Pelvic Organ Prolapse - Diagnosis

When Drs. McClure and McRackan first see a patient, they ask about the frequency and severity of the problem. Is it urgency incontinence or stress incontinence? About half the time, it will be a mixture of the two. The objective is to first address whichever problem is worse. To evaluate the problem further, they obtain a detailed history from the patient:

Severity of the problem
Prior pelvic or bladder surgeries
Other treatments already tried
History of childbirth
Sexual activity
Vaginal dryness due to low estrogen levels
Heavy lifting
Voiding complaints
Constipation
Most troublesome complaint
Other medical problems

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The next step is the physical exam, including a thorough pelvic exam to check for the nature and severity of any prolapse. It’s important that the pelvic exam be performed with the patient not only in a supine position but also standing. To further evaluate POP, a physician can use the single blade of a vaginal speculum to alternatively lift the bladder and push down on the rectum while the patient strains. Organ prolapse into the vagina is called a cystocele when it’s the bladder, a rectocele when it’s the rectum, and an enterocele when it’s small bowel. When the apex of the vagina prolapses its called vaginal vault prolapse.

Ancillary testing provides additional information. One example is urodynamic testing in which a small catheter is inserted into the bladder and a balloon catheter is placed in the rectum. The bladder is filled with sterile solution. Special transducers connected to the urethral and rectal catheters measure intra-abdominal and bladder pressure during the filling and voiding process. Perianal surface electrodes register sphincter muscular activity. After the initial test, the bladder is filled again and the urethral catheter removed. To see if there is leakage, the patient is asked to strain. If the patient has a cystocele, the bladder is manually lifted to its normal anatomical position and then has the patient strain and cough to see if there is leakage. A cystocele can mask underlying urinary stress incontinence. If both defects are present, it’s important to correct each for successful resolution of the problem.

Once the physical exam and ancillary tests are complete, Dr. McClure or Dr. McRackan sit down with the patient to go over the results and develop an individual treatment plan. Understanding and managing patient’s expectations about outcomes are critical for successful treatment and satisfied patients.

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