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Pelvic organ prolapse.

Pelvic organ prolapse, a condition in which the ligaments and muscles that suspend the vagina within the pelvic cavity weaken or break, is a frequent cause of urinary and fecal incontinence. Stigma, embarrassment and the belief that pelvic organ prolapse is a natural part of aging prevents many women from seeking treatment. Medical imaging modalities such as defecography, dynamic magnetic resonance imaging and ultrasound help health care providers make effective treatment decisions.

After reading this article, the reader should be able to:

* Describe the anatomy of the pelvic cavity.

* Describe types of pelvic organ prolapse.

* State risk factors associated with pelvic organ prolapse.

* Relate pelvic organ prolapse to urinary and fecal incontinence.

* Describe the steps to diagnose pelvic organ prolapse.

* Discuss the role of diagnostic imaging in evaluating pelvic organ prolapse.

* Describe typical medical and surgical pelvic organ prolapse management strategies.

* Understand special patient management considerations.

Approximately 1 in every 10 women undergo surgery for pelvic organ prolapse and associated urinary and fecal incontinence by the time they reach age 70. (1) This is a significant underestimation of the number of women who actually need treatment because many women believe that pelvic organ prolapse is a natural part of aging and is untreatable. Women believe that major surgery is the only treatment option. And, because some physicians also have these misperceptions, many women who ask their doctors for help may not receive adequate or appropriate care. (2) These impressions, in addition to the stigma and embarrassment associated with the condition, are why pelvic organ prolapse is under-reported and undertreated.

Baby boomer women are starting to change this picture. Demographic research projects a 45% increase in the demand for medical and surgical services related to pelvic organ prolapse over the next 30 years. (3) Clinicians need to recognize "normal" pelvic floor architectural relationships to reliably diagnose and treat pelvic organ prolapse and related conditions.

Medical imaging research helps clinicians differentiate patients with mild pelvic organ prolapse who can benefit from medical management from patients who require surgery to reduce discomfort and to improve quality of life. The imaging modalities used to diagnose pelvic organ prolapse provide dynamic pictures that help radiologists, urogynecologists, gynecologists and other specialists evaluate the anatomical and functional relationships that occur during the defecation process when pressure increases on pelvic cavity organs.

The Pelvic Cavity

The pelvic cavity is the space enclosed by the pelvic bones and contains the urinary bladder, the urethra, part of the large intestine and the reproductive organs. The abdominal cavity, located above the pelvic cavity, is not a structurally separate entity; together, these 2 regions are sometimes called the abdominopelvic cavity. (See Fig. 1.)

The pelvic cavity consists of 3 compartments. The anterior compartment contains the bladder and the urethra, the middle compartment contains the vagina and the posterior compartment contains the rectum. (4) An intricate and integrated system of fascia, ligaments and muscles helps maintain the architectural relationships between these 3 regions. Because these areas are functionally integrated units, a defect in 1 compartment often affects other pelvic cavity regions.

The pelvic floor fascia and ligaments, like a hammock, passively support the vagina and the organs that rest on them. Pelvic floor muscles provide active support when they contract in response to coughing, standing and other physical activities that temporarily increase pressure on the pelvic floor. Damage to either the passive or active support system causes displacement of pelvic cavity organs.

What Is Pelvic Organ Prolapse?

Pelvic organ prolapse occurs when the ligaments and muscles that suspend the vagina within the pelvic cavity weaken or break. This causes the vaginal walls, which are attached to the ligaments and muscles, to sag. The vagina may slide toward and sometimes through the vaginal opening as prolapse worsens or progresses. Once the vagina is no longer inside the body, the pelvic organs lose vaginal support and follow the same downward path. The pelvic organs are contained within the displaced vagina.

Clinicians use various terms to describe pelvic organ prolapse. When the anterior vaginal wall sags, the bladder, which rests upon the vaginal wall, also falls from its usual position. This kind of sagging is called a cystocele, or an anterior compartment defect. (See Fig. 2.) When the posterior vaginal wall sags, the rectum moves downward and may produce a rectocele, or a posterior compartment defect. (See Fig. 3.)

When the apex, or top, of the vagina falls from its normal position it forms an apical prolapse. Sometimes the uterus, located above the vaginal apex, also falls along with the vagina. Though many believe otherwise, the uterus does not cause the prolapse--it is simply following the prolapse out of the body. Women often have pelvic support weaknesses that include all 3 regions of the vagina. (See Fig. 4.)

