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 Valsalva maneuver, is the initial step, and when imaging is deemed necessary, fluoroscopy CCP or MR defecography is usually appropriate as the initial imaging of a vaginal protrusion or bulge or clinically suspected pelvic organ prolapse.

Initial Assessment

The physical examination should begin with a visual inspection of the vaginal opening for any tissue bulging beyond the introitus. Then, use a speculum to examine each vaginal wall separately while asking the patient to bear down.

Classification and Symptom Assessment

The POP-Q (Pelvic Organ Prolapse Quantification) system is the standard classification method, which measures specific points in the vagina relative to the hymen, grading prolapse from stage 0 (no prolapse) to stage 4 (complete eversion) 1. During the exam, identify which compartments are affected: anterior (cystocele), posterior (rectocele), apical (uterine or vault prolapse), or a combination. Ask about symptoms like pelvic pressure, a bulge sensation, urinary or bowel dysfunction, and sexual difficulties, as symptom severity doesn't always correlate with anatomical findings.

Imaging

When clinical evaluation suggests the need for imaging, fluoroscopy CCP or MR defecography is recommended as the initial imaging 1, with fluoroscopy Cystocolpoproctography (CCP) being one of the imaging tests of choice for evaluation of a protruding or bulging vaginal mass or clinically suspected POP, especially in the setting of posterior compartment prolapse 1. CCP involves fluoroscopic imaging during defecation with the patient sitting in a physiologic upright position on a fluoroscopic commode, allowing for functional evaluation and assessment of barium contrast retention within rectoceles.

Considerations

A standing examination may reveal prolapse not evident in the supine position. This assessment is essential for determining appropriate management, which ranges from conservative approaches like pelvic floor exercises to surgical intervention depending on severity and symptoms. The choice between CCP and other imaging modalities like MR defecography should be based on the specific clinical scenario and the availability of resources.

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.