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 Valsalva maneuver, and consider imaging tests such as MR defecography or fluoroscopy cystocolpoproctography if clinical evaluation is difficult or considered inadequate. Begin with visual inspection of the vaginal opening, noting any tissue protruding beyond the hymenal ring 1. Then use a speculum to examine each vaginal wall separately while asking the patient to bear down. The POP-Q (Pelvic Organ Prolapse Quantification) system is the standard classification method, which measures specific points in the vagina relative to the hymen 1. This system grades prolapse from stage 0 (no prolapse) to stage 4 (complete eversion). 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 1. A thorough assessment should include evaluation of pelvic floor muscle strength through digital examination.
Key Components of Assessment
- Visual inspection of the vaginal opening
- Speculum examination of each vaginal wall
- Use of the POP-Q system for classification
- Identification of affected compartments
- Evaluation of pelvic floor muscle strength
- Consideration of symptoms and their impact on quality of life
Imaging Tests
Imaging tests such as MR defecography or fluoroscopy cystocolpoproctography may be necessary if clinical evaluation is difficult or considered inadequate 1. MR defecography allows for comprehensive anatomic and functional evaluation of the entire pelvic floor, while fluoroscopy cystocolpoproctography provides functional evaluation in the physiologic upright seated positioning. The choice of imaging test depends on the specific clinical scenario and the availability of resources.
Importance of Comprehensive Assessment
A comprehensive approach to assessing vaginal prolapse is essential for proper classification of the prolapse type and severity, which guides appropriate management decisions 1. This approach should include a thorough physical examination, evaluation of symptoms, and consideration of imaging tests if necessary. By prioritizing a comprehensive assessment, healthcare providers can ensure that patients receive optimal care and management for their vaginal prolapse.
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