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164 Pelvic Organ Prolapse Made Simple: Uterine Prolapse, Cystocele & Rectocele on Exams

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Episode 164: Pelvic Organ Prolapse

Clean Notes (Review Book)

Uterine Prolapse

  • Descent of the uterus into or through the vaginal canal due to weakening of the pelvic floor ligaments and musculature.
  • Severity is graded by how far the uterus descends. Procidentia refers specifically to the most severe form, complete uterine prolapse (Grade 4 Baden-Walker / Stage IV POP-Q), where the entire uterus has exited the vaginal opening. The term is not used for partial prolapse.

Risk Factors

  • Vaginal delivery and multiparity: the strongest risk factors. Each vaginal delivery stretches and can damage pelvic floor support structures.
  • Menopause: decreased estrogen reduces collagen synthesis and pelvic floor tone.
  • Obesity and chronic increased intraabdominal pressure (straining, chronic cough, heavy lifting).
  • Connective tissue disorders (Marfan, Ehlers-Danlos).
  • Prior pelvic surgery.

Clinical Presentation

  • Pelvic pressure or heaviness, classically described as a feeling of something “falling out” or a bulge at the vaginal opening.
  • Symptoms worsen with prolonged standing and improve when lying down (gravity-dependent).
  • Urinary symptoms: stress incontinence, urinary frequency, urgency, or paradoxically difficulty voiding if the uterus kinks the urethra.
  • Difficulty with intercourse.
  • In Grade III-IV: the cervix or uterus is visible or palpable outside the introitus; the patient or clinician can see it.
  • The question stem would likely describe a postmenopausal multiparous woman with pelvic pressure, a sensation of vaginal bulging, and urinary symptoms.

Diagnostics

  • Pelvic exam performed with the patient standing or straining (Valsalva) to fully demonstrate prolapse.
  • Two grading systems:
  • Baden-Walker halfway system: clinical grading 0-4 based on descent relative to the hymen. 0 = none, 4 = full eversion (procidentia).
  • POP-Q (Pelvic Organ Prolapse Quantification): 9 anatomic points measured in cm from the hymen, staged 0-IV. More detailed, used for surgical planning.
  • Urodynamic testing: a series of bladder function studies that measure bladder pressure during filling and voiding, urine flow rate, and the point at which leaking occurs. Used pre-operatively if urinary symptoms are prominent and the type of incontinence (stress vs. urge) is unclear, so the right surgical procedure can be planned alongside the prolapse repair.
  • Prolapse often coexists with cystocele and rectocele, examine for both on exam.

Treatment

  • Asymptomatic or mild: observation, pelvic floor exercises (Kegel exercises) to strengthen support.
  • Pessary: a silicone or rubber device inserted into the vagina to mechanically support the uterus. First-line for women who prefer non-surgical management or who are poor surgical candidates.
  • Vaginal estrogen: for postmenopausal women to improve tissue quality and pessary tolerance (does not reverse prolapse on its own).
  • Surgical repair: the core principle is re-establishing apical (top of vagina) support. Hysterectomy alone does NOT repair prolapse, if the apex is not re-suspended, the vaginal cuff prolapses next. Two paths:
  • Uterine-preserving suspension (for women who want to keep the uterus): sacrospinous ligament fixation, uterosacral ligament suspension, or sacrohysteropexy (uterus suspended to the sacrum with mesh).
  • Hysterectomy PLUS apical suspension: vaginal, laparoscopic, or abdominal hysterectomy combined with uterosacral ligament suspension, sacrospinous fixation of the vaginal cuff, or sacrocolpopexy (vaginal cuff suspended to the sacrum with mesh).
  • Concurrent repair of cystocele and rectocele is usually performed at the time of surgical correction.

Exam Keys

  • Pelvic heaviness + bulge + worse with standing/straining + postmenopausal multiparous woman = uterine prolapse.
  • Pessary is the non-surgical treatment of choice.
  • Grade IV (procidentia) = complete eversion of the uterus through the introitus.
  • Urinary symptoms can go either way: incontinence OR retention depending on how the prolapsed uterus affects the urethra.
  • Kegel exercises help mild prolapse and reduce progression.

Cystocele

  • Herniation of the posterior wall of the bladder into the anterior vaginal wall, creating an anterior vaginal bulge.
  • The most common form of pelvic organ prolapse. Urine pools in the herniated portion of the bladder, impairing complete emptying.

Risk Factors

  • Vaginal delivery and multiparity: trauma to the anterior vaginal wall and pubocervical fascia.
  • Menopause: decreased estrogen reduces connective tissue and pelvic floor support.
  • Obesity and chronic increases in intraabdominal pressure (straining, heavy lifting, chronic cough).
  • Prior pelvic surgery.
  • Cystoceles often coexist with uterine prolapse and rectocele, examine for all three.

