As a part of the pelvic organ prolapse examination, urethral mobility often is measured. Many women with prolapse will have urethral hypermobility (defined as a resting urethral angle greater than 30 degrees or a maximal strain angle greater than 30 degrees). The presence of urethral mobility in combination with symptoms of stress incontinence may help determine whether an incontinence procedure should be performed. However, studies have shown that nearly all women with stage II to IV prolapse have urethral hypermobility, and asymptomatic parous women have an average maximum straining angle of 54 degrees (27,28). During pelvic examination, the urethra is typically swabbed with Betadine, and lidocaine jelly is placed in the urethra or on a cotton tip swab. The swab is placed in the urethra at the urethrovesical junction and, with the use of a goniometer (Fig. 27.10), the baseline urethral angle from the horizontal and maximal strain angles is measured.
Figure 27.10 Goniometer, which is used to measure baseline urethral angle and maximal strain angle of the urethra with a cotton tip swab in place.
Patients with prolapse exhibit the full range of lower urinary tract symptoms. Despite the fact that some patients may not have significant symptoms, it is important to obtain objective information about bladder and urethral function. With severe POP, the urethral kinking effect of the prolapse may mask a potential urine leakage problem; therefore, basic office bladder testing with prolapse reduction should be performed to mimic bladder and urethral function if the prolapse were treated. At a minimum, the following assessments should be performed: a clean catch or catheterized urine sample to test for infection, a postvoid residual (PVR) volume, and assessment of bladder sensation, which can be performed as a part of office cystometrics. Although there is no consensus as to what constitutes an abnormal PVR volume, provided the patient has voided 150 mL or more, a PVR less than or equal to 100 mL is acceptable (27). Reduction stress testing at the time of simple office cystometrics can be performed with the use of a pessary, large cotton swab, ring forceps, or the posterior blade of a speculum. Care should be taken that the urethra not be overly straightened (with a resultant false-positive test result) or obstructed (with a resultant false-negative test result), or that tension is not placed on the puborectalis muscles by excessive posterior retraction. These risks can be minimized by orienting the vaginal apex toward the sacrum.
Once a decision is made to perform surgical repair of the posterior compartment based on symptoms, type, and location of defects, an appropriate approach should be determined and the patient should be made aware of the expected outcomes and potential adverse effects such as pain and sexual dysfunction. If the patient has defecatory dysfunction with a rectocele and symptoms of constipation, pain with defecation, fecal or ﬂatal incontinence, or any signs of levator spasm or anal sphincter spasm, appropriate evaluation and conservative management of concurrent conditions could be initiated before repair of the rectocele and continued postoperatively (28).
Imaging Diagnostic imaging of the pelvis in women with pelvic organ prolapse is not routinely performed. However, if clinically indicated, tests that may be performed include ﬂuoroscopic evaluation of bladder function, ultrasound of the pelvis, and defecography for patients in whom intussusception or rectal mucosal prolapse are suspected. Magnetic resonance imaging is increasingly being used for the evaluation of pelvic pathology such as mullerian anomalies and pelvic pain; however, generalized use in women with prolapse is not currently clinically indicated and is used primarily for research purposes.