Although as many as 50% of women older than age 50 have some degree of pelvic organ prolapse (15), fewer than 20% seek treatment (16). This may result from a number of causes, including lack of symptoms, embarrassment, or misperceptions about available treatment options. Although pelvic organ prolapse is not life threatening, it can impose a significant burden of social and physical restrictions of activities, impact on psychological well-being, and overall quality of life.
Symptoms Pelvic organ prolapse often is accompanied by symptoms of voiding dysfunction, including urinary incontinence, obstructive voiding symptoms, urinary urgency and frequency, and, at the extreme, urinary retention and upper renal compromise with resultant pain or anuria. Other symptoms often associated with POP include pelvic pain, defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal incontinence), back and ﬂank pain, overall pelvic discomfort, and dyspareunia. Patients seeking care for prolapse may have one or several of these symptoms involving the lower pelvic ﬂoor. Choice of treatment usually depends on severity of the symptoms and the degree of prolapse consistent with the patient’s general health and level of activity (16).
Data relating pelvic ﬂoor symptoms to the extent and location of prolapse are weak (17–19). Any symptoms associated with physical findings of lower stage prolapse require careful evaluation, especially if surgery is being considered. A recent retrospective study of 330 patients reported that women with more advanced prolapse were less likely to have symptoms of stress incontinence and more likely to use manual reduction of the prolapse to void. Therefore, careful consideration of lower urinary tract symptoms is important. Prolapse severity was not associated with bowel or sexual problems in this study (20).
Physical Examination In evaluating patients with pelvic organ prolapse, it is particularly useful to divide the pelvis into compartments, each of which may exhibit specific defects. The use of a Graves speculum or Baden retractor can help to evaluate the apical compartment of the vagina. The anterior and posterior compartments are best examined with the use of a univalve or Sims speculum. The speculum is placed posteriorly to retract the posterior wall downward when examining the anterior compartment and placed anteriorly to retract the anterior wall upward when examining the posterior compartment. A rectovaginal examination may be useful in evaluating the posterior compartment to distinguish a posterior vaginal wall defect from a dissecting apical enterocele or a combination of both.
If an anterior lateral detachment defect is suspected, an open ring forceps (or a Baden retractor) may be placed in the vagina at a 45-degree angle posteriorly cephalad to hold the lateral fornices adjacent to the pelvic sidewall.
During the evaluation of each compartment, the patient is encouraged to perform Valsalva so the full extent of the prolapse can be ascertained. If the findings determined with Valsalva are inconsistent with the patient’s description of her symptoms, it may be helpful to perform a standing straining examination with the bladder empty (20,21).