What are the diagnostic approaches for rectal prolapse and bladder prolapse (cystocele)?

From the Guidelines

Diagnosing rectal and bladder prolapse requires a thorough physical examination and sometimes imaging studies, with cystocolpoproctography (CCP) being one of the initial imaging tests of choice for evaluation of defecatory dysfunction and pelvic organ prolapse (POP) 1. The diagnosis of rectal prolapse typically begins with a visual inspection of the anus during straining, where the doctor may observe rectal tissue protruding through the anal opening. A digital rectal examination helps assess sphincter tone and rule out other conditions.

• Defecography, which involves taking X-rays after introducing contrast material into the rectum, can visualize the prolapse during defecation.
• For bladder prolapse (cystocele), the diagnosis involves a pelvic examination where the patient may be asked to bear down while the doctor observes for bulging of the anterior vaginal wall.
• A voiding cystourethrogram may be performed to assess bladder function and position.
• Urodynamic testing can evaluate bladder function and identify any associated urinary symptoms.
• MRI provides detailed images of pelvic organs and supporting structures, and MR defecography is beneficial in detecting or characterizing enteroceles as a cause of posterior vaginal bulge 1. Both conditions often require a multidisciplinary approach involving gastroenterologists, gynecologists, and urologists, as they frequently coexist with other pelvic floor disorders.
• Early diagnosis is important as treatment is more effective in earlier stages, ranging from conservative measures like pelvic floor exercises to surgical repair depending on severity.
• CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colpocele, rectocele, and peritoneocele, and excellent correlation for detection of internal rectal prolapse (intrarectal and intra-anal) 1. The choice of imaging modality depends on the specific clinical presentation and the availability of imaging facilities, with CCP being a useful initial imaging test for evaluating defecatory dysfunction and POP 1.
• MR defecography has moderate to good correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele 1. In summary, a combination of physical examination and imaging studies, including CCP and MR defecography, is essential for accurate diagnosis and management of rectal and bladder prolapse, with the goal of improving morbidity, mortality, and quality of life outcomes 1.

From the Research

Rectal Prolapse Diagnostics

• Rectal prolapse can be diagnosed through a physical exam, colonoscopy, anoscopy, and in some cases, anal manometry and defecography 2.
• The diagnosis of rectal prolapse is often associated with a range of symptoms including pain, incomplete evacuation, bloody and/or mucous rectal discharge, and fecal incontinence or constipation 2, 3.
• Digital rectal examination can be used to identify rectovaginal septal defects, including rectocele, with moderate agreement between digital rectal examination and translabial ultrasound findings 4.

Bladder Prolapse Diagnostics

• Bladder prolapse, also known as cystocele, can be diagnosed through physical examination, with the Baden-Walker grading system used to assess the severity of the prolapse 5.
• Dynamic pelvic magnetic resonance imaging (dMRI) can be used to evaluate pelvic organ prolapse, including bladder prolapse, with good correlation between dMRI findings and physical examination findings for anatomically significant prolapse in the anterior compartment 5.
• dMRI may be superior to physical examination for detecting enteroceles and distinguishing them from rectoceles, particularly in cases where the presence of an enterocele is unclear in the apical and/or posterior compartments 5.

Combined Rectal and Bladder Prolapse Diagnostics

• Rectal and bladder prolapse often coexist with other pelvic floor disorders, and patients may have symptoms associated with combined rectal and genital prolapse 3, 6.
• A comprehensive diagnostic evaluation, including physical examination, imaging studies, and other tests, is necessary to accurately diagnose and manage combined rectal and bladder prolapse 2, 6, 5.