• Position the patient in dorsal lithotomy with adequate lighting 1
• Perform examination at rest, during Valsalva maneuver (straining), and during cough to assess maximal descent 2, 1
• Begin with external genital assessment for lesions, trauma, or infection before internal examination 1

Compartment-Specific Assessment

Anterior Compartment (Cystocele):

• Use the posterior blade of the speculum to depress the posterior vaginal wall while examining the anterior wall 1
• Cystocele appears as a bulging of the anterior vaginal wall descending toward or through the introitus 3, 4
• The bladder descends below the pubic symphysis in advanced cases 2
• Ask patient about urinary symptoms: stress incontinence, difficulty emptying bladder, frequent urination, urgency, incomplete voiding, or need for digital splinting to void 2
• Large cystoceles may cause urethral kinking and paradoxical overflow incontinence 4

Posterior Compartment (Rectocele):

• Use the anterior blade of the speculum to retract the anterior vaginal wall while examining the posterior wall 1
• Rectocele manifests as bulging of the posterior vaginal wall protruding anteriorly into the vaginal canal 3, 5
• The bulge pushes the posterior wall downward toward the vaginal hiatus, creating a characteristic "kneeling effect" 5
• Ask about defecatory symptoms: incomplete evacuation of stool, need for vaginal or perineal splinting to defecate 2, 6

Apical Compartment (Uterine/Vault Prolapse):

• Assess the cervix position (or vaginal cuff if post-hysterectomy) relative to the hymenal ring 1, 6
• Uterine prolapse shows descent of the cervix toward or beyond the introitus 6
• In severe (third-degree) prolapse, the cervix protrudes outside the vaginal introitus and patients report a "mass" protruding from the vagina 6
• Patients describe pelvic heaviness, fullness, or low back pain that worsens with exertion and improves with rest 6
• Look for mucosal ulcerations or bleeding from cervical rubbing against clothing in severe cases 6

Critical Clinical Considerations

Multi-Compartment Involvement

• Assess all three compartments systematically, as multi-compartment prolapse is extremely common—uterine prolapse is often associated with concomitant rectocele, cystocele, and/or enterocele 3, 6, 4
• Lateral vaginal wall defects frequently coexist with apical or posterior prolapse and must not be overlooked 1

Levator Muscle Assessment

• Palpate levator ani muscle integrity bilaterally during digital examination, as levator muscle defects predict surgical recurrence and should influence management planning 2, 1
• Levator muscle avulsion can be detected on examination and correlates with imaging findings 2, 1

Common Pitfalls to Avoid

• Failing to examine each compartment separately with proper speculum retraction leads to missed diagnoses 1
• Examining only in supine position without Valsalva maneuver underestimates the true extent of prolapse 2, 1
• Overlooking concomitant urinary or defecatory symptoms that guide compartment-specific assessment 2, 6, 4

When Imaging Is Indicated

Clinical examination is adequate for most straightforward cases, but consider imaging when: 2, 1

• Clinical evaluation is difficult or inadequate
• Symptoms persist despite treatment
• Multi-compartment involvement is suspected but unclear on examination
• Detailed anatomic assessment is needed for surgical planning

Transperineal ultrasound (TPUS) is the preferred first-line imaging modality (not transvaginal ultrasound), providing dynamic functional assessment with 59.6% prediction rate for anterior compartment and 61.5% for posterior compartment prolapse 2, 1