A vaginal eversion is when the vagina turns inside out, similar to a pants pocket. When this extreme situation occurs, the "pocket" may contain the uterus, bladder and sometimes fat. Protrusion of the small bowel or an enterocele is also commonly associated with a vaginal eversion. (5) (See Fig. 5.) A hysterectomy increases the risk of later having vaginal eversion. (6)

Some prolapses of the pelvic organs are not as severe as the previously described conditions. Although the pelvic organs may not be 100% in place, they do not sag enough to produce noticeable or bothersome symptoms. In fact, research shows that 50% of menopausal women have some degree of pelvic organ prolapse; of those, only 10% to 20% have noticeable symptoms. (7)

Risk Factors

Many studies reveal that pregnancy is the most significant risk factor associated with pelvic organ prolapse. During labor and delivery, the pelvic muscles stretch to allow the baby to move through the birth canal. Sometimes this weakens or even tears supportive muscles. Childbirth also can cause nerve damage, which can prevent pelvic floor muscle contraction and disengage pelvic organ support. When pelvic floor muscles fail, the ligaments that connect the vagina and uterus to the pelvis may temporarily provide support. If these overstressed ligaments weaken or break, pelvic organ prolapse--with its origin 20 or 30 years earlier during labor and delivery--continues a downward descent. Additional pregnancy-related risk factors include:

* Having a large baby.

* Multiple births.

* Prolonged labor.

* Use of forceps or vacuum extraction.

* Closely spaced births.

Pregnancy is not the only risk factor; women who never gave birth or had cesarean deliveries also can have pelvic organ prolapse. (8) Examples of other risk factors include:

* Obesity.

* Large uterine fibroids.

* Chronic coughing.

* Heavy lifting.

* Hysterectomy.

* Smoking.

* Chronic constipation.

* Previous pelvic surgeries.

Some genetic conditions can put women at risk for pelvic organ prolapse. Marfan and Ehler-Danlos syndromes are 2 rare, inherited conditions that affect the structure of connective tissue and its ability to support organs throughout the body. As a result, women with these syndromes have connective tissue-related problems ranging from aneurysms to fragile skin to unstable joints. (9,10)

Pelvic organ prolapse is more common among certain racial groups. Using the demographic data from a cross-sectional analysis of more than 27 000 women enrolled in a hormone replacement therapy clinical trial, researchers discovered that Hispanic and white women have the highest risk for pelvic organ prolapse and that black women have the lowest risk for this condition. (11) The study suggests that understanding the link between race and pelvic organ prolapse may help provide patients with improved preventive strategies such as weight-loss and smoking cessation programs.

Related Problems

Depending on the location and degree of prolapse, related problems can range from stress incontinence and urinary retention to fecal incontinence, constipation and fecal retention. Stress incontinence, often described as "laugh and leak," occurs when pelvic organ prolapse causes the bladder and urethra to move from their usual positions. When this happens, the sphincters that control urination can no longer withstand the increased pressure caused by a full bladder, coughing, sneezing or even standing from a seated position. Women with stress incontinence often experience constant urine leakage, or "dribbling." They may lose larger amounts of urine when an event such as a cough puts extra pressure on the bladder.

Urinary retention may occur when pelvic organ prolapse causes the bladder to slide down into the vagina. Because of resulting kinks in the urethra, some women cannot completely empty their bladder or urinate at all without first pushing the bladder-containing bulge back into the pelvic cavity. Although this problem may seem like an improvement over dribbling and wetness, these women experience constant urgency and frequent bladder infections. (1)

Nearly 1 out of every 3 women with prolapse-related urinary incontinence also have fecal incontinence (R. Rogers, oral communication, July 2005). Fecal incontinence describes a range of conditions that include the involuntary passing of gas and the inability to control passing watery or solid stool. Gas is the most difficult bowel material to control, followed by liquid and then solid feces. Perineal tears, often caused by childbirth, are probably the most common cause of fecal incontinence. (1) Other causes of fecal incontinence include anal sphincter damage, chronic diarrhea and chronic constipation with stool impaction.


Women who have pelvic organ prolapse are usually aware that something is wrong. Although some seek treatment, embarrassment or the assumption that prolapse is just a part of aging keeps many women from voluntarily discussing their concerns with a physician.

This means that health care providers need to be skilled at asking open-ended questions so patients can comfortably talk about this emotion-laded topic.

