Pelvic organ prolapse

Classification

Three compartments

• Anterior compartment: cystocele and urethrocele, i.e. the anterior vaginal wall with the bladder and urethra.
• Posterior compartment: rectocele and enterocele with contents of the pouch of Douglas.
• Mnemonic for the examination: assess each compartment individually, as descensus often occurs in combination.

Grading

• Common clinical practice: grade I to III according to the position of the lowest point relative to the hymenal ring.
• Grade I: the lowest point remains above the hymenal ring.
• Grade II: the lowest point reaches approximately the introitus.
• Grade III: the descent protrudes beyond the introitus; a total prolapse is called procidentia.
• The differentiated system: POP-Q with six defined points, measured in centimetres relative to the hymen.

Clinical features

Symptoms and long-term consequences

• Key symptoms: foreign body and dragging sensation, low back pain and a pulling-down feeling.
• In severe cases: post-void residual volume, micturition and defecation disorders requiring manual reduction.
• Acute presentation can include: urinary retention, pain and bleeding from a decubitus ulcer of the prolapsed wall.

More facts from the study questions

• The clinical grading from I to III is based on the relationship of the lowest point to the hymenal ring.
• In Grade I, the lowest point of the prolapse is still located above the hymenal ring.
• The strength of the pelvic floor muscles is assessed as part of the clinical examination.
• Muscle strength is graded by palpation using the Oxford scale (Grades 0 to 5).
• The standard examination is performed in a supine position, with the patient asked to strain or cough.
• Genital prolapse is divided into three compartments: anterior, middle, and posterior.
• The anterior compartment comprises the anterior vaginal wall with the adjacent bladder (cystocele) and urethra (urethrocele).
• Grade II prolapse is present when the lowest point reaches approximately the introitus.
• If the prolapse extends beyond the introitus, it is a Grade III prolapse (or procidentia in case of total prolapse).

Diagnosis

Examination itself

• Examination is performed: in a supine position with straining and, if there is a discrepancy with the patient's complaints, additionally in a standing position.
• Without this step, the finding is underestimated: asking the patient to strain forcefully or cough.
• Bladder filling: the finding is re-evaluated with an empty bladder because it presents differently then.
• Pelvic floor strength: is graded on palpation from 0 to 5 using the Oxford scale.

Typical imaging findings

• Clinical finding: A prolapsed soft tissue body lies in front of the introitus. On its apex there are broad, sharply outlined defects with a fibrin-covered base and fresh bleeding points; the surrounding mucosa is dry and keratinised.

Keep learning in the app

Further reading (selection)

1. StatPearls: Pelvic Organ Prolapse (NCBI Bookshelf)
2. DocCheck Flexikon, Descensus genitalis

Cross-references