Version May 2024
INTRODUCTION — Pelvic organ prolapse (POP) includes defects of the anterior, apical, and posterior vaginal wall. Defects of pelvic support often do not occur in isolation. As an example, one series of 384 women undergoing surgical repair of POP reported the following types and frequencies of defects: anterior compartment only (40 percent), posterior compartment only (7 percent), apex only (6 percent), anterior and posterior compartments (16 percent), anterior compartment and apex (9 percent), posterior compartment and apex (5 percent), and all three compartments (18 percent) [1].
Posterior vaginal defects may be associated with:
●Rectocele (anterior protrusion of the rectum)
●Sigmoidocele (protrusion of the sigmoid colon)
●Enterocele (protrusion of the small bowel)
These entities can be difficult to distinguish on physical examination. Pelvic floor fluoroscopy has confirmed that there is no correlation between the fluoroscopic position of the small bowel or rectum and any apical or posterior wall POP site [2]. Furthermore, the degree of anatomic distortion often does not correlate with functional impairment [3].
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
RISK FACTORS — The risk factors for posterior vaginal defects are the same as for general pelvic organ prolapse. The most common risk factors for any form of vaginal prolapse are vaginal childbirth, advancing age, and increasing body mass index. The impact of cesarean birth is less clear. Other risk factors include chronically elevated intra-abdominal pressure and collagen vascular disease. The role of hysterectomy is unclear for posterior vaginal defects, but may be involved in apical prolapse. Prolapse risk factors are presented in detail elsewhere.
●(See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)
CLINICAL MANIFESTATIONS — Symptoms commonly associated with posterior POP include splinting, pelvic pressure, constipation, sexual dysfunction, fecal incontinence, and defecatory dysfunction. Of note, increasing severity of prolapse does not necessarily correlate with increased symptomatology [4,5].
●Splinting – The need to splint, or place manual pressure on the vagina, rectum, or perineum, to defecate is the most specific symptom of posterior vaginal prolapse [4,6]; however, many women with rectoceles do not have this symptom, and women without rectoceles may require splinting in order to defecate [5]. Infrequent defecation is not likely related to a rectocele and may require additional evaluation.
●Pelvic pressure – Another common symptom of prolapse is a sensation of pelvic pressure/heaviness or protrusion of tissue from the vagina. Patients frequently describe this as feeling like they are sitting on an egg or complain of low backache or heaviness. This feeling is usually relieved by lying down, is less noticeable in the morning, and worsens as the day progresses. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)
●Constipation – Many women state that they are constipated; it is important to determine whether they are referring to excessive straining, hard lumpy stools, splinting, feeling of incomplete emptying, or infrequent stools. Women with a large rectocele may trap stool within this rectal pocket, which may lead to a feeling of incomplete emptying, and possibly soiling. (See "Etiology and evaluation of chronic constipation in adults", section on 'Evaluation'.)
●Sexual dysfunction – Sexual dysfunction is also a common complaint of women with pelvic floor disorders. One study reported patients with increasing severity of prolapse and detrusor instability were less likely to be sexually active compared with patients with stress incontinence or mixed incontinence, but overall sexual satisfaction was independent of diagnosis or therapy for urinary incontinence or prolapse [7]. Another study noted that women with prolapse and urinary incontinence did not differ significantly from continent women without prolapse in terms of sexual function, although increasing age correlated with worse sexual function [8]. Increasing prolapse severity predicted interference with sexual activity, but did not affect frequency of intercourse or sexual satisfaction. Patients may also complain of a sensation of vaginal laxity. (See "Sexual function in females with pelvic floor and lower urinary tract disorders", section on 'Impact on sexual function'.)