Patient History

While taking the patient's medical history, the clinician may ask about pregnancy and childbirth experiences and dietary and smoking habits. The patient may then volunteer having had a difficult childbirth delivery and even that she experienced urine leakage for a short time afterward. This, and information such as having chronic constipation, are clues that the patient may have pelvic organ prolapse and prolapse-related incontinence problems.

Women who have mild pelvic organ prolapse often do not report having any symptoms related to their condition. With moderate pelvic organ prolapse, many women describe their symptoms as "feeling like I am sitting on a ball." Frequently, patients say they have lower abdominal and back discomfort that worsens after standing for long periods or at the end of the day. Others may volunteer that their vagina seems different or that they feel or see protruding tissue. Other symptoms that women may mention include difficulties during intercourse, constipation or the sensation that "something feels stuck" after a bowel movement.

Physical Examination

During physical examination, tim clinician thoroughly inspects the abdomen, urogenital areas and rectum for masses and indications of reduced muscle tone. Urinalysis, particularly when patients mention urinary urgency, is another important diagnostic tool; ruling out a urinary tract infection can save women from undue worry, time and expense (R. Rogers, oral communication, July 2005).

If urine loss is reported, the patient should undergo tests to differentiate between neurological and prolapserelated causes. (See Table 1.) Tests such as the cotton-tipped swab test are office procedures. Others, such as urodynamic testing, require specialized training and facilities.

During the physical examination the doctor asks the patient to cough, bear down or perform a Valsalva maneuver (the patient tries to exhale with her nose pinched and mouth closed) to see if and how far the vagina protrudes as a result of the additional abdominal pressure. Next, the physician opens the vagina with a speculum to inspect the cervix and vagina and measure vaginal length. The physician places half a speculum against one wall of the vagina and asks the patient to perform a Valsalva maneuver again; this is repeated for each side to reveal evidence of anterior and posterior vaginal wall defects as well as vaginal apex sagging. (See Fig. 6.) The physician also measures the anterior, posterior and apical vaginal walls, the vaginal opening and the perineum. These important measurements help rate the prolapse and plan treatment.

There are several ways to describe pelvic organ prolapse size and severity. Many physicians simply tell patients that they have a small, medium or large prolapse. Other physicians use a ruler to measure the vaginal protrusion. The hymenal ring, located at the vaginal opening, serves as the reference point. A negative number means that prolapsed tissues and organs are still contained inside the body and do not protrude past the hymen; a positive number means that pelvic organ prolapse extends past the hymen and is outside the body (R. Rogers, oral communication, July 2005). (See Table 2 and Fig. 7.)

Some physicians rate pelvic organ prolapse using the standardized Pelvic Organ Prolapse Quantification (POP-Q) method. Rather than simply describe a prolapse as small or large, POP-Q staging compares the location of specific anterior, posterior and apical sites to the hymenal ring. The stages, numbered from 1 to 4, refer to the prolapse severity. (See Table 3.) Although these staging methods help the clinician describe the extent of pelvic organ prolapse, they do not define or identify the organs that lie behind each bulge. A variety of medical imaging modalities and techniques can identify these organs and reveal defects not observed during physical examination.

Medical Imaging and Diagnosis

Medical imaging has helped researchers learn about normal pelvic floor architecture and functional dynamics and is improving pelvic organ prolapse diagnosis and treatment. In various studies of both asymptomatic and symptomatic women, medical imaging has revealed a wide range of "normal" pelvic appearances. In a seminal study of 56 asymptomatic women, Mathieu and colleagues defined 5 criteria that describe normal pelvic activity. (12) Using evacuation defecography as the imaging modality, defecation of a fabricated fecal substitute revealed the following criteria:

* Increased anorectal angulation.

* Obliteration of the puborectal muscle impression.

* Wide anal canal opening.

* Total evacuation of contrast media.

* Normal pelvic floor resistance.

