Pelvic organ prolapse in women: Diagnostic evaluation

INTRODUCTION — Pelvic organ prolapse (POP), the herniation of the pelvic organs to or beyond the vaginal walls, occurs in up to 50 percent of parous women and causes a variety of pelvic, urinary, bowel, and sexual symptoms [1]. POP stage is diagnosed on pelvic examination. A medical history is also important to elicit commonly associated symptoms since treatment of urinary or fecal symptoms is typically coordinated with treatment for POP. Asymptomatic POP may not require treatment.

The diagnostic evaluation of women with POP is reviewed here.

An overview of the female pelvic examination, POP, and treatment options are discussed separately and include:

●(See "The gynecologic history and pelvic examination".)

●(See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)

●(See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

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 transmasculine and gender-expansive individuals.

CLASSIFICATION OF PELVIC ORGAN PROLAPSE — Historically, the severity of prolapse was graded using a variety of imprecise classification systems that were not easily reproduced or communicated in a standard way among clinicians [2]. The Pelvic Organ Prolapse Quantitation system (POP-Q), introduced in 1996, has become the standard classification system [3].

POP-Q system — The POP-Q system is an objective, site-specific system for describing and staging POP in women [2]. The POP-Q system involves quantitative measurements of various points representing anterior, apical, and posterior vaginal prolapse to create a "topographic" map of the vagina. These anatomic points can then be used to determine the stage of the prolapse (figure 1 and figure 2 and table 1) [2,3].

The POP-Q system is the POP classification system of choice of the International Continence Society (ICS), the American Urogynecologic Society (AUGS), and the Society of Gynecologic Surgeons (SGS) [3]. The American College of Obstetricians and Gynecologists has also recommended its use [4]. It has proven interobserver and intraobserver reliability [5] and is the system used most commonly in the medical literature [6,7]. Intraoperative POP-Q measurements correlate well with preoperative findings, with slightly more prolapse under anesthesia when traction is placed on the POP-Q points [8].

The S-POP-Q may be an easier classification system to use in routine clinical practice. It was developed by the International Urogynecology Association to provide a less cumbersome examination tool [9]. The S-POP-Q stages prolapse for the anterior and posterior vaginal walls, the apex/cuff of the vagina and the cervix. For women posthysterectomy, there are three stages; for women with an intact uterus there are four. The examination is carried out similarly to the standard POP-Q examination, with a half speculum placed in the vagina to visualize the vaginal walls and cervix. (See 'Simplified POP-Q' below.)

In this topic, classification of POP will be described using the original POP-Q. (See 'Using the POP-Q system' below.)

Baden-Walker system — While not recommended by leading societies, the Baden-Walker Halfway Scoring System is another commonly used POP staging system. The degree, or grade, of each prolapsed structure is described individually (eg, grade 1 anterior vaginal wall prolapse or grade 3 uterine prolapse). The grade/degree is defined as the extent of prolapse for each structure noted on examination while the patient is straining. Because there are no clear demarcations among the cut-off stages, the Baden-Walker system lacks the precision and reproducibility of the POP-Q system.

The system has five degrees/grades [10]. For the urethra, posterior descent is graded, for other anatomic sites, the lowest part is graded:

●0 – Normal position for each respective site

●1 – Descent halfway to the hymen

●2 – Descent to the hymen

●3 – Descent halfway past the hymen

●4 – Maximum possible descent for each site

Modifications of this system also exist.

The Baden-Walker system lacks the precision and reproducibility of the POP-Q system.

SYMPTOM AND MEDICAL HISTORY — The medical history includes symptoms specific to prolapse, as well as urinary, defecatory, and sexual problems, which are often associated with POP. A multidisciplinary working group has proposed use of a combined set of validated questionnaires, titled IMPACT, to assess patient-reported outcomes specific to pelvic floor disorders [11]. A detailed discussion of symptoms associated with POP can be found separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

No robust screening questionnaires for mild POP exist. Some epidemiologic studies have used a single question to screen for prolapse from a validated pelvic floor distress questionnaire [12], which likely captures only those patients with severe prolapse. By asking the question "Do you experience bulging or something falling out you can see or feel in the vaginal area?", the National Health and Nutrition Examination Survey reported a 3 percent prevalence rate of advanced prolapse in the study population of nearly 2500 women [13]. Women with a positive response to this question should undergo a pelvic examination.

