Diagnosing Pelvic Organ Prolapse with Pelvic Floor Examination
The initial evaluation of pelvic organ prolapse begins with a systematic physical examination using a standardized quantification system—either the Pelvic Organ Prolapse Quantification (POP-Q) or Simplified POP (S-POP) system—as these are the only methods with sufficient reproducibility for clinical use. 1
Essential Examination Technique
Patient Positioning and Preparation
- Perform the examination with an empty bladder 1
- Begin with the patient in the supine position, but if prolapse cannot be adequately demonstrated, repeat the examination with the patient standing to observe maximum extent of prolapse 1, 2
- The standing examination is particularly valuable as it best reveals the maximum extent of pelvic organ prolapse 2
Systematic Assessment of Compartments
Evaluate all three vaginal compartments systematically 3:
- Anterior compartment: Look for cystocele (bladder descent) and/or urethrocele (urethral descent)
- Apical compartment: Assess for uterine/cervical prolapse or vaginal vault prolapse (in post-hysterectomy patients)
- Posterior compartment: Identify rectocele (rectal wall bulging into vagina)
Key Measurements During Examination
Measure the genital hiatus and perineal body both at rest AND during maximal straining, as these measurements assess different aspects of pelvic floor function 2. Values are consistently higher with maximal strain compared to rest 2.
Internal points can be measured with or without a speculum—there is no significant difference except for total vaginal length (TVL) 2.
Critical Clinical Correlation
The most reliable symptom correlating with POP diagnosis is the patient's report of a vaginal bulge (moderate to good correlation), while other prolapse-associated symptoms correlate poorly with examination findings 4. Physical examination detects only 83% of cystoceles, 77% of rectoceles, and 51% of enteroceles compared to imaging studies 3.
When Physical Examination is Insufficient
Imaging should be obtained when 3:
- Clinical evaluation is difficult or inadequate
- Patients present with persistent or recurrent prolapse after treatment
- There is need to differentiate between cul-de-sac hernias and rectoceles (both present as posterior vaginal bulge)
- Occult pelvic floor disorders in other compartments need evaluation
Imaging Modalities (When Indicated)
MR defecography and fluoroscopic cystocolpoproctography (CCP) are the imaging tests of choice for comprehensive evaluation when physical examination is inadequate 3:
- CCP detects 96% of cystoceles, 94% of rectoceles, but only 35% of enteroceles compared to physical examination 3
- MR defecography shows best agreement with physical examination for anterior compartment prolapse (85%), compared to middle compartment (63%) and posterior compartment (79%) 3
- MR defecography is particularly beneficial for detecting or differentiating enteroceles, as physical examination misdiagnoses 10% of enteroceles as rectoceles 3
Common Pitfalls to Avoid
- Do not rely solely on patient symptoms to diagnose or exclude POP—physical examination is essential 1, 4
- Do not perform examination only in supine position if prolapse is not adequately demonstrated—standing examination is critical 2
- Do not measure genital hiatus and perineal body only at rest—straining measurements provide additional functional information 2
- Do not assume physical examination detects all prolapse—it misses significant percentages of enteroceles and other compartment involvement 3, 4
Additional Considerations for Associated Dysfunction
When urinary symptoms coexist, perform cough stress test with bladder volume of at least 200 mL and with prolapse reduced (using speculum or pessary) 1. Post-void residual >100 mL is commonly used to assess voiding difficulty 1.
Levator ani muscle avulsion, which can be identified on careful pelvic examination, is a major risk factor for POP recurrence and treatment failure and must be documented 4.