Dynamic magnetic resonance (MR) imaging is another research and diagnostic tool. In this modality, radiologists use the pubococcygeal line rather than the hymenal ring as the reference point. (See Table 4.) Generally, pelvic organ prolapse is the diagnosis when bearing down causes movement of the bladder base, uterine cervix and vaginal apex below the pubococcygeal line. (13) Widening of the rectovaginal space by peritoneal fat, the small bowel or sigmoid colon indicates the presence of a peritoneocele, enterocele or a sigmoidocele. The trapping of contrast after evacuation indicates a rectocele. (13)

By providing visual information, medical imaging transfers the responsibility of discussing incontinencerelated issues from the patient to the clinician. Improved communication between the patient and the health care provider can help her make an educated decision because treatment options have been discussed and defined. Studies demonstrate that medical imaging often reveals more extensive prolapse than what was discovered during the physical examination. Evacuation defecography shows that the physical exam misses nearly 1 out of every 2 enteroceles. Other studies have found that evacuation defecography changed the diagnosis of rectocele, enterocele and cystocele in 75% of patients. (14) According to researchers, the relative insensitivity of physical examination to detect prolapse is because of:

* The patient's inability to forcefully strain during the physical examination.

* Difficulty in identifying bulge contents by palpation.

* Complete pelvic floor relaxation only occurring during voiding and defecation.

Complementing the physical examination with medical imaging improves the outcome of a comprehensive surgical procedure, possibly reducing the need for additional pelvic organ prolapse surgeries.


Defecography, also called evacuation proctography, is a diagnostic radiographic technique that shows how the lower bowel responds to feces arriving from the sigmoid colon. Defecography demonstrates pelvic floor movement in addition to the normal rectal and anal canal changes that occur during defecation and evacuation. The technique is used to evaluate or confirm conditions such as functional obstructions, rectal prolapse, rectocele and fecal incontinence.

Patient preparation and testing procedures vary. Many medical imaging facilities have the patient use an enema or a glycerin suppository to clean the bowel before contrast media administration. Barium often is thickened with potato starch or some other substance to make the media similar in consistency to feces. A bladder syringe or a caulking gun is used to inject approximately 120 cc of contrast medium directly into the rectum. Some facilities inject contrast gel into the vagina to facilitate the diagnosis of enteroceles. (15) (See Figs. 8 and 9.)

Typically, evacuation defecography imaging requires the following steps:

* Pre-evacuation lateral imaging to assess anorectal configuration and pelvic floor position.

* Rapid evacuation into a radiolucent commode to assess anorectal function and pelvic floor movements.

* Postevacuation imaging to assess return to pre-evacuation position and rectal emptying efficiency.

Dynamic Magnetic Resonance

Advances in MR technology have made it possible to obtain anatomical and functional information in 1 examination procedure. Advantages of MR to evaluate pelvic organ prolapse include avoiding ionizing radiation and the ability to obtain detailed images of soft tissue and multiplanar images. Dynamic MR, in which the patient bears down and increases abdominal pressure, provides a realistic view of pelvic cavity dynamics and organ movement.

An ongoing study at the University of New Mexico Health Science Center is using dynamic MR to evaluate the efficacy of medical management to treat women with POP-Q 2-staged prolapse. Rather than surgery, these women have the option of wearing a removable internal support, or pessary. Preliminary results show that a pessary limits bladder movement even when bearing down. (See Fig. 10.)

The optimal MR imaging methodology for pelvic organ prolapse varies. It is possible to image patients at rest, straining or while defecating. However, many researchers state that images taken while the patient strains or defecates an injected mixture of ultrasound gel and mashed potatoes provides the most realistic information. The addition of gadopentetate dimeglumine to the injected mixture provides rectal contrast, making it easier to evaluate the patient for rectal evacuation abnormalities. (5)

Patient positioning is another important variable. Many researchers are concerned that patients may have difficulty defecating while supine and that asking patients to do so during the procedure may mask clinically important pelvic floor defects. Other researchers believe that having patients seated during the procedure masks problems and symptoms that occur during the course of daily activities. Patients usually are asked to void before undergoing dynamic MR imaging so that the full and distended bladder does not prevent movement of the uterus and the small bowel. (5)


Medical researchers are developing new ways to use ultrasound to detect pelvic floor and lower urinary tract structural changes associated with incontinence. Some medical researchers and clinicians believe that a pelvic floor ultrasound may become an important gynecological screening tool similar to an annual mammogram. However, before a pelvic floor ultrasound can become part of a woman's annual exam, researchers need to establish:

* Anatomical norms.

* Measurement technologies that provide reproducible results.

* Standardized patient preparation and positioning. Ultrasound research has found that among young, nulligravid and continent women there is a wide range of "normal" values for various pelvic floor structures at rest and when performing Valsalva maneuvers. (See Table 5.) Ultrasound studies also show that urethral diverticula and funneling or widening of the proximal urethra during a Valsalva maneuver are some of the anatomical changes associated with pelvic organ prolapse and associated stress incontinence. (16) Ultrasound can uncover many other incontinence-related tissue and structural changes that are not detectable during a routine gynecological examination. (See Table 6 and Fig. 11.)

