Hello and welcome to the Physician Assistant Exam Review Podcast episode 164. This one’s going to be all about pelvic organ prolapse. This was a topic I did not understand or pay much attention to when I was in PA school. It’s something that I spend a lot of time with now. I work in urogynecology, I don’t know, for the last 15 years, probably once or twice a week doing urogyn surgery. So this has become a mainstay of the things that I do on a day-to-day basis. Welcome to the Physician Assistant Exam Review Podcast.

This is where we talk about medical topics, but with an eye toward your PANCE, with an eye toward your end of rotation exams, with an eye towards how this information is going to impact you right now and in the future. We’re not doing one of the other, we’re not getting deep dives into the topics. We don’t pretend that you’re going to become an expert that you can recite a Cecil or Current on any of these topics. We are going to make sure that we can paint a picture so you have a broad understanding of what these things are. So that you can do deeper dives later, especially as you go into these different areas. But for now, it’s how are they going to come on your test? How are you going to be able to remember them?

There’s so much to learn, so much to do. And I get that the overwhelm is real. I hear about it all the time. But some of it is you’ve got to start taking some initiative. You have to start finding ways to work better, work faster. You have to start finding things that work for you. I know that it’s a struggle, I know that it’s tough.

But I’m finding, and my coaches have actually come to me and said, I feel like a lot of our students are wanting us to hand it to them, want us to give them a step-by-step process. And because everyone’s so different, we can’t. That’s a lot of what 33 Days to Pass the PANCE does, is I introduce, I’m trying to think of a number, lots of different tools, lots of different concepts and ideas, but every brain works differently, every student has a different history. Everybody works in a different fashion. So I can’t just hand it to you. I can’t say this is the way to study. It doesn’t work that way.

There are different things to try, different methods to work on. We’ll talk about some today. But anyway, the whole point here is to say that I expect you to be thinking. I expect you to be working, not just sitting back and letting the information wash over you and then expect you to retain it. That’s just not realistic. We’re not robots, right? We don’t have a scanning capability.

We have to internalize things. We have to think about them. We have to process them in order for them to stick. We can’t just see them once. Our brains require multiple touches to make anything stick for sure. Or a really good system, which most of us don’t have when we hit PA school for memorization. So if you have someone or you are someone, if you are someone who’s struggling and you know other people who are struggling, do me and them a favor.

Please share the show. Share the content we produce here. It may be the difference in keeping someone in school. Maybe the difference in getting someone through their PANCE. I can’t encourage that enough. We grow through your recommendations. I do very little as far as outreach goes.

I spend a lot of my time on these shows and on all the different things, including the 33 Days to Pass the PANCE program and the students in there. So currently I’m not putting a ton of effort into growing the show, which means all the more that I need your help and the other students need your help. So please let people know, let your faculty know about the program, about what we’ve been doing here for the past 15 years. And if it’s helping you, please share it out to other people, especially when they ask how you’re making out, how you’re succeeding.

All right, let’s jump into our priming questions for today. What is the pathognomonic symptom for rectocele? What’s the pathognomonic symptom for rectocele? How do you distinguish a cystocele from a rectocele on a physical exam? And what’s the first line, non-surgical treatment for uterine prolapse? So as we moved into today’s medical topics, we’re going to cover uterine prolapse, we’re going to cover cystocele, we’re going to cover rectocele. And that’s going to be, it’s going to be a quick show, but this is something I need you to wrap your head around a little bit, because these are going to be easy questions to get right.

I’m telling you, just easy questions to get right, if you can understand them. And there’s not that much to it. But it’s going to be real short. It’s going to be real quick. We’re just going to hit these highlights, and then we’re going to get out of here for this week. Uterine prolapse is the descent of the uterus, into or through the vaginal canal, due to weakening of the pelvic floor, ligaments, and musculature. So what happens here is the ligaments that are supposed to hold the uterus up, mostly the uterosacral ligaments, but there are others.

That tissue becomes weak for one reason or another, which we’ll get to in a second. And the uterus comes down into the vaginal canal. Now this is graded on different scales of severity. Procidentia is the most severe form. That’s a term you should know. This is complete uterine prolapse. Risk factors for this are vaginal delivery and multiparity.

