How to assess for pelvic organ prolapse (POP)?

From the Guidelines

To assess for vaginal prolapse, a thorough physical examination with the patient in the lithotomy position, both at rest and during a Valsalva maneuver, is the initial step, followed by imaging with fluoroscopy CCP or MR defecography if deemed necessary after clinical evaluation, as these procedures are equivalent alternatives for providing the necessary clinical information 1. When performing the physical examination, begin with a visual inspection of the vaginal opening, looking for any tissue bulging beyond the vaginal introitus. Then, use a speculum to examine each vaginal wall separately - anterior, posterior, and apical - while asking the patient to bear down. The POP-Q (Pelvic Organ Prolapse Quantification) system is the standard classification method, which measures specific points relative to the hymen to determine prolapse severity on a scale from stage 0 (no prolapse) to stage 4 (complete eversion).

Some key points to consider during the examination include:

• Assessing for stress urinary incontinence by having the patient cough with a full bladder
• Evaluating pelvic floor muscle strength by asking the patient to contract these muscles around your examining fingers
• Asking questions about symptoms like pelvic pressure, vaginal bulging, urinary or bowel dysfunction, and sexual difficulties, as symptoms don't always correlate with anatomical findings
• Considering the use of imaging tests like fluoroscopy CCP, which involves dynamic imaging during defecation with the patient sitting in a physiologic upright position on a fluoroscopic commode, and has been shown to demonstrate good agreement with surgical findings for detection of certain types of prolapse 1

The choice of imaging test, if necessary, should be based on the specific clinical presentation and the need for functional evaluation in the physiologic upright seated positioning, with fluoroscopy CCP being one of the imaging tests of choice for evaluation of a protruding or bulging vaginal mass or clinically suspected pelvic organ prolapse 1.

From the Research

Assessment of Vaginal Prolapse

To assess for vaginal prolapse, the following steps can be taken:

• A thorough history and physical examination are essential for diagnosing vaginal prolapse 2, 3, 4.
• The physical examination should include an evaluation of the anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff scar after hysterectomy), and posterior vaginal wall 2, 3, 5.
• Additional testing may be indicated for evaluation of bowel and bladder symptoms 2, 3.
• A pelvic examination can confirm the presence of pelvic organ prolapse and identify risk factors for treatment failure or recurrence after surgical management or pessary placement 6.

Key Factors to Consider

When assessing for vaginal prolapse, the following factors should be considered:

• The presence of a vaginal bulge or pressure, bladder, bowel, or sexual symptoms 2, 3.
• The stage of prolapse, as a higher stage is associated with a greater risk of recurrence or treatment failure 6.
• The presence of levator ani muscle avulsion, which is a major risk factor for POP recurrence or treatment failure 6.
• Vaginal and genital measurements, which can help identify risk factors for treatment failure or recurrence 6.

Examination Techniques

The following examination techniques can be used to assess for vaginal prolapse:

• Vaginal speculum examination to visualize the vaginal walls and cervix 6, 5.
• Digital vaginal examination to assess the vaginal walls, cervix, and uterus 6, 5.
• A systematic approach to the female pelvic examination, including anatomic landmarks of the external genitalia, vagina, and uterus 5.