Patient preparation and placement can affect ultrasound results. Patients should be examined with a partially filled bladder to make it easier to demonstrate urethral funneling. (16) Some researchers recommend that sonographers position the patient in a semireclining position because they claim that patients lying fiat have difficulty performing a Valsalva maneuver. (16) Although it is easier for patients to perform Valsalva maneuvers when standing, it is difficult to place and manipulate the ultrasound transducer below the patient. Other ultrasound researchers report that the supine position does not compromise the patient's ability to perform a Valsalva maneuver (R. Hall, oral communication, November 2003).

Medical Management

Medical treatments that help women manage pelvic organ prolapse include strategies that either reduce pressure on the pelvic floor or provide pelvic floor support. Increasing dietary fluid and fiber helps prevent constipation and produces softer stools to avoid straining. Weight loss may reduce prolapse symptoms by reducing pressure on the pelvic floor. Helping patients stop smoking may eliminate excessive coughing, which also causes excessive pressure.

Pelvic floor exercises (PFEs) and pessaries are treatments that supplement pelvic organ support. To exercise pelvic floor muscles, women squeeze and then relax their vagina. Although the squeeze motion is identical to the motion used to stop urine flow, women should not perform PFEs when urinating because doing so may eventually make emptying the bladder more difficult. (1) Research shows 60% to 80% of women who regularly perform PFEs for a minimum of 3 months can reduce and sometimes eliminate prolapse-related urinary incontinence. (1) Patients must continue a PFE regimen to maintain improved continence.

Many women who have stress incontinence use silicone vaginal pessaries to reposition the urethra. Often clinicians recommend the simple ring pessary to compress the urethra and thereby manage stress incontinence. (See Fig. 12.)

Frequently, women who have stress incontinence also have extensive pelvic organ prolapse. In this situation, a pessary that has both an incontinence knob and a support rim to help prevent pelvic cavity organs from sagging into the vagina can help alleviate incontinence and pelvic organ prolapse problems. (See Fig. 13.)

Surgical Management

Day surgery procedures or more extensive surgical repairs may be the best option when medical managemerit is ineffective or does not provide sufficient relief. (1) The midurethral sling, a relatively new technique used to support and reposition the urethra, is usually a day surgery procedure. This treatment involves weaving a supportive ribbon under the middle portion of the urethra. Depending on the type of midurethral sling procedure, support materials can include polypropylene ribbons or cadaver and fibrous tissue pieces taken from the patient or from a human cadaver. The surgeon does not attach the support ribbon to structurally stable tissues or bone. (See Fig. 14.) The implant provides support by increasing friction, which decreases organ movement. Over time, the body deposits collagen in and around the implant, permanently positioning the support ribbon.

Anterior repairs to support the urethra and bladder and posterior repairs to treat rectocele and enterocele are more invasive and require more extensive surgery. Surgical techniques also are available to treat vaginal vault prolapse.

Patients in the Medical Imaging Facility

Women with pelvic organ prolapse and associated urinary and fecal problems probably constitute a significant percentage of all medical imaging patients. While some patients undergo procedures to diagnose the type and amount of prolapse, others are there for reasons unrelated to pelvic organ prolapse.

Many women undergoing a prolapse-related diagnostic procedure such as evacuation defecography or dynamic MR are embarrassed about their condition and are afraid that they might leak urine or feces during the test. The procedures are sometimes physically awkward and involve actions that do not come easily or naturally to many patients. This is why it is important for the radiologic technologist to be reassuring and calm and clearly explain the procedure and what actions the patient will be required to perform. Asking the patient to rehearse the steps before actually performing the diagnostic procedure can be helpful.

Women who come to a medical imaging facility for a mammogram, a kidney-urethra-bladder test to detect kidney stones or any other imaging procedure also may have prolapse and urinary and fecal incontinence. Incontinence can affect patient positioning, the ability to tolerate confinement in MR equipment and the technologist's ability to obtain artifact-free images. Patients who have stress incontinence may be reluctant to get into positions that put pressure on their bladder and urinary sphincter. Few patients voluntarily report having pelvic organ prolapse or incontinence, but open-ended questioning can provide information that allows the radiologic technologist to adjust procedures to accommodate patient needs. Questions such as, "Would you like to schedule a bathroom break?" and "Do you find certain positions uncomfortable?" often reveal further information.