●Fecal incontinence – The rate of fecal incontinence in patients who present to urogynecology clinics ranges from 16 to 54 percent [9,10]. In one population-based study of women aged 50 years and older, the age-adjusted prevalence of fecal incontinence alone was 15 percent, urinary incontinence alone was 48 percent, and combined urinary and fecal incontinence was 9 percent [11]. It is not surprising that fecal incontinence is associated with prolapse, as both disorders share similar risk factors, such as obstetric trauma and advanced age [12]. Nevertheless, a cause and effect relationship between fecal incontinence and posterior vaginal prolapse has not been proven, and studies have not shown a consistent correlation between fecal incontinence and severity of prolapse. Because many women are reluctant to initiate a conversation about anal incontinence due to embarrassment, it is important to ask about accidental loss of solid or liquid stool or gas. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Evaluation'.)
●Defecatory dysfunction – Defecatory dysfunction refers to difficulty with defecation, but excludes fecal incontinence. While the etiology is often multifactorial, posterior vaginal wall defects can contribute to symptoms. In addition, systemic causes include diabetes mellitus, thyroid disorders, and neuromuscular diseases. Drug-related causes include beta blockers, calcium channel blockers, anticholinergics, antidepressants, nonsteroidal anti-inflammatory drugs, iron sulfate, aluminum antacids, and opiates. Mechanical obstruction from Hirschsprung's disease, malignancy, or inflammatory bowel disease, and psychiatric conditions, such as dementia, anorexia, and depression, can also affect bowel function. Insufficient fiber or fluid intake may be contributing factors [13]. (See "Etiology and evaluation of chronic constipation in adults".)
DIAGNOSIS — The diagnosis of posterior wall defects is clinical and based on physical examination findings of a posterior vaginal bulge with straining and palpation of breaks in the rectovaginal fascia on rectovaginal examination (figure 1 and picture 1 and figure 2).
EVALUATION — The diagnostic evaluation consists mainly of a history and physical examination. Women whose symptoms are not consistent with examination findings or who have recurrent posterior vaginal wall defects may benefit from imaging assessment as well. Imaging is not routinely used in the evaluation of posterior wall defects as the diagnosis is mainly clinical.
History — A history evaluates for the main clinical manifestations associated with posterior POP, including splinting, pelvic pressure, constipation, sexual dysfunction, fecal incontinence, and defecatory dysfunction (see 'Clinical manifestations' above). Women often do not volunteer information regarding these problems unless directly asked. Prolapse is asymptomatic or associated with only mild symptoms in many women. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Symptom and medical history'.)
Prolapse-related symptoms tend to become bothersome when the prolapse extends beyond the hymenal ring [14]. As an example, a 4 year prospective study of 260 women reported that worsening of vaginal descent over time was associated with increased pelvic floor symptoms [15]. Increasing apical descent was associated with symptomatic prolapse and increasing posterior descent was associated with obstructive bowel complaints (eg, splinting or straining to defecate or incomplete bowel emptying). A threshold effect was seen when the leading edge of the vaginal prolapse approached the hymen.
In addition, women are asked about symptoms or urinary or fecal incontinence. While neither are symptoms of prolapse, both can occur in women with POP since all three disorders share some of the same risk factors (eg, prior vaginal birth). In addition, women who are considering surgical correction of a posterior vaginal defect typically want to pursue surgical correction of the other symptoms at the same time.
Physical examination — The examination of a rectocele includes assessment of the anatomy and confirmation of prolapse, evaluation of the perineal body and posterior vaginal wall, performance of a focused neurologic examination, and examination of the anal sphincter.
Pelvic examination — The woman is generally examined in the dorsal lithotomy or semirecumbent position. There is good correlation between the degree of prolapse in the supine and standing positions during maximal Valsalva [16], but prolapse is still more evident in the upright position [17]. Therefore, if the degree of prolapse observed in the lithotomy position is not consistent with the patient's description of her symptoms, a standing examination should be performed. However, it is physically more difficult to make measurements of prolapse in this position.
