What is the appropriate physical examination method to assess uterine prolapse?

Physical Examination of Uterine Prolapse

Examination Position and Technique

The physical examination for uterine prolapse should be performed in the dorsal lithotomy position with the patient performing maximal Valsalva maneuver, as this adequately reveals the degree of prolapse without routinely requiring examination in the standing position. 1

• Examination in dorsal lithotomy with maximal Valsalva shows excellent correlation (R values 0.96–0.98) with standing examination for all six vaginal prolapse measurement points 1
• The stages of prolapse are identical in 94% of patients (48 of 51) between dorsal lithotomy and standing positions 1
• When upright examination is performed, 70% of patients have the same stage, 26% have a higher stage, and only 4% have a lower stage compared to lithotomy 2

Enhanced Detection Techniques

For patients with stage I or II prolapse on routine examination, adding cervical traction during POP-Q assessment reveals maximal prolapse and upstages 70.5% of patients (61.5% by one stage, 9.0% by two stages) at an acceptable pain level. 3

• Cervical traction examination causes VAS pain scores ≥5 in 39.7% of women, compared to only 2.6% with standing examination, but remains acceptable to patients 3
• The median point C measurement changes from -5 cm at routine examination to -0.5 cm with cervical traction, revealing significantly more apical descent 3

Standardized Assessment System

All examinations must use the Pelvic Organ Prolapse Quantification (POP-Q) system to document nine site-specific measurements and assign summary stages. 4, 2

• The six key vaginal prolapse points (Aa, Ba, C, Ap, Bp, D) must be measured at rest and during maximal Valsalva 2, 1
• Total vaginal length, perineal body, and genital hiatus measurements are performed at rest in dorsal lithotomy 1
• Assessment must evaluate all three compartments: anterior (bladder/cystocele), middle (uterus/apical), and posterior (rectum/rectocele) 4

Essential Components of Physical Examination

The examination must include external genital assessment, speculum examination of each vaginal wall compartment separately, and assessment of levator muscle integrity. 4, 5

• Levator muscle defects predict surgical recurrence after repair and must influence treatment planning 4, 5
• Document symptoms of pelvic pressure, vaginal bulge sensation, urinary dysfunction, bowel dysfunction, or sexual dysfunction 4
• Assess for lateral vaginal wall defects, which often coexist with apical or posterior prolapse and are frequently missed 4, 5

Clinical Pitfalls to Avoid

• Do not fail to assess all compartments—multicompartment involvement is common, and missing lateral wall defects leads to incomplete diagnosis 4, 5
• Do not overlook levator muscle defects—these predict up to one-third of surgical failures and should be documented 6, 4
• Do not rely solely on lithotomy examination in borderline cases—consider cervical traction or standing examination when clinical suspicion exceeds findings, as 36% of stage 0-I patients are actually stage II or greater when examined upright 3, 2
• Do not proceed with prolapse treatment in perimenopausal women with abnormal bleeding before performing endometrial sampling to exclude hyperplasia or malignancy 4

When Imaging Is Indicated

• Imaging is necessary when clinical evaluation is difficult or inadequate, symptoms persist or recur after treatment, or comprehensive multicompartment evaluation is needed 4
• Transperineal ultrasound (TPUS) is the preferred first-line imaging modality, offering non-invasive real-time functional assessment with 59.6% sensitivity for anterior compartment, 61.5% for posterior, but only 32.6% for middle compartment 4, 5
• MR defecography is reserved for comprehensive evaluation when TPUS is insufficient, showing 85% agreement with physical exam for anterior compartment, 79% for posterior, and superior detection of enteroceles (45% of exam-visible enteroceles vs. only 30% detected by exam alone) 6, 7