Because procedures such as evacuation defecography require patients not to void before testing, reminding them not to worry about leaks is helpful. Positioning patients on an absorbent pad can help incontinent patients feel more comfortable.

Many preprocedural questionnaires ask patients about indwelling hardware, but few specifically mention vaginal pessaries. Vaginal pessaries support and reposition pelvic cavity organs and wearing one can cause anatomical distortion; therefore, patients should remove or have their pessary removed before undergoing lower abdominal medical imaging procedures. However, it is safe for patients to wear a pessary, which are made of rubber, when having a MR procedure for reasons unrelated to pelvic organ prolapse and incontinence. (17)


Many people believe that pelvic organ prolapse and incontinence are the last health stigmas of the 21st century. (2) In addition to misunderstanding and embarrassment, pelvic organ prolapse compromises quality of life and makes otherwise healthy women feel frail and sickly. Women often lose the self-confidence necessary to work and to socialize with friends and family.

Pelvic organ prolapse and incontinence, while not lethal, are very expensive conditions. Researchers estimate that the total costs of urinary incontinence--including items such as laundry, absorbency product and clothing purchases, time lost from work and the costs of treating urinary tract infections and depression--are at least $26.3 billion per year. (1) These studies also state that, for each woman older than 65, the annual cost of urinary incontinence is $3565.

Although medical treatment and surgical repairs do not cure prolapse and urinary and fecal incontinence, they can make these conditions easier to manage. When women do receive treatment, they often comment that they wish they had asked for help earlier. One woman, after learning that a pessary could help her manage pelvic organ prolapse, said, "Just hearing about treatment options made me feel like I had been let out of prison." (1)

Directed Reading Continuing Education Quiz

To receive Category A continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Choose the answer that is most correct based on the text. Transfer your responses to the answer sheet on Page 413 and then follow the directions for submitting the answer sheet to the American Society of Radiologic Technologists. You also may take Directed Reading quizzes online at Effective October 1, 2002, new and reinstated members are ineligible to take DRs from journals published prior to their most recent join date unless they have purchased a back issue from ASRT.

* Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.

1. What is the chance a woman will have surgery for pelvic organ prolapse by the age of 70?

a. 1 in 2

b. 1 in 10

c. 1 in 50

d. 1 in 1000

2. Which of the following structure(s) is/are in the anterior pelvic compartment?

a. vagina

b. rectum

c. bladder and rectum

d. urethra and bladder

3. What is another term for cyctocele?

a. posterior compartment defect

b. anterior compartment defect

c. apical defect

d. fallen uterus

4. Which of the following statements is true about women who have had a hysterectomy?

a. These women are at added risk for vaginal eversion.

b. They rarely have apical compartment defects.

c. These women are not at risk for pelvic organ prolapse.

d. They rarely have enteroceles.

5. For most women, what is the most significant risk factor associated with pelvic organ prolapse?

a. genetics

b. lifting heavy objects

c. pregnancy

d. participating in sports

6. "Laugh and leak" refers to:

a. urinary urgency.

b. fecal incontinence.

c. stress incontinence.

d. passing gas.

7. What is the most common cause of anal incontinence?

a. chronic diarrhea

b. perineal tears

c. stool impaction

d. analsphincter damage

8. During the patient history portion of a physical examination, which of the following symptoms is usually reported by a woman with a mild prolapse?

a. back discomfort that worsens at the end of the day

b. difficulty emptying her bladder

c. no symptoms are reported

d. a feeling as though she is sitting on a ball

9. What is the purpose of performing a urinalysis when a woman reports leaking and other prolapse-related symptoms?

a. rule out a urinary tract infection

b. check for blood in urine

c. rule out diabetes

d. check for overhydration

10. What anatomical reference point is used during the physical examination to assess pelvic prolapse?

a. hymenal ring

b. apical vaginal wall

c. pubococcygeal line

d. sigmoid colon

11. What symptom may occur when the bladder slides down into the vagina?

a. urine leakage

b. difficulty emptying bladder

c. stool impaction

d. muscle pain

12. Using the Pelvic Organ Prolapse Quantification System (POp-Q) Staging method, a stage 4 prolapse is:

a. inside the body and above the hymenal ring.

b. small.

c. only slightly beyond its normal position.

d. complete eversion.