We use the following approach to determine the severity of prolapse:
●Visualize the posterior vaginal wall – A speculum, or single retractor, is used to elevate the anterior wall and reduce any uterine or apical prolapse.
•A Sims retractor or the posterior blade of a bivalve speculum inserted into the vagina allows gentle pressure on the anterior vaginal wall to isolate visualization of the posterior vaginal wall.
•If the posterior blade of a bivalve speculum is used, the device is rotated 180 degrees and used to elevate the anterior vaginal wall.
●Increase abdominal pressure – The patient is asked to increase abdominal pressure with a Valsalva maneuver or cough. The stage of prolapse (Stage 0-IV) (figure 3A-B) is described using the pelvic organ prolapse quantification (POP-Q) system, a standardized, validated tool for measuring and staging POP (figure 4A-B) [18]. Evaluation and staging of concurrent anterior wall and apical prolapse should also be performed, so that they may be addressed at the time of surgery. (See "Pelvic organ prolapse in women: Diagnostic evaluation".)
●Evaluate descent of perineal body – The perineal body should be evaluated for descent. This may be difficult to measure, but documentation of its presence or absence can be helpful in planning surgery. Descent of the perineal body occurs from lack of continuity of suspensory support from the apex (level I) to the perineal body (level III) (figure 5); pudendal neuropathy may also play a role. It also may result from a mass effect of the rectum or small bowel herniating into the perineal body (perineocele). Fecal incontinence may be an associated finding [19].
●Perform rectovaginal examination – The posterior vaginal wall and perineal body are best evaluated by rectovaginal examination. This is typically performed in the outpatient setting and repeated in the operative setting if the patient undergoes surgical correction.
•Rectocele – The diagnosis of rectocele is confirmed if the areas of anterior rectal wall bulging and posterior wall prolapse are the same.
•Enterocele – An enterocele should be suspected if loops of small bowel can be palpated, and a sigmoidocele should be suspected if sigmoid colon is palpated. Performing a rectovaginal examination in the standing position may improve detection of an enterocele by allowing the bowel to enter the enterocele sac. Revaluation for enterocele should be performed in the operating room (if the patient undergoes surgical repair) because if an enterocele is missed, posterior wall prolapse may persist following surgical management. Many surgeons elevate the rectal finger up to the posterior vaginal wall to identify an area with less support, although the preoperative clinical examination is less accurate than surgical identification of site-specific defects of the posterior vaginal wall (figure 2) [20,21].
•Rectal prolapse or intussusception – Finally, pressure on the posterior wall of the vagina, directed downward toward the rectum, may facilitate identification of rectal prolapse or intussusception.
Focused neurologic examination — In addition to the physical examination described above, a focused neurologic examination is performed to identify abnormalities that may contribute to rectocele. Although the detection rate of neurologic abnormalities is low in the absence of a history of neurologic disease, women with an abnormal focused neurologic examination should then undergo a complete neurologic examination [22].
This focused neurologic examination includes evaluation of perineal sensation, pelvic floor motor function, and sacral nerves 2-4. To assess sensation, the patient is asked to discriminate between sharp and dull stimuli on the vulva, perineum, and inner thighs bilaterally. Motor function is assessed by the examiner placing one or two fingers intravaginally and asking the patient to contract and relax the pelvic floor muscles around the examiner's fingers. Lastly, assessment of sacral nerves 2 to 4 includes assessment of the bulbocavernosus reflex and anal wink.
Assessment of anal sphincter — As anal incontinence commonly occurs in the presence of a rectocele because they share similar risk factors, the anal sphincter is examined as part of the rectocele evaluation. The anal sphincter is palpated and assessed for tone, squeeze, symmetry and/or disruption. On digital rectal examination, the examiner should feel the external anal sphincter contract concentrically and the anal verge should be pulled inward [23]. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Physical examination'.)