Symptom assessment is important, since treatment is generally not indicated for asymptomatic POP. In addition, assessment of POP symptoms and their impact on a patient’s quality of life helps patients and clinicians set treatment goals [14-16]. Treatment of urinary or defecatory conditions is typically coordinated with POP treatment. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Symptomatic prolapse'.)

Current symptoms or history of conditions that may mimic (eg, pelvic mass, genital tract bleeding) or exacerbate (eg, etiologies of urinary or fecal incontinence other than POP) symptoms of POP should also be elicited. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

In addition, the medical history should include a review of medical comorbidities that could impact whether the patient is a candidate for surgical treatment. (See "Overview of the principles of medical consultation and perioperative medicine".)

DIAGNOSIS — POP is diagnosed with a pelvic examination using the POP quantification (POP-Q) system. A medical history is also important to elicit prolapse-associated symptoms, since treatment is generally indicated only for symptomatic prolapse. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Symptomatic prolapse'.)

APPROACH TO THE EXAMINATION

Examination components — Physical examination of women with POP includes the following components:

●Visual inspection

●Speculum examination

●Bimanual pelvic examination

●Rectovaginal examination

●Neuromuscular examination

Each component of the examination is discussed in the sections below.

Equipment — Instruments that are useful in assessment of pelvic prolapse include a Sims retractor (single blade speculum) or a bivalve speculum that can be easily taken apart so that the anterior and posterior blades can be used separately to observe individual compartments of the vagina (anterior, posterior, apical).

To make the measurements for the POP-Q system, a ruler or a large cotton swab or sponge forceps marked in 1 cm increments is used [2,6].

Patient positioning — The examination is performed in both the dorsal lithotomy and standing positions with the patient relaxed and then straining (to demonstrate the maximum degree of prolapse) [17]. The extent of prolapse visualized on examination should confirm the patient's description of bulging symptoms. If the severity of prolapse visualized does not correlate with the patient's description, a handheld mirror may be beneficial to confirm that what the provider is seeing is the full extent of the prolapse.

●Dorsal lithotomy – The patient is examined initially in the dorsal lithotomy position. A prospective series of 218 women reported that performing the pelvic examination in the left lateral position (a common position used to assess pelvic support in the United Kingdom) yielded results that correlated highly with findings in the lithotomy position [18].

●Standing – The examination is then repeated with the patient standing [17,19]. This is the position that will best approximate the extent of prolapse that the patient experiences daily. In the standing position, the patient places one foot on a well-supported footstool. The examining gown is lifted slightly to expose the genital area during the examination [20].

Additional techniques to help the patient reproduce the extent of prolapse can include:

●In office – Patients who have difficulty generating a Valsalva maneuver in dorsal lithotomy or standing positions may be able to elicit the full extent of prolapse by sitting on the toilet and coughing and/or straining.

●At home – For patients who are unable to reproduce the bulge that they experience at home, a photograph of the prolapse at its full extent can be helpful.

Documentation — A full description of the examination is recorded, including [2]:

●Type of examination table, speculum, and retractors

●Patient position

●Bladder and rectal fullness

It is important to note and document any episodes of urinary, fecal, or flatal incontinence that occur during the examination.

The findings of the examination should be recorded using a quantitative and reproducible method for recording POP. We use the POP-Q system, as noted above. (See 'POP-Q system' above.)

VISUAL INSPECTION — The first part of the examination is a visual inspection of the vulvar, perineal, and perianal areas with the patient in the dorsal lithotomy position. As during other components of the examination, the inspection should be performed initially with the patient relaxed and then while straining. Findings that should be noted during this component of the examination include:

●Transverse diameter of the genital hiatus (eg, the space between the labia majora)

●Protrusion of the vaginal walls or cervix to or beyond the introitus (uterine procidentia)

●Length and condition of the perineum

●Rectal prolapse

In patients with prolapse to or beyond the hymen, the vaginal tissue is examined for ulceration.

Any other findings (eg, skin or mucosal lesions) should be noted and evaluated appropriately. (See "The gynecologic history and pelvic examination", section on 'External genitalia'.)

SPECULUM AND BIMANUAL EXAMINATION — The speculum and bimanual examinations are the principal components used to evaluate POP. The patient is examined in the dorsal lithotomy and then standing positions, while relaxed and then straining, as noted above. (See 'Patient positioning' above.)