13. During the physical examination, why is a half-speculum placed along one vaginal wall?

a. to reveal evidence of vaginal wall defects

b. to measure the vaginal length

c. to make it easier for the patient to perform a Valsalva maneuver

d. to observe if the patient can perform pelvic floor exercises

14. A patient whose prolapse extends more than 1 cm beyond the hymen, but no more than 2 cm of the total vaginal length, has a:

a. + 1 prolapse.

b. POP-Q3 prolapse.

c. small prolapse.

d. complete eversion.

15. What is the dynamic magnetic resonance (MR) anatomical reference point for pelvic organ prolapse imaging?

a. hymenal ring

b. cervix

c. pessary location

d. pubococcygeal line

16. The physical examination often does not reveal the true prolapse extent.

a. true

b. false

17. Which of the following conditions can evacuation defecography help diagnose?

a. urinary incontinence

b. stress incontinence

c. rectocele

d. urethral funneling

18. What is the purpose of rapid evacuation into a radiolucent commode?

a. assess anorectal function

b. diagnose anal sphincter tears

c. diagnose acystocele

d. evaluate pessary support

19. All of the following factors are advantages of dynamic MR evaluation except:

a. avoids ionizing radiation.

b. provides a realistic view of pelvic cavity dynamics.

c. insensitive to patient positioning.

d. provides detailed visualization of soft tissues.

20. Pelvic floor ultrasound is a well-defined imaging technique to assess pelvic organ prolapse.

a. true

b. false

21. Which of the following approaches is not used to medically manage pelvic organ prolapse?

a. using a pessary

b. increasing dietary fiber

c. performing pelvic floor exercises

d. midurethral sling

22. Why is it important to ask women if they are wearing a pessary before they undergo a lower abdominal medical imaging procedure?

a. The pessary becomes hot when exposed to electromagnetic fields.

b. Being placed in certain positions is uncomfortable when wearing a pessary.

c. Wearing one makes defecation difficult.

d. The pessary causes anatomic distortion.

DRI0006008 Expiration Date: June 30; 2008* Approved for 1.0 Cat. ACE credit


(1.) Rogers R, Shagam JY, Kleinschmidt S. Regaining Continence: What Every Woman Needs to Know. New York, NY: Prometheus Books; 2006.

(2.) The health repercussions of stigma. The Pfizer Journal. Available at: Accessed October 23, 2005.

(3.) Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol. 2001;184:1496-1501.

(4.) Stoker J, Halligan S, Bartram CI. Pelvic floor imaging. Radiology. 2001;218 (3):621-641.

(5.) Pannu HK, Kaufman HS, Cundiff GW, Genadry R, Bluemke DA, Fishman EK. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities. Radiographics. 2000;20:1567-1582.

(6.) Adam RA. Enterocele and massive vagina eversion. e-Medicine. Available at: Accessed December 2, 2005.

(7.) Rush CB, Entman SS. Pelvic organ prolapse and stress urinary incontinence. Med Clin North Am. 1995;79 (6):1473-1479.

(8.) Nygaard I, Bradely C, Brandt D, Women's Health Initiative. Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol. 2004;104(3):489-497.

(9.) American Heart Association. Marfan syndrome. Available at: Accessed October 17, 2005.

(10.) Arthritis Foundation. Ehlers-danlos syndrome (EDS). available at: Accessed October 17, 2005.

(11.) Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186 (6):1160-1166.

(12.) Mahieu P, Pringot J, Bodart P. Defecography: I. Description of a new procedure and results in normal patients. Gastrointest Radiol. 1984;9 (3):247-251.

(13.) Kelvin FM, Pannu HK. Dynamic cysyoproctography: fluoroscopic and MRI techniques for evaluating pelvic organ prolapse. In: Bartram CI, DeLancey JOL, eds. Imaging Pelvic Floor Disorders. New York, NY: Springer; 2003:51-68.

(14.) Altringer WE, Saclarides TJ, Dominguez JM, Brubaker LT, et al. Four-contrast defecography: pelvic "floor-oscopy." Dis Colon Rectum. 1995;38 (7):695-699.

(15.) Halligan S. Evacuation proctography. In: Bartram CI, DeLancey JOL, eds. Imaging Pelvic Floor Disorelers. New York, NY: Springer; 2003:45-50.

(16.) Tunn R, Petri E. Introital and transvaginal as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. Ultrasound Obstet Gynecol. 2003;22:205-213.