Assessment of urinary incontinence — Clinically, screening for stress urinary incontinence can be performed as part of the patient's initial evaluation with a supine cough stress test, office cystometry, or urodynamic evaluation. In our practice, we ask the patient, with a full bladder, to stand with her legs slightly spread and then Valsalva or cough as hard as possible. Demonstrable urine loss with this maneuver is considered a positive cough stress test and may indicate the presence of stress urinary incontinence. A similar test may be performed in the supine position with office cystometry with retrograde filling of the bladder. Urodynamic testing may also be helpful, especially in the setting of urge symptoms suggesting detrusor overactivity or mixed incontinence, or patients who have undergone prior incontinence surgery. Assessment of urinary incontinence symptoms preoperatively will aid in planning a concomitant anti-incontinence procedure at the time of prolapse repair. (See "Female urinary incontinence: Evaluation", section on 'Evaluation'.)
In contrast to the patients who present preoperatively with simultaneous complaints of urinary incontinence and prolapse, others may develop de novo urinary incontinence postoperatively. Posterior wall defects may compress the urethra and thereby mask stress urinary incontinence, which has been termed occult stress incontinence. There is no certain method for assessing for occult stress incontinence. Gentle reduction of the posterior vaginal wall into its correct anatomic position at the time of Valsalva or cough may demonstrate the previously occult stress urinary incontinence. During urodynamics, simulating correction of the prolapse may also cause women to demonstrate stress incontinence or to have an increase in leak volumes. If occult stress urinary incontinence is uncovered, then this should be factored into preoperative surgical recommendations and surgical planning.
Imaging — Because clinical examination is the main diagnostic modality for posterior vaginal defects, radiologic confirmation of the presence or absence of a rectocele is not typically performed. Women who may benefit from imaging are those whose physical examination findings that do not correlate with symptoms or women with recurrent posterior wall prolapse. There is no standardized method of establishing a radiological diagnosis of a rectocele; however, a number of imaging techniques have been used.
Defecography — Defecography provides a two-dimensional view of the efficiency of rectal emptying and quantification of rectal parameters. The size of the rectocele is determined by measuring the distance between the line of the anterior border of the anal canal and the maximal point of the bulge of the anterior rectal wall into the posterior vaginal wall [24]. Anything less than 2 cm is considered normal, while a rectocele is considered large if the anterior rectal wall protrudes more than 3.5 cm [25,26]. Defecography performed following surgical management of rectoceles has generally shown a reduction in the size of the rectocele and improvement in emptying. The American Gastroenterological Association (AGA) guideline for anorectal testing techniques (see section on Evacuation proctography [defecography]) [27], as well as other AGA guidelines, can be accessed through the AGA website.
Rectoceles that retain contrast tend to be larger than those that do not [28]. However, fluoroscopic evidence of barium trapping does not correlate well to patient symptoms. In the symptomatic, older adult population, one study found no association between the abnormalities demonstrated by defecography and symptoms [29].
Defecation is achieved through the coordination of relaxation of the levator ani and external anal sphincter and contraction of the colon. If the puborectalis or external anal sphincter is paradoxically contracted during defecation (pelvic floor dyssynergia), then conservative measures, such as enemas or biofeedback, may be more therapeutic than surgery. An electrophysiologic analysis of the puborectalis during anal manometry or defecography may help in diagnosing pelvic floor dyssynergia. The clinician may suspect pelvic floor dyssynergia in patients who complain of concomitant voiding dysfunction or obstructed defecation. Additionally, an anorectal examination revealing high sphincter tone that cannot be voluntarily relaxed may prompt a defecography investigation. Another situation in which defecography might influence treatment is the identification of a sigmoidocele or intussusception; the surgical approach to prolapse management might then also include a Halban culdoplasty, a sigmoid resection, or a sigmoidopexy. Finally, intussusception and occult rectal prolapse may warrant surgical management with ventral rectopexy.