Prolapse of each anatomic compartment is evaluated as follows:

●Apical prolapse (prolapse of the cervix or vaginal vault) – A bivalve speculum is inserted into the vagina and then slowly withdrawn; any descent of the apex is noted.

●Anterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum is inserted into the vagina with gentle pressure on the posterior vaginal wall to isolate visualization of the anterior vaginal wall.

●Posterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum into the vagina with 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.

The terms anterior vaginal wall prolapse, posterior vaginal wall prolapse and apical prolapse are preferred to the terms "cystocele," "rectocele," and "enterocele" because vaginal topography does not reliably predict the location of the associated viscera in women with POP. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Terminology'.)

To complete the examination, a bimanual examination is performed in order to evaluate for any coexisting pelvic abnormalities. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)

Using the POP-Q system — In the POP-Q system, the topography of the vagina is described using six points (two on the anterior vaginal wall, two on the superior vagina, and two on the posterior vaginal wall) and several other measurements (figure 1) [2]. Taken together, these measurements can be used to produce a sagittal diagram of the prolapse.

During the examination, the maximum extent of prolapse is determined for each of the six points. Maximal prolapse is defined by the following findings:

●Vaginal wall becomes tight during straining

●Traction on the prolapse causes no further descent

●Patient confirms that protrusion is maximal

The maximal point of prolapse of each of the six points is then recorded in relation to a fixed point of reference, the anterior-posterior plane of the hymen.

All measurements are expressed in centimeters; increments of 0.5 cm can also be used, if clinically useful. A minus sign is used to designate a point that is proximal, or superior, to the hymenal plane (eg, -3 cm), while points distal or inferior to the hymenal plane are preceded by a positive sign (eg, +2 cm).

The measurements can be marked on line diagrams (figure 3), noted on a grid (figure 2), or recorded in text form.

POP-Q measurements — Each point is located by measuring along the vaginal wall or identifying the most dependent point of a prolapsed structure. The measurement is then taken of the distance from the point to the hymenal plane. The anterior and posterior vaginal measurements are independent of each other (they do not need to match). The anatomic location of each point is (figure 1) [21,22]:

●Anterior vaginal wall points:

•Point Aa is located in the midline of the anterior vaginal wall, 3 cm proximal to the external urethral meatus, corresponding approximately to the urethrovesical junction. The quantitative value of point Aa is anywhere from -3 to +3 cm from the hymenal plane, depending upon the extent of anterior wall prolapse.

•Point Ba is the most distal (ie, most dependent) position of any part of the anterior vaginal wall between point Aa and the vaginal cuff or anterior vaginal fornix. If there is no prolapse, point Ba is -3 cm by definition. In a woman with total posthysterectomy vault prolapse, Ba has a positive value equal to the distance between the vaginal apex and hymenal plane (so the quantitative value of point Ba can range from the most supported measurement [-3], to the most prolapse portion beyond the hymenal ring [this may exceed +3 cm]).

●Superior vagina points:

•Point C is the most distal (ie, most dependent) edge of the cervix or the leading edge of the vaginal cuff (posthysterectomy).

•Point D is measured only in women with a cervix. It is the deepest point of the posterior fornix, corresponding approximately to where the uterosacral ligaments attach to the posterior cervix. Measuring this point distinguishes between suspensory failure of the uterosacral-cardinal ligament complex and cervical elongation: if point C is significantly more positive than point D (>4 cm), the cervix is elongated.

●Posterior vaginal wall points (these are analogous to the two points on the anterior wall):

•Point Ap is located in the midline of the posterior vaginal wall, 3 cm proximal to the posterior hymen. The quantitative value of point Ap is anywhere from -3 to +3 cm from the hymenal plane, depending upon the extent of posterior wall prolapse.

•Point Bp is the most distal (ie, most dependent) position of any part of the upper posterior vaginal wall between point Ap and the vaginal cuff or posterior vaginal fornix. If there is no prolapse, point Bp is -3 cm by definition. In a woman with total posthysterectomy vaginal prolapse, Bp has a positive value equal to the distance between the vaginal apex and hymenal plane (so the quantitative value of point Bp can range from the most supported measurement [-3], to the most prolapse portion beyond the hymenal ring [this may exceed +3 cm]).

In addition, the total vaginal length (TVL) is measured by reducing point C or D to its most superior position (eg, with a swab or ring forceps).