(17.) MRI safety. St. Michaels Hospital Web site. Available at: Accessed December 4, 2005.

(18.) Dietz HP, Eldridge A, Grace M, Clarke B. Normal values for pelvic organ descent in healthy nulligravid young caucasian women. Available at: Accessed December 3, 2005.

Janet Yagoda Shagam, Ph.D., is an award-winning freelance medical and science writer living in Albuquerque, NM. She is also a professional writing instructor at the University of New Mexico.

Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3917.

This article is a Directed Reading.
Table 1
Tests for Prolapse

Test                What It Tests For        Results

Postvoid residual   Voiding efficiency       Large amounts of retained
                                             urine may indicate nerve
                                             damage resulting from
                                             diabetes or an obstruction

Bladder stress      Urge sensations with     Leaking with coughing may
test                bladder filling and      indicate prolapse and
                    ability to hold urine    stress incontinence

Cotton-tipped       Mobile urethra           Inadequate urethral
swab test                                    support

Cystoscopy          Inside of the bladder;   Can determine if an
                    bladder and bladder      anatomical abnormality is
                    neck response to         causing symptoms

Urodynamics         Pressure differences     Used as a preoperative
                    between the abdomen,     diagnostic to indicate the
                    bladder and urethra      most effective surgical

Table 2
Prolapse Staging by Physical Measurement

Number         Prolapse Position

-3             Only slightly beyond its normal position

-2             Beyond its normal position but
               does not sag very far

-1             Almost to the hymen

 0             To the hymen

+1             Only slightly beyond the hymen

+2             Several centimeters beyond the hymen

+3             Many centimeters beyond the hymen

+4 or higher   Very far past the hymen, to the
               point that the vagina may be nearly
               completely inside out

Table 3
Pelvic Organ Prolapse Quantification
System (POP-Q) Staging (6)

Stage   Description

0       No prolapse; the apex can descend 2 cm
        relative to the total vaginal length

1       Most distal portion of the prolapse is at least
        1 cm above the hymen

2       Maximal extent of the prolapse is within 1 cm of
        the hymen (inside or outside the vagina)

3       Prolapse extends more than 1 cm beyond
        the hymen, but no more than 2 cm of the total
        vaginal length

4       Complete eversion

Table 4
Radiologic Prolapse Staging: Cystocele,
Enterocele, Sigmoidocele and Vaginal
Vault Prolapse

Size       Descent Below the Pubococcygeal Line

Small                     < 3 cm
Moderate                  3-6 cm
Large                     > 6 cm

Table 5
Range of Normal Pelvic Organ Parameters--Translabial Ultrasound (6)

Parameter                   Mean Value      Standard Deviation

Posterior urethrovesical    114[degrees]    10.6[degrees]
Posterior urethrovesical    145[degrees]    23.3[degrees]
 angle--Valsalva maneuver
Urethral rotation           32.1[degrees]   23.5[degrees]
Bladder neck mobility       17.3 mm         8.8 mm
Cystocele decent            13.7 mm         9.4 mm
Uterine decent              31.5 mm         13.4 mm
Rectal decent               8.6 mm          16.1 mm

Parameter                   Range

Posterior urethrovesical    90[degrees]-130[degrees]
Posterior urethrovesical    100[degrees]-180[degrees]
 angle--Valsalva maneuver
Urethral rotation           0[degrees]-90[degrees]
Bladder neck mobility       1.2 mm to 40.2 mm
Cystocele decent            30.3 mm to -10 mm *
Uterine decent              59 mm to 0 mm
Rectal decent               54 mm to -22 mm

* Negative values correspond to movement below the symphysis pubis.

Table 6
Voiding Problems and Related Ultrasound Findings (6)

Voiding Problem         Ultrasound Finding

Recurrent urinary       Urethral and bladder diverticula, postvoiding
tract infections        residual volume, foreign bodies such as bladder
                        stones and sutures

Urgency and frequency   Urethral and bladder diverticula, bladder wall
                        masses, foreign bodies, fibroids, funneling of
                        the upper urethra

Painful urination and   Urethral diverticula, intrauterine device
painful intercourse

Urge incontinence       Bladder wall thickening greater than 5 mm

Stress incontinence     Upper urethral funneling, urethral
                        hypermobility, fixed or hypomobile urethra, no
                        pelvic floor reactivity
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Author:Shagam, Janet Yagoda
Publication:Radiologic Technology
Geographic Code:1USA
Date:May 1, 2006
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