The limitations of defecography include that it requires special equipment, exposes the patient to radiation, does not show the rectum and adjacent soft tissue structures simultaneously, and is uncomfortable and poorly tolerated. Additionally, standardized criteria are not uniformly applied, making this a difficult test to interpret, and there has been only a limited correlation between clinical outcome and radiologic results [30].
Contrast studies of bowel — When findings on physical examination are disproportional to the patient's defecatory dysfunction symptom severity, a defecography may be useful to discern anatomic defects. A contrast study of the small and large bowel may reveal an enterocele, sigmoidocele, perineocele, and paroxysmal puborectalis contraction during defecation. Rectal intussusception and perineal descent may also be identified, although the clinical significance of rectal intussusception has not been completely determined. The dynamic nature of the study provides insight into the defecation process. Retention of more than 10 percent of the barium following defecation is referred to as barium trapping. However, this examination is done in an artificial environment, which may make the patient more prone to incomplete emptying, and is of limited clinical utility in diagnosing rectoceles.
Magnetic resonance imaging — Dynamic magnetic resonance imaging (MRI) provides high quality images of the pelvic soft tissues and viscera, is noninvasive, and does not require ionizing radiation or significant patient preparation. However, there is poor correlation between MRI grading of prolapse and clinical staging. MRI defecography has also been performed in the dorsal supine position with a sonographic transmission gel placed in the rectum and vagina. Images are obtained resting, while performing a Valsalva maneuver, and with evacuation in the dorsal supine position with the legs together. However, the true extent of the prolapse may not be exhibited during a Valsalva maneuver in this position, since this is not a normal position for defecation and may not simulate the woman's ability to defecate. An upright evaluation has been described, but requires an open configuration MRI unit that is available in only a few medical centers.
The limitations of MRI imaging include a lack of standardization in the grading of prolapse, high cost, and relatively limited availability. At this time, it is mainly utilized in the research setting. However, if defecography is inconclusive and the patient requires further investigation, MRI is another diagnostic option.
Ancillary testing — The patient's preoperative symptoms and surgical goals should guide the provider in the selection of additional testing.
●Women with the main complaint of constipation may benefit from a colon transit study. The test entails ingestion of radio-opaque markers, followed by serial abdominal radiographs until all of the markers are gone. (See "Etiology and evaluation of chronic constipation in adults".)
●Women whose examination is concerning for a disrupted anal sphincter proceed with endoanal ultrasound. Endoanal ultrasound visualizes the sphincter complex and can identify sphincter disruption or thinning. This technique is considered the gold standard for anal sphincter imaging and studies have reported 100 percent sensitivity in identifying sphincter defects [31].
●Women whose examination is concerning for neurologic impairment of the anal sphincter (weak tone or squeeze, asymmetric squeeze, or abnormal neurologic examination above) proceed with anorectal manometry (ARM). The two modalities are often used together to assess the anal sphincter apparatus [32]. In addition, an EMG study of the external anal sphincter can provide further diagnostic neurologic information. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Additional studies'.)
MANAGEMENT — Treatment should be pursued only if the patient's prolapse is symptomatic. She should be counseled regarding potential outcomes with expectant management, nonsurgical options (pessary, physical therapy), and surgery. It is crucial to determine what the patient wants and expects from any intervention.
Treatment of bowel symptoms — For women whose primary complaint is constipation, dietary modifications, including increased fluid intake, fiber, and laxatives, should be encouraged as a first step. A woman who describes life-long infrequent bowel movements (less than one per week) and absence of a daily urge to defecate is unlikely to be cured of her constipation with a rectocele repair. (See "Management of chronic constipation in adults".)