Finally, two additional measurements give a frontal (coronal) view of the prolapse from the perspective of an examination in the lithotomy position. These measurements complement the points determined in the sagittal view:

●The genital hiatus (gh) is measured anterior-posteriorly from the middle of the external urethral meatus to the posterior midline hymen. If the location of the hymen is obscured by a band of skin (usually from surgery or episiotomy repair), the firm tissue of the perineal body is the posterior margin of this measurement.

●The perineal body (pb) is measured from the posterior margin of the genital hiatus to the midanal opening.

POP-Q staging — The POP-Q system provides a detailed description of vaginal anatomy. For the purposes of simple clinical communication or grouping patients for research purposes, an ordinal staging system using the POP-Q measurements was developed.

●Stage 0 – No prolapse. Points Aa, Ap, Ba, and Bp are all -3 cm and point D (if uterus is present) or C (posthysterectomy) equals or nearly equals TVL (-TVL cm to -[TVL-2] cm).

●Stage I – The requirements for stage 0 are not met, but the most distal portion of the prolapse is >1 cm proximal to the level of the hymenal plane (ie, quantitation value <-1 cm).

●Stage II – The most distal portion of the prolapse is between ≤1 cm proximal to the hymenal plane and ≤1 cm distal to the hymenal plane (ie, quantitation value ≥-1 cm to ≤+1 cm).

●Stage III – The most distal portion of the prolapse is between >1 cm distal to the hymenal plane, but no further than 2 cm less than the total vaginal length in centimeters (quantitative value >+1 cm but <+[TVL-2] cm). In other words, the maximum prolapse is more than 1 cm outside the hymenal plane, but it is 2 cm less than the maximum possible protrusion.

●Stage IV – Eversion of the total length of the vagina. The protrusion extends to or beyond (TVL-2) cm (quantitative value ≥+[TVL-2] cm).

It may be helpful to designate the leading edge of prolapse, such as stage 2 prolapse with the anterior compartment leading.

Modifications of the POP-Q system and reporting POP-Q results

Simplified POP-Q — A simplified version of the POP-Q system, which was developed by an international group of investigators, has been proposed [9,23]. Like the standard POP-Q examination, the Simple POP-Q (S-POP-Q) measures the anterior, posterior and up to two measurements of the apex, including both the cervix, in women who still have one, and posterior cul-de-sac. The S-POP-Q records the ordinal stage of the four measurements by estimating the distances involved. For measurement of the anterior wall, a point approximately 3 cm or halfway up the anterior vaginal wall is visualized, the woman is asked to strain, and the amount of descent is recorded. A similar process is carried out to estimate the descent of the posterior wall. Finally, a Sims speculum is utilized to record the descent of the apex of the vagina. The following definitions are used to Stage the prolapse:

●Stage 1 – Prolapse where the given point remains at least 1 cm above the hymenal remnants.

●Stage 2 – Prolapse where the given point descends to the introitus, defined as an area extending from 1 cm above to 1 cm below the hymenal remnants.

●Stage 3 – Prolapse where the given point descends greater than 1 cm past the hymenal remnants, but does not represent complete vaginal vault eversion or complete uterine procidentia. This implies that at least some portion of the vaginal mucosa is not everted.

●Stage 4 – Complete vaginal vault eversion or complete uterine procidentia. This implies that the vagina and/or uterus are maximally prolapsed with essentially the entire extent of the vaginal mucosa everted.

The S-POP-Q has been validated against the original staging system of the POP-Q and has been found to be highly correlated [9,23].

SLmax — SL_max, also known as maximum vaginal descent, was introduced as a continuous value of vaginal support that describes prolapse as a single summary score. This measure is calculated as a single score for comparison of prolapse between populations and is not meant to replace the more detailed POP-Q. SL_max simply represents the most distal presenting part of the vagina, in centimeters. The minimum value is -3 by definition, and the measure was shown to correlate well with POP-Q measurements and results of the Pelvic Organ Prolapse Distress Inventory [24].

Additional examination techniques

Simulated apical support — Repeating the speculum examination with simulated apical support (ie, supporting the vaginal apex with a large cotton swab or ring forceps) approximates the results following apical prolapse repair. Reduction of apical prolapse temporarily corrects anterior and posterior vaginal wall prolapse in many women [25]. This examination technique may help a clinician decide whether a vaginal pessary may be helpful or, in preoperative patients, whether to perform apical prolapse relapse repair. (See "Vaginal pessaries: Indications, devices, and approach to selection" and "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant repair of apical and anterior or posterior prolapse'.)