This is the strongest risk factor. So if you think about the concern that the tissues may be stretched out and weakened, the pelvic floor ligaments and musculature may be weakened, a really powerful indicator, a really powerful risk factor is going to be vaginal deliveries, right? If you have a pregnant person who had C-sections, not going to be the same when we’re talking about uterine prolapse. Menopause is also a risk factor. You get decreased estrogen, reduces collagen synthesis, and the pelvic floor tone. Obesity and chronic increased intra-abdominal pressure, so straining, chronic cough, heavy lifting. Speaking of that, like I said, I work with a fantastic urogynecologist.

She was telling me the other day, not too long ago, about a study she came across that I believe I’m going to misquote this, but you’re going to get the idea. That was done on, they were comparing military females to civilian females. And what they came across was they had the military females had increased risk or an increased occurrence of prolapse. And one of the thoughts here was the increased straining or heavy lifting that was going on that this definitely has an impact. Other risk factors, connective tissue disorders, like Marfan’s or Ehlers-Danlos, these are connective tissue disorders so that you get, I don’t have a better way to say it, other than kind of stretchy. You can actually pull on someone’s skin. I don’t know, I wish I had a better way to describe this.

It’s not going to come across the right way. But you can actually pinch someone’s skin and pull it up like an inch or two off their body because their connective tissues just different. Their ligaments are lax. I had one of the nurses I used to work with who worked in this department had this very badly and she would show it off to us. Prior pelvic organ surgery is another one. That is a risk factor here. Clinical presentation, the patient comes in with a pelvic pressure or heaviness.

They feel like something might be falling out or there’s a bulge in the vaginal canal. The symptoms worsen with prolonged standing and they improve lying down, makes sense, right? You can get urinary incontinence, you get frequency, you can get difficulty voiding, and all those symptoms are because the bladder is right there. And again, this is really hard for me to understand as a PA student. Once I started doing C-sections, once I started doing hysterectomies and saw this anatomy, it became much more obvious. The bladder is literally sitting on top of the vagina and on top of the uterus. When you do a hysterectomy or a C-section, you actually have to dissect the bladder off of the cervix and the vagina as part of the surgery, right?

It is sitting right there. So if you can picture if the uterus falls down into the vaginal canal, it’s going to take the bladder kind of with it. So it’s going to cause a bunch of different symptoms that are going to be urinary symptoms. You can get that frequency because the bladder is compressed. You can get difficulty voiding because the urethra has been kinked a little bit by the pressure there. So all those things are possible. Again, this isn’t, it’s a little hard when you just say the words out loud to picture what’s going on.

But if you think it through, it’s not that complicated. It’s pretty obvious how this is going to work. Patients may complain about issues with intercourse, again, for obvious reasons. Grade 3-4 is where the cervix or uterus are visible or palpable outside the introitus. The question stem here is likely going to describe a postmenopausal, multiparous woman, with pelvic pressure and vaginal bulge and urinary symptoms. That package pretty much points towards some kind of issue, usually uterine prolapse. Diagnostics, a pelvic exam is going to be number one, obviously.

If you can have the patient strain to demonstrate the prolapse, it becomes more obvious, we also can see once we put a patient to sleep, it becomes more obvious, right? Because the muscle tone relaxes. There’s a couple of different grading systems. You can get the Baden-Walker halfway system and the POP-Q or pelvic organ prolapse quantification. I put them in the notes. You can check on the website. I’m not going to go through them in detail now because you’re not going to remember them.

I’m not sure how relevant they are for you, but I just put some notes in there for you. Urodynamic testing is something that they do for this. This is a bladder function study measuring bladder pressure during filling, voiding flow rate and leak points. So you can tell if the patient’s going to need a sling for urinary incontinence. Treatment, asymptomatic, or mild, you’re going to observe this. If they just have some complaints, but it’s really not that bad, you can observe it. Or if it’s just noticed on physical exam, but they don’t have any complaints.

Pelvic floor exercises, so Kegel exercises can be useful. They definitely have physical therapy for this. They installed a physical therapy, oh, I know what you call it, office. Yeah, I guess office makes sense, a physical therapy office in our hospital, specifically for pelvic floor work, which has been fantastic, a huge success. You can use a pessary, which is a first line non-surgical option for uterine prolapse. This mechanically supports the uterus. So this is a plastic or rubber disc that gets inserted into the vagina and it will help the uterosacral ligaments to support the uterus.

