Physical Examination

A pelvic examination should be performed with the patient in the lithotomy position. A detailed assessment of the support of all segments of the vagina should be made using the International Continence Society's pelvic organ prolapse quantitation (POP-Q) system. In addition, an assessment for central, lateral, and superior anterior vaginal support defects should be performed. If physical findings do not correspond to symptoms or if the maximum extent of the prolapse cannot be confirmed, the woman should be examined in the standing position. Use of a birthing chair tilted so the patient is 45 degree above the horizontal can also be useful for obtaining the maximal degree of prolapse while maintaining vaginal access to make the POP-Q measurements.

A method for clinically identifying paravaginal defects in women with prolapse was originally described by Richardson and subsequently standardized by Baden and Walker. A curved ring forceps is placed in the lateral vaginal sulci and directed toward the ischial spines along the course of the arcus tendineus fasciae pelvis (ATFP) to reproduce the lateral support of the vagina. A Sims speculum is placed posteriorly to expose the anterior vaginal wall and reduce any posterior prolapse. The patient is asked to strain maximally and, if complete reduction of the anterior prolapse occurs with the ring forceps in this position, she is thought to have paravaginal defects. If, when she strains, the anterior vagina continues to bulge between the arms of the ring forceps without any evidence of reduction, then this suggests a midline loss of support. If supporting the lateral vagina results in partial reduction of the prolapse, then she is thought to have lost both midline and lateral support. Unilateral elevation of each vaginal sulcus allows differentiation of bilateral and unilateral paravaginal defects.

Current evidence suggests that this technique of physically assessing anterior vaginal support may not accurately reflect findings at the time of surgery. A study of 117 women found a discrepancy between the prevalence of paravaginal defects noted at a standardized preoperative clinical examination (63%) and the prevalence of discrete paravaginal detachment noted at surgery (42%).' The clinical finding of paravaginal defects in this study was sensitive (sensitivity 92%) but not specific (specificity 52%) and had an adequate negative predictive value (91%), but low positive predictive value (61%). Subjects in whom normal paravaginal support was found at physical examination usually had intact paravaginal support confirmed at surgery, but less than two-thirds of women who were thought to have paravaginal defects based on physical examination actually had them at the time of surgery.

Pregnancy And Childbirth

Pregnancy And Childbirth

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