Inspection for paravaginal defects — Evaluation for paravaginal defects is not part of the POP-Q system because the clinical significance of paravaginal defects is unclear. Paravaginal defects occur when the anterior vaginal wall detaches from its lateral support, the arcus tendineus. The arcus tendineus is a line of connective tissue that runs from posterior (ischial spine) to anterior (symphysis pubis) anteriorly (figure 4). Surgical repair of paravaginal defects is not typically performed as it does not improve surgical outcomes. (See "Pelvic organ prolapse in women: Surgical repair of anterior vaginal wall prolapse" and "Pelvic organ prolapse in women: Surgical repair of anterior vaginal wall prolapse", section on 'Paravaginal defect repair'.)

RECTOVAGINAL EXAMINATION — A rectovaginal examination is performed to:

●Diagnose an enterocele

●Differentiate between a high rectocele and an enterocele

●Assess the integrity of the perineal body

●Detect rectal prolapse

The best method for detecting an enterocele is to perform the rectovaginal examination with the patient standing; the small bowel can be palpated in the cul-de-sac between thumb and forefinger (figure 5). (See "Posterior vaginal defects (eg, rectocele): Clinical manifestations, diagnosis, and nonsurgical management".)

NEUROMUSCULAR EXAMINATION

Neurologic evaluation — Gross neurologic assessment of the vulva and perineum is performed to screen for neurologic disease, although there is a low detection rate in the absence of gross neurologic symptoms or a prior diagnosis of a neurologic disorder.

●Medical and neurologic history – Detailed neurologic evaluation begins with a thorough medical history, including a personal or family history of neurologic disease or related conditions. Any abnormalities of speech or gross motor function should be noted while taking the medical history.

●Sensation – Sensory of the lumbosacral dermatomes for light touch and sharp touch is performed using a small cotton swab and a sharp point [26]. If sensory function is abnormal, more detailed neurologic testing may be warranted.

●Sacral reflexes – Sacral reflexes should also be assessed. To evaluate for sacral nerve integrity, the bulbocavernosus reflex is elicited by gently tapping or squeezing the clitoris. The anocutaneous reflex (anal wink sign) is triggered by stroking the skin immediately surrounding the anus and observing a reflexive contraction of the external anal sphincter; this reflex should be elicited bilaterally. Absence of these reflexes is not always abnormal and hyperreflexia or asymmetry may in fact be more suggestive of a neurologic etiology. As with sensory function, abnormal findings of reflex testing warrant a more detailed neurologic examination and possible referral to a specialist.

●Motor function – Sacral nerve route motor function is further evaluated by having the patient move the lower extremity; this includes active extension and flexion of the knee, ankle, and toes. Strength is assessed by having the patient move each joint against resistance. The patellar and plantar reflexes are also assessed.

If abnormal findings are encountered, the patient should be referred to a neurologist.

Pelvic floor muscle testing — The pelvic floor musculature is inspected to evaluate integrity and symmetry. The examiner should also note the presence of scarring and whether pelvic floor contraction pulls the perineum inward. Palpation through the vagina or rectum helps in assessing pelvic floor squeeze strength and levator muscle thickness. The tone and strength of the pelvic floor muscles can be assessed by asking the patient to contract the pelvic floor muscles around the examining fingers. Women with poor pelvic floor muscle function may benefit from pelvic physical therapy.

Guidelines have been published by the International Continence Society to assess pelvic floor musculature tone [27]. Four conditions have been defined: normal pelvic floor muscles are those which can voluntarily contract and relax, overactive pelvic floor muscles are muscles which do not relax, underactive pelvic floor muscles are those which cannot voluntarily contract, and nonfunctioning pelvic floor muscles is when there is no pelvic floor muscle action palpable [28]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Pelvic floor muscle exercises'.)

Instrumental muscle testing is available, but none of these techniques has proven clinical applicability in the assessment of POP. Electromyography with needle electrodes permits visualization of individual motor unit action potentials; surface electrodes detect activity of groups of motor units. Pressure recording from the urethra, vagina, and anus can be used to assess pelvic floor muscle strength.