While defecatory dysfunction is common in women with prolapse, the extent of the prolapse does not necessarily correlate with the extent of bowel symptoms. If the woman's primary complaint is defecatory dysfunction or fecal incontinence, and not a bulge, ancillary testing should be pursued based on the woman's complaints. In this setting, surgical correction of a rectocele or perineal body defect may not correct her symptoms, although it may improve them [33-38]. A longitudinal cohort study of over 3500 patients who underwent pelvic organ prolapse surgery reported a linear increase in obstructive defecatory symptoms (splinting, straining, and incomplete evacuation) with worsening prolapse severity (stages 0 to 2) [39]. Obstructed defecation symptoms improved more in women undergoing posterior compartment procedures compared with women undergoing repair of other compartments. Surgical repair tends to improve outlet dysfunction, where the stool gets trapped in the rectocele, but does not address issues such as slow transit constipation, which can be associated with abdominal bloating. Sitz marker studies can aid in the diagnosis of slow transit constipation. (See 'Ancillary testing' above and "Fecal incontinence in adults: Etiology and evaluation", section on 'Evaluation'.)
Expectant management — The natural history of prolapse in a six-year longitudinal study of postmenopausal women enrolled in the Women's Health Initiative estrogen and progestin trial demonstrated that mild posterior vaginal prolapse (Baden Walker grade 1) had an annual regression rate of 22 percent per 100 woman-years, but more advanced stages of prolapse (grades 2-3) were unlikely to regress [40]. Rectocele progression significantly increased with increasing parity. Another WHI site followed women over the course of four years, and reported that annual progression rates (defined as ≥1 cm change in leading edge of prolapse) exceeded regression rates when the POP-Q stage was ≥stage II, and regression exceeded progression rates in stage 1 prolapse [41].
Observation with yearly examinations is appropriate for women who are mildly symptomatic. Pelvic floor muscle exercises can also be recommended. Surgery for asymptomatic patients is not indicated. On the other hand, expectant management should be abandoned if the woman develops hydronephrosis from chronic ureteral kinking, vaginal erosions that do not resolve with conservative management, or obstructed urination or defecation.
Pessary — There are two main categories of pessaries: supportive and space-occupying. The ring pessary, with or without support, is a commonly used supportive pessary, while Gellhorn and cube pessaries are commonly used space-occupying pessaries [42]. In one series, 73 of 100 consecutive women with pelvic organ prolapse were successfully fit for a pessary [43,44]. Nearly all prolapse symptoms (bulge, pressure, discharge, splinting) resolved, urinary symptoms improved by 50 percent, and de novo occult stress urinary incontinence developed in 20 percent of women. Unsuccessful pessary fitting was associated with a short vaginal length (≤6 cm) and a wide vaginal introitus (four finger breadths). There was no difference in success rates in patients with anterior versus apical versus posterior vaginal prolapse.
There are no data that support the use of one type of pessary over another in women with posterior defects. In our practice, we tailor the pessary fitting to the concomitant pelvic floor defects present, the ability to insert/remove the pessary, and sexual activity. If the patient is sexually active and is able to insert/remove the pessary, we attempt a fitting with a ring pessary with support. A Gellhorn pessary may be more effective for those patients with more advanced posterior prolapse (ie, stage 3 or 4 prolapse) and do not desire intravaginal intercourse. Pessaries may not be as effective for those women who have more distal rectoceles. Nevertheless, reduction of apical and more proximal prolapse can often assist in symptom reduction. Those who choose a pessary over surgery are more likely to be older than 70 years of age, and have less severe prolapse [45]. (See "Vaginal pessaries: Indications, devices, and approach to selection".)
Pelvic floor muscle training — Pelvic floor muscle training can be effective for treatment of urinary and fecal incontinence, but its role in treatment of prolapse is unclear. Physical therapy aims to increase the strength and endurance of the pelvic muscles and therefore improve support for pelvic organs. One trial attempted to investigate the role of perioperative (both pre- and postoperative) physiotherapy in women undergoing corrective surgery for pelvic organ prolapse [46]. Women were randomly assigned to perform or not perform physical therapy before undergoing surgery. Those assigned to the intervention had higher scores on quality of life questionnaires and higher maximum pelvic floor muscle squeeze on manometry. It may be that increasing the strength of the levator ani muscles improved support of the pelvic organs during the crucial window of postoperative healing. However, this study was hampered by short follow-up of three months, and long-term studies have not been performed that demonstrate persistent benefits.