Vaginal estrogen can improve the tissue quality and it can also help with, there’s an issue, one of the issues with using a pessary: one, it just sounds uncomfortable, right? I appreciate that. But the second part of that is the longer it stays in the more uncomfortable it gets, there’s wear on the tissue. So I say that because the vaginal estrogen will help to alleviate some of the wear in the tissue from that pessary, but long-term use is different. And then lastly, we have surgical repair, which is where I come in. I work in, for a community hospital as a first assist in all kinds of subspecialty. So we work in orthopedics, we work in ENT, we work in plastics, we work in GYN, we work in, try to think of what else, we do GYN, and we help in urogyn.

So here when we work in surgical repair, the key is to reestablish support. So one of the main keys here, and this isn’t going to come up on your test, but I wish people would take away from this section in your practice, especially if you’re going into family med or gynecology or any of these areas. A hysterectomy alone does not repair prolapse. Let me say that again, hysterectomy alone does not repair prolapse. The patients that we see are generally speaking postmenopausal women with 25 to 30 gram size uterus, right? We’re not talking about a 2,000 gram uterus, where the weight of the uterus is the problem. What we’re saying is the ligaments have been stretched out.

The ligaments are no longer functioning. The tissue is no longer functioning to hold up the cervix and the vagina. Simply removing that 30 gram uterus is not going to be enough to keep the cervix in place. You have to actually reestablish the support of the vagina and the cervix. There’s a couple ways you can do that, but that’s a key that we see a lot still where patients will have a hysterectomy for uterine prolapse, and it’s not going to solve the problem. Yes, the uterus will no longer be falling out, but you will have an issue where the cervix and the vagina are still, the cervix is still coming out through the introitus. So even if you have no uterus, you still have a problem, right?

So how do we do that? There’s a couple of different ways to treat this. So you can do a sacrospinous ligament fixation, you can do a uterosacral ligament suspension. Those are the ways you can do it while preserving the uterus because you may have a situation where patients don’t want their uterus out or they don’t want a more invasive technique. So you can support them through a vaginal surgery. Another thing that we do very commonly is a sacrocolpopexy. In order to do that, we have to do a hysterectomy.

And then we do an apical suspension by putting a mesh along the anterior vaginal wall and along the posterior vaginal wall. And then suspending the vagina and the cervix to the sacrum. So we’re actually re-establishing those ligaments. You could also, another thing you could do that can be less invasive, is to do a uterosacral suspension. So you can tighten up the uterosacral ligaments. That tends to not work as well, but is also a possibility. I’m getting a little deeper into the weeds here than you need to get.

Certainly not important for your cases. I guess the most important thing for you to understand is that, and again, where I started this, is that a hysterectomy alone is not going to solve the problem. You have to do an apical suspension. You have to reinforce those ligaments. It’ll also usually repair a cystocele and rectocele at the same time. We’ll get to that in just a second.

Exam keys, pelvic heaviness plus a bulge, plus worse with standing or straining, in a menopausal or multiparous woman, this equals uterine prolapse until proven otherwise, right? You’re going to lean into that. Pessary is the non-surgical treatment, but it’s really not going to help long-term. Procidentia is the term for complete eversion of the uterus through the introitus. You can get all kinds of different urinary symptoms from incontinence to retention. And Kegels is also a mainstay of treatment here, and it’ll help with mild prolapse, but it’s not going to reduce the progression much if once those ligaments have relaxed too far. Cystocele.

This is a herniation of the posterior wall of the bladder into the anterior vaginal wall, a herniation of the posterior wall of the bladder into the anterior vaginal wall, creating an anterior vaginal bulge. This is the most common form of pelvic organ prolapse. So what happens here, again, I said that the bladder sits right up on top of the anterior wall of the vagina. Over time, and through, again, the relaxation of those tissues, the stretching out of the tissues and ligaments there, the bladder will actually sit down into the vagina, especially when standing. This will cause a pooling of urine in that area. It also might cause incomplete emptying. Again, risk factors are going to be vaginal delivery and multiparity, menopause, obesity, chronic increased intra-abdominal pressure, pelvic organ surgery.

And again, this usually goes along with uterine prolapse and rectocele. Because if we’re talking about someone with Marfan syndrome or Ehlers-Danlos or some connective tissue disorder, some underlying connective tissue issue, connective tissue issue. That’s a good one. You’re not just going to get one of these, right? All of the ligaments and musculature are going to be weakened. It’s not so specific to one area or another. So these usually go together, not always.