ANCILLARY STUDIES — Ancillary diagnostic procedures are performed mainly for evaluation of bladder or bowel function. Additional testing is occasionally used to further evaluate prolapse itself [29]. Infrequently, women will present with complaints of prolapse, yet on examination have evidence of excellent vaginal support as measured by the POP-Q. It is possible that these women have descent of the perineum or that they have an enterocele that descends between the vaginal and rectum or bladder and rectum without displacing the anterior or posterior vaginal walls.

Whether to proceed with ancillary testing depends upon the presenting symptoms and whether there are symptoms that do not correlate with physical examination findings (eg, bladder or bowel symptoms are present in the absence of prolapse).

Evaluation of prolapse

Photography — If prolapse is stage II or greater, photographs that include a centimeter tape as a frame of reference can help objectively document presurgical findings or serial changes in an individual patient.

Imaging — There are few clinical uses of imaging to evaluate the anatomic findings of prolapse. Imaging techniques are used for some aspects of evaluation of urinary or bowel function. (See "Female urinary incontinence: Evaluation", section on 'Evaluation' and "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Diagnosis and classification'.)

Dynamic magnetic resonance imaging (dMRI) is under investigation for use in identifying site-specific pelvic support defects, as well as differentiating between a rectocele and an enterocele [30]. However, there are no standardized criteria for use of this modality for the diagnosis of POP, and it is largely used for research purposes [31]. A retrospective study compared dMRI defecography phase findings with physical examination grading of POP using the Baden-Walker system. The defecography phase of the dMRI correlated well with the Baden-Walker evaluation for anatomically significant prolapse in both the anterior and posterior compartments; however, the dMRI was superior to physical examination for enterocele detection and was better able to distinguish an enterocele from a rectocele [32]. Therefore, the dMRI may have the greatest diagnostic value in patients with apical and posterior compartment defects where the presence of an enterocele is suspected but not certain on physical examination. dMRI may also be a useful diagnostic tool when patients' symptoms are in excess of their physical examination findings.

Perineal ultrasound — Ultrasound of the perineum can identify levator ani defects as well as prolapse of the bladder, rectum, and/or intestines into the vagina. The ability to diagnose levator ani evulsion from the symphysis pubis after childbirth or other perineal trauma is emerging as an important predictor of both the development of prolapse as well as the success and failure of prolapse repairs [33].

Urinary tract evaluation — Urinary tract evaluation for women with prolapse is guided by an individual patient’s complaints (eg, incontinence, urinary retention). Studies may include testing for urinary tract infection, urinary incontinence, or urinary retention.

This section will briefly discuss major components of urinary tract evaluation in women with POP. A detailed discussion of the evaluation of women with urinary incontinence, overactive bladder syndrome, or obstructive urinary symptoms can be found separately. (See "Female urinary incontinence: Evaluation" and "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure" and "Urodynamic evaluation of women with incontinence".)

Urinary incontinence — Urinary incontinence often coexists with POP. While women with POP often have stress urinary incontinence (SUI) symptoms, many women with stage II or higher apical prolapse remain continent despite loss of anterior vaginal and bladder/urethral support. However, 13 to 65 percent of continent women develop symptoms of SUI after surgical correction of the prolapse [34-37]. This likely occurs because the prolapse kinks and obstructs the urethra; this obstruction is alleviated when the prolapse is repaired. This is referred to as "occult" or "potential" stress incontinence.

All continent women with apical prolapse should have a preoperative evaluation for occult SUI by reducing the prolapse and observing whether or not the patient leaks with cough or Valsalva. However, preoperative prolapse reduction testing does not accurately predict postoperative stress incontinence (approximately 40 percent of women with negative testing will develop postoperative stress incontinence) [38]. The routine use of urodynamics in women with prolapse, with or without symptomatic SUI, is controversial. Urodynamic testing is time-consuming and incurs expense, and it is unclear whether it improves surgical decision-making in women with uncomplicated SUI. We suggest urodynamics be performed only in women with complicated SUI (eg, previous anti-incontinence surgery, neurogenic lower urinary tract dysfunction, or suspicion of a nonstress etiology of urinary incontinence) or when symptoms are not consistent with physical examination findings. The approach to women with prolapse and urinary incontinence is presented in detail separately.

Women with prolapse also commonly have urgency urinary incontinence (UUI) symptoms. Whether or not these symptoms resolve with surgical correction of the prolapse is controversial, although most providers feel that prolapse reduction is an important component of UUI treatment in women with advanced POP.

