From the Guidelines
To assess for vaginal prolapse, perform a thorough physical examination with the patient in the lithotomy position, both at rest and during a Valsalva maneuver, and consider imaging tests such as MR defecography or fluoroscopy cystocolpoproctography if clinical evaluation is difficult or considered inadequate. The physical examination should begin with 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 while asking the patient to bear down. The Pelvic Organ Prolapse Quantification (POP-Q) system is the standard method for objectively measuring prolapse, which involves measuring specific points in the vagina relative to the hymen 1. These measurements classify prolapse into stages 0-4, with stage 0 being no prolapse and stage 4 being complete eversion. During the examination, assess for specific types of prolapse including cystocele (anterior wall), rectocele (posterior wall), uterine prolapse, or vaginal vault prolapse (in women who've had hysterectomies) 1. Also evaluate pelvic floor muscle strength by asking the patient to contract these muscles around your examining fingers. A thorough assessment should include questions about associated symptoms such as pelvic pressure, urinary or bowel dysfunction, and impact on quality of life.
Key Points to Consider
- The initial evaluation of patients with pelvic floor dysfunction is clinical, with history and physical examination forming key elements of patient evaluation 1.
- Imaging tests such as MR defecography or fluoroscopy cystocolpoproctography may be necessary when clinical evaluation is difficult or considered inadequate 1.
- MR defecography allows for comprehensive anatomic and functional evaluation of the entire pelvic floor and is one of the initial imaging tests of choice for evaluation of a vaginal protrusion or bulge or clinically suspected pelvic organ prolapse 1.
- Fluoroscopy cystocolpoproctography demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colpocele, rectocele, and peritoneocele and is an initial imaging test in the setting of posterior compartment prolapse 1.
Imaging Tests
- MR defecography: allows for comprehensive anatomic and functional evaluation of the entire pelvic floor and is one of the initial imaging tests of choice for evaluation of a vaginal protrusion or bulge or clinically suspected pelvic organ prolapse 1.
- Fluoroscopy cystocolpoproctography: demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colpocele, rectocele, and peritoneocele and is an initial imaging test in the setting of posterior compartment prolapse 1.
Physical Examination
- Visual inspection of the vaginal opening
- Speculum examination of each vaginal wall
- Assessment of pelvic floor muscle strength
- Use of the Pelvic Organ Prolapse Quantification (POP-Q) system to objectively measure prolapse 1.
Associated Symptoms
- Pelvic pressure
- Urinary or bowel dysfunction
- Impact on quality of life
- Questions about associated symptoms should be included in the thorough assessment to determine the severity of prolapse and guide appropriate treatment options 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, 4
- 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 5
Key Findings
- Prolapse-associated symptoms are poorly correlated with pelvic organ prolapse diagnosis, but the presence of a vaginal bulge is moderately to well correlated with the stage of prolapse 5
- A higher stage of pelvic organ prolapse and levator ani muscle avulsion are major risk factors for recurrence or treatment failure 5
- Treatment options should be tailored to meet the patient's medical health and personal functional goals 6
Examination Techniques
- A systematic approach to the female pelvic examination is necessary to accurately identify anatomic landmarks and defects in pelvic support 4
- Knowledge and awareness of normal anatomic landmarks will improve a clinician's ability to identify defects in pelvic support and allow for better diagnosis and treatment of pelvic organ prolapse 4