Sometimes you just have one or sometimes you have the whole all of it, but sometimes, you know, but that’s if you think about the way that this works, that just makes sense. And these patients are going to have an anterior vaginal bulge. That’s kind of the key here, right where that bladder sits. They’re going to have an anterior vaginal bulge. Urinary symptoms here are going to be the most important feature that they’re going to complain about, frequency, urgency, incomplete bladder emptying, stress incontinence, leaking with a cough, sneeze or a Valsalva. Again, large cystoceles can paradoxically cause urinary retention because you’re kinking off the urethra, so don’t be fooled by that. But I’d be really surprised on your exam if they’re going to go that far.

The question stem here is again going to be very similar. Multiparous woman with urinary leaking on exertion and a bulge at the vaginal opening on pelvic exam. You’re going to have a hard time discerning that from uterine prolapse and you’re going to have to do some exams to find that out a little bit deeper. The clinical presentation is going to be pretty similar.

Okay, so how do we tell these apart? We’re going to do a pelvic exam with the Valsalva, like we said before, to demonstrate that cystocele, that anterior vaginal wall bulge. The posterior wall would be a rectocele which we’re going to get to in a second. You can do urodynamic testing, like we talked about, and a post-void residual to see if it’s elevated. Treatment here is going to be, again, similar: pelvic floor exercises like Kegels are the first line for mild disease, you can do a pessary to help hold the anterior vaginal wall, vaginal estrogen especially in postmenopausal women, and you can do an anterior colporrhaphy, which is a surgical repair, you’re plicating the anterior vaginal wall and the pubocervical fascia. So you’re going to be taking that tissue down and repairing it so that it has less laxity to it.

Exam keys, anterior vaginal bulge, plus urinary symptoms is a cystocele. If you should have that anterior wall, that anterior wall is really the key to this. And that surgical repair is an anterior colporrhaphy. Although, I, again, I’d be shocked if you had to know that. Rectocele is a herniation of the anterior rectal wall into the posterior vaginal wall, creating a posterior vaginal bulge. Don’t memorize those words. Picture it in your mind.

The rectum sits directly behind or posterior to the vagina. So if a person is standing and the rectum is herniating into the vagina, it’s going to be through the posterior wall of the vagina, right? It’s going to be the anterior wall of the rectum. Don’t memorize it, understand it. That’s a really key principle and we’re going to talk about that in just a second. Here stool collects in the herniated pouch causing incomplete evacuation. What do you think our risk factors are for this?

If you said vaginal delivery and multiparity, you would be right. Constipation and chronic straining can add to these, menopause, obesity, heavy lifting. And again, this frequently goes along with cystocele and uterine prolapse. They, the three travel together for the reasons we spoke about a second ago. Here we don’t have an anterior vaginal bulge. We have a posterior vaginal bulge, the tissue prolapsing at or outside the vagina opening. You can get issues with constipation and incomplete rectal emptying, sensation of needing to push again after defecating because you feel that fullness.

And here’s the term you may see on your exam, it’s called splinting, where the patient presses on the posterior vaginal wall or perineum with a finger to assist defecation. Because they’re having trouble making a bowel movement because it’s pressing into the wrong space. Right? It’s pressing into the posterior vagina. So the patients will develop over time a habit or a technique called splinting, which is pressing on the posterior vaginal wall to assist in defecation. And this is pathognomonic for rectocele. Pelvic pressure and fullness, similar to that of a prolapse.

And the question stem here is going to be a multiparous woman who reports needing to press on her vagina to have a bowel movement and notices a vaginal bulge. Again, where is that bulge going to be? It’s going to be posterior. So diagnostics, we’re going to do a pelvic exam with Valsalva. We’re looking for that posterior vaginal wall bulge. And we’re not necessarily looking for that. We should be able to see it on exam with this story.

Maybe you’re looking for it, but in general, they’re going to complain about some fullness. And you’re not sure if we’re talking about a full uterine prolapse, a rectocele or a cystocele. And so you’re trying to make that determination. The treatment: dietary fiber and stool softeners will help reduce straining and address the primary issues of constipation. You can do that, again, that pelvic floor, physical therapy and kegels, a pessary to help support the walls of the vagina might be useful. Or here we do a posterior colporrhaphy in the operating room. We plicate the rectovaginal septum and posterior vaginal wall to help reinforce that tissue.