●(See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Occult SUI'.)

●(See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Approach based on patient presentation'.)

●(See "Surgical management of stress urinary incontinence in females: Preoperative evaluation for a primary procedure", section on 'Urodynamic testing'.)

Urinary retention — A postvoid residual (PVR) urine volume is one method used to evaluate for urinary retention. Voiding trials to assess PVR can be either retrograde or spontaneous. At least one study has reported that ultrasound assessment of PVR may be less reliable in patients with more advanced prolapse [39]. There is no clear consensus on what is a normal or abnormal PVR urine volume. In general, a PVR of greater than 100 cc can be suggestive of voiding dysfunction or detrusor weakness; the range of normal values for PVR and treatment options remains controversial [40-42]. After prolapse repair, the majority of women with preoperative urinary retention have improved PVRs [43]. (See "Postoperative urinary retention in females", section on 'Voiding trials'.)

Bowel function evaluation — Women who are undergoing evaluation for POP may also require further evaluation of anal incontinence or obstructive symptoms (eg, constipation, incomplete emptying). Defecography may demonstrate an enterocele that was not detected on POP-Q. A detailed discussion of the evaluation of these conditions can be found separately. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Evaluation' and "Etiology and evaluation of chronic constipation in adults", section on 'Evaluation'.)

DIFFERENTIAL DIAGNOSIS — In women with symptoms of a vaginal bulge or pelvic pressure, a pelvic mass should be excluded with pelvic examination, and if appropriate, imaging studies. Common conditions that may present with these symptoms include adnexal (eg, benign ovarian cysts or ovarian cancer) and uterine masses (eg, fibroids). Women with genital tract bleeding should also undergo appropriate evaluation to identify the source of bleeding and exclude malignancy. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Diagnostic evaluation' and "Causes of female genital tract bleeding" and "Approach to the patient with an adnexal mass", section on 'Clinical presentation'.)

Urinary (incontinence, retention, overactive bladder syndrome) or bowel (incontinence, obstructive symptoms) conditions are often associated with POP, as noted above (see "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'). While these symptoms are suggestive of POP, pelvic examination may reveal the presence of one or more of these conditions without significant prolapse. Regardless of the presence or absence of POP, women with these symptoms should undergo thorough evaluation to determine whether they are caused or exacerbated by medical conditions other than POP. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Evaluation' and "Etiology and evaluation of chronic constipation in adults", section on 'Evaluation' and "Female urinary incontinence: Evaluation", section on 'Evaluation'.)

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" and "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

●Definition – Pelvic organ prolapse (POP) is herniation of the pelvic organs to or beyond the vaginal walls. A medical history is important to elicit prolapse-associated symptoms, since treatment is generally indicated only for symptomatic prolapse. (See 'Introduction' above.)

●Medical history – The medical history includes symptoms specific to prolapse, as well as urinary, defecatory, and sexual complaints, which are often associated with POP. Conditions that mimic prolapse (eg, pelvic mass) or comorbidities that may impact surgical treatment are assessed during the medical history. (See 'Symptom and medical history' above.)

●Diagnosis – POP is diagnosed during pelvic examination using the Pelvic Organ Prolapse Quantitation (POP-Q) system. POP-Q is an objective, site-specific system for describing (figure 2), staging (table 1), and communicating the sites and degree of POP (figure 3). While other classification systems exist, these are less precise and difficult to reproduce and communicate. (See 'Classification of pelvic organ prolapse' above.)

•POP-Q – Each point is located by measuring along the vaginal wall or identifying the most dependent point of a prolapsed structure. The measurement is then taken of the distance from the point to the hymenal plane. The anterior and posterior vaginal measurements are independent of each other (they do not need to match). (See 'Using the POP-Q system' above.)

•Rectovaginal exam – A rectovaginal examination is performed to diagnose an enterocele and differentiate between a high rectocele and an enterocele. (See 'Rectovaginal examination' above.)

•Neuromuscular examination – Gross neurologic assessment is performed to screen for neurologic disease. Assessment includes a history, testing of sensation, sacral reflexes, motor function, and pelvic floor muscle strength. (See 'Neuromuscular examination' above.)

●Additional tests – Ancillary diagnostic procedures are performed mainly for evaluation of bladder or bowel function, although additional testing is occasionally used to further evaluate prolapse itself. (See 'Ancillary studies' above.)