Given that there are minimal adverse effects from pelvic floor muscle training, the main drawbacks are the cost of providing instruction and the investment of time patients need to make in order to maximize efficacy. Patients will obtain the most benefit from physical therapy by an experienced physical therapist or nurse practitioner in a supervised program, usually consisting of one to two visits per week for 8 to 12 weeks, with ongoing maintenance exercises. Nevertheless, advanced prolapse is unlikely to resolve with physical therapy alone.
Surgery — The surgical approach to management of posterior vaginal wall defects is reviewed separately. Constipation should be managed in women with posterior wall prolapsed to avoid progression of the prolapse or recurrence if surgical management is pursued. (See "Surgical management of posterior vaginal defects".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse".)
SUMMARY AND RECOMMENDATIONS
●Types of posterior vaginal defects – Posterior vaginal defects may lead to one or more of the following: rectocele (anterior protrusion of the rectum), sigmoidocele (protrusion of the sigmoid colon), and enterocele (protrusion of the small bowel). (See 'Introduction' above.)
●Risk factors – Vaginal childbirth, increasing age, and increasing body mass index are the most consistently identified risk factors for developing prolapse. The impact of cesarean birth is less clear. Hysterectomy and chronic elevated intra-abdominal pressures have also been implicated. (See 'Risk factors' above.)
●Symptoms – Symptoms commonly associated with posterior vaginal defects include splinting, pelvic pressure, constipation, sexual dysfunction, and defecatory dysfunction. Increasing severity of prolapse does not necessarily correlate with increased symptomatology. (See 'Clinical manifestations' above.)
●Clinical diagnosis – The diagnosis of posterior wall defects is clinical, based on findings from history and physical examination. Defects of pelvic support often do not occur in isolation; all areas of pelvis support should be evaluated and documented. The routine use of adjunctive imaging or other studies is not necessary for most patients. (See 'Diagnosis' above.)
•Pelvic examination – The stage of prolapse (Stage 0-IV) (figure 3A-B) is described using the pelvic organ prolapse quantification (POP-Q) system, a standardized, validated tool for measuring and staging POP (figure 4A-B). A rectovaginal examination should be performed to look for an enterocele or sigmoidocele (figure 6), which should be taken into consideration for preoperative planning. (See 'Physical examination' above.)
•Neurologic examination – Neurologic examination to assess S2-S4 nerves is also important (eg, sensation assessment, bulbocavernosus reflex, anal wink). (See 'Focused neurologic examination' above.)
•Anal sphincter evaluation – Anal sphincter assessment should be performed, especially in the setting of a history of a prior fourth degree laceration or symptoms of fecal incontinence. (See 'Assessment of anal sphincter' above.)
●Occult urinary incontinence – Women with more than mild prolapse (Stage I) should be evaluated for occult urinary incontinence. Posterior wall defects may compress the urethra and thereby mask stress urinary incontinence. (See 'Assessment of urinary incontinence' above.)
●Treatment options
•Asymptomatic – Asymptomatic prolapse does not require treatment.
•Symptomatic – Initial treatment options for symptomatic prolapse include resolution of bowel symptoms, typically with diet, pelvic floor physical therapy, and/or placement of a pessary. For patients with bothersome symptoms who wish to avoid surgery and the cost and time requirements of pelvic floor muscle training, we suggest a pessary trial (Grade 2C). Surgical correction is an option for those who do not have an adequate response to less invasive treatments or who prefer to proceed directly to anatomic correction.
-(See 'Pessary' above.)
-(See "Vaginal pessaries: Indications, devices, and approach to selection".)
-(See "Vaginal pessaries: Insertion and fitting, management, and complications".)
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