So we go from an anterior vaginal wall bulge, which is a cystocele, to a posterior vaginal wall bulge, which is a rectocele. Again, it sounds like a lot of words. It’s not that complicated. Splinting is your key term for this and your surgical repair is a posterior colporrhaphy, but again, I would be shocked if they asked you about that specifically. I had something else in mind, but our study tip for today, because we just wrapped up prolapse, so that’ll be the end of our medical content. Study tip for today, it’s going to be sometimes it’s, and this is what I want to talk about the beginning about taking some initiative and understand and seeing what works for you and when you need to pivot, when you need to understand things. I teach multiple ways to take tests, multiple ways to go through questions because not all questions are the same, not all test takers are the same.

So if you just look at me, when I’m taking a test, I probably go through questions at least three to four different ways, whether they’re short, whether they’re long, whether it’s something I understand, whether it’s something I don’t understand, whether I’m lost, whether I totally get what we’re doing. All different techniques and tools. The same goes with study. And I bring it up here because generally people fall into two camps when it comes to studying. The idea that you should memorize and the idea that you should understand. I am much worse at memorizing than I am at understanding and rebuilding my memory. That being said, there’s a time and a place to memorize.

I will use that as one of my tools. It’s not either or. It is this a good place to apply it. Is this a good place to apply understanding and I’ll rebuild the images when I need them? I am never, and this is why I struggled in PA school, ever going to remember that a cystocele has an anterior bulge and it’s the posterior wall of the bladder, herniating into the anterior wall of the vagina. Not in a million years, but I just said that from memory. How can that be the same?

Well, because I’m picturing into my mind as I’m saying it, I’m literally in my head watching the bladder fall into the vagina. There’s only one way that can happen. From the posterior wall of the vagina through the anterior wall, I’m sorry, from the posterior wall of the bladder through the anterior wall of the vagina. But I’ll never remember it. I’ll never memorize that list. That’s never, never going to happen for me. But I’ve discovered over the years that if I understand something I can rebuild that memory.

The key is understanding when, is to know what tools are available and then knowing when to apply them for you. There are certain things that just straight up get memorized. There are certain things that absolutely just get understood and rebuilt at the time. I hope that after listening to this show for a while, you start to see some of these different tools and how they can be used in different settings, in different places, and what might work for you moving forward. Again, different from what works for your friends. You may be like me and struggle to memorize. The person sitting next to you may be great at memorization.

So they go all in and just pure memorize everything. It’s going to be a little different for everyone. So you can use other people’s tools, but pay attention to what works for you, not just what’s getting good scores for other people.

All right, let’s go back and hit our priming questions. What is the pathognomonic symptom for rectocele? We just covered this. What was the word we used? Splinting. And what was it? It was putting pressure on the posterior vaginal wall to assist defecation.

How do you distinguish a cystocele from a rectocele on exam? Well, this is pretty easy to just picture the anatomy, right? A cystocele is an anterior wall bulge, a rectocele is a posterior wall bulge. What’s the first line, non-surgical treatment for a uterine prolapse? Pessary.

All right, well done. Again, this is not a complicated section. This is not heart murmurs, but it is something to understand and be able to get right. It’s not that hard. There’s most likely going to be a question on this, on your exam, easy, easy one to pick up. If this episode helped in any way, like I said earlier, please, please, please let someone else know about it. Let a classmate know, let a faculty member know that you’ve been listening to this, that it’s been changing the way that you do things, that you’ve been thinking differently, and it’s helping you score higher in less time.

It’s so important to me and to the members of your cohort, and the members of your faculty and your program, that we can share this information. I’d like to be a small part of that journey, and I really appreciate you allowing me to do that. So thank you so much for your participation here. Thank you so much for the kind emails I’ve been getting from people saying how much it’s been helping on their EORs and everywhere else. If you want to go deeper, our next cohort of 33 Days to Pass the PANCE will be starting June 1st. So registration will open up fairly soon in the middle of May we’re getting there. So we’ll run cohorts every other month this year in 2026, we’re expanding it from five cohorts to six this year because the demand’s been so high, it’s been going so well.

But if you’re interested, head over to physicianassistantexamreview.com/33 to find out more about going deeper into some of these ideas. Until next time, keep working, keep showing up, keep thinking about how you’re approaching the material, keep thinking about how you’re taking your exams. I’ll see you next week. Take care.