Clinical Presentation

  • Anterior vaginal bulge: the hallmark finding. The patient may notice tissue at or outside the vaginal opening.
  • Urinary symptoms are the dominant complaint: urinary frequency, urgency, incomplete bladder emptying, and stress incontinence (leaking with cough, sneeze, Valsalva).
  • Paradoxically, large cystoceles can cause urinary retention by kinking the urethra as the bladder herniates forward.
  • Symptoms worse with prolonged standing, exercise, and Valsalva, better when lying down.
  • The question stem would likely describe a multiparous woman with urinary leaking on exertion and a bulge at the vaginal opening on pelvic exam.

Diagnostics

  • Pelvic exam with the patient performing a Valsalva maneuver or standing, demonstrates the cystocele.
  • A bulge on the anterior vaginal wall = cystocele. A bulge on the posterior wall = rectocele. This distinction is made on exam.
  • Urodynamic testing if the specific type of incontinence is unclear or surgery is planned.
  • Post-void residual (PVR): elevated if the cystocele is causing incomplete emptying.

Treatment

  • Pelvic floor exercises (Kegel exercises): first-line for mild cystocele and stress incontinence.
  • Pessary: mechanical support for the anterior vaginal wall. Effective non-surgical option. Requires fitting and regular follow-up.
  • Vaginal estrogen: improves tissue quality in postmenopausal women, adjunct to pessary.
  • Surgical repair (anterior colporrhaphy): surgical plication of the anterior vaginal wall and pubocervical fascia. Definitive treatment for symptomatic or large cystoceles.

Exam Keys

  • Anterior vaginal bulge + urinary symptoms (frequency, incomplete emptying, stress incontinence) = cystocele.
  • Anterior wall bulge = cystocele (bladder). Posterior wall bulge = rectocele (rectum). Get the anatomy right.
  • Stress incontinence = leaks with Valsalva. Urge incontinence = can’t make it to the bathroom. Cystocele can cause both.
  • Pessary is the go-to non-surgical fix.
  • Surgical repair = anterior colporrhaphy.

Rectocele

  • Herniation of the anterior rectal wall into the posterior vaginal wall, creating a posterior vaginal bulge.
  • Because the rectum herniates into the vaginal canal, stool can collect in the herniated pouch, causing incomplete evacuation.

Risk Factors

  • Vaginal delivery and multiparity: injury to the rectovaginal septum and posterior vaginal wall.
  • Constipation and chronic straining: the most modifiable risk factor.
  • Menopause (decreased estrogen, reduced pelvic floor support).
  • Obesity, heavy lifting, chronic increases in intraabdominal pressure.
  • Rectoceles frequently coexist with cystocele and uterine prolapse.

Clinical Presentation

  • Posterior vaginal bulge: tissue prolapsing at or outside the vaginal opening.
  • Defecatory dysfunction: constipation, incomplete rectal emptying, a sensation of needing to push again after defecating.
  • Splinting: the patient presses on the posterior vaginal wall or perineum with a finger to assist defecation. This is the pathognomonic symptom of rectocele and the one boards use to identify it.
  • Pelvic pressure and fullness, similar to other prolapse types.
  • The question stem would likely describe a multiparous woman who reports needing to press on her vagina to have a bowel movement and notices a vaginal bulge.

Diagnostics

  • Pelvic exam with Valsalva: posterior vaginal wall bulge distinguishes rectocele from cystocele (anterior wall).
  • Defecography (fluoroscopic imaging during defecation): confirms the diagnosis and quantifies the extent of herniation in complex cases.
  • Colonoscopy if concurrent colorectal pathology needs to be excluded.

Treatment

  • Dietary fiber and stool softeners: reduce straining and address the primary driver in constipation-predominant cases.
  • Pelvic floor physical therapy: strengthens the pelvic floor and improves defecatory coordination.
  • Pessary: can support the posterior wall, though less effective for rectocele than for anterior prolapse.
  • Surgical repair (posterior colporrhaphy): plication of the rectovaginal septum and posterior vaginal wall. Indicated for symptomatic rectoceles failing conservative management.

Exam Keys

  • Posterior vaginal bulge + splinting to defecate = rectocele.
  • Splinting (pushing on the vaginal wall to defecate) is the buzzword that makes this diagnosis.
  • Posterior wall = rectocele (rectum). Anterior wall = cystocele (bladder). Know the anatomy.
  • Conservative first: fiber, stool softeners, pelvic floor therapy.
  • Surgical repair = posterior colporrhaphy.