It is essential to quality care that the physician carefully evaluate all aspects of pelvic support and whether or not a patient has coexisting defects or problems such as urinary incontinence. Many patients who present with anterior vaginal prolapse will complain of symptoms directly associated with the protrusion of the vaginal wall as well as symptoms of voiding difficulty or urinary incontinence (22,23). Symptoms directly related to the prolapse include pelvic pressure, sensation of a vaginal bulge, vaginal fullness, low back pain, difficulty sitting, spotting, and dyspareunia. Urinary symptoms such as voiding difficulty or stress urinary incontinence commonly occur in patients with anterior vaginal prolapse (24). Many women report the need to manipulate the prolapse or use abdominal or vaginal pressure in order to facilitate voiding. Often patients report a feeling of incomplete emptying of the bladder. As the prolapse advances, many women with prior urinary incontinence will report an improvement of this condition. This is due to a kinking-type mechanism between the urethra and the advancing anterior vagina, which results in an obstruction to normal urinary flow (23). This condition could place the patient at greater risk for urinary tract infections.

Other important medical considerations include the presence of urinary urgency or frequency and past history of significant diseases, surgeries, medications, and allergies. If the patient has undergone prior pelvic operations, particularly for incontinence or prolapse, we find it very important to review these operative notes. There are sometimes important technical lessons to be learned from them, and this is preferable to learning them intraoperatively. Occasionally, such notes may guide the surgeon to alter the surgical recommendation. At the very least, the operative details, if thoroughly dictated, will add preincision knowledge and confidence to the surgical team.

The dynamic pelvic examination for prolapse may be conducted in one or more of three positions. Examining a patient in the lithotomy position is most often used. However, a seated upright position with the same forceful, repeated Valsalva bearing-down efforts might contribute high-quality observations while maximizing prolapse findings. Initially, a visual inspection of the external genitalia is performed. The examiner should describe any exteriorized bulge or abnormality. Atrophy, including labial agglutination, pallor, dystrophic changes, or local lesions should be noted. The patient is then asked to bear down while the examiner gently parts the labia. One may note any defects without using the potentially artifact-producing speculum. Should the examiner still have difficulty in confirming the total extent of a prolapse, the patient may be examined in the standing position with either leg elevated by a single step. This enables the examiner to define the full extent of prolapse and its components. A gentle rectovaginal examination, with the thumb in the posterior vaginal fornix and the index finger in the rectal ampulla, before and during Valsalva effort, is a good diagnostic examination for enterocele.

The warmed, moistened posterior blade of a Graves or Pedersen speculum or a Sims retractor is placed, according to vaginal size, to gently depress the posterior aspect of the vagina. This allows the examiner an optimal view of the anterior vaginal wall. After this initial visual examination is complete, the patient is asked to bear down forcefully with her lungs full or to cough. The examiner notes extent and place of descent. When examining the anterior wall for prolapse, one must not only perform Pelvic Organ Prolapse Quantification (POPQ; 25) measurements for prolapse severity, but also assign specific sites of defect (i.e., central/midline, PVD, TD). While observing anterior descent during Valsalva effort, one ought to pay particular attention to the area of the urethrovesical crease. It is quite common in patients with anterior pelvic organ prolapse to note rotational descent of the bladder neck. This finding will usually predict a positive cotton swab test for urethral hypermobility. Careful attention is paid to the presence or absence of rugal folds, as well as noting whether or not there is a loss of the lateral sulcus and/or anterior fornix. Other simple tools help answer the important question: “Is this anterior prolapse secondary to a central and/or a PVD?” A separated ring forcep or Baden vaginal wall analyzer is placed into the lateral sulcus and the curve is pointed posteriorly toward the ischial spines; the lateral vagina is returned to the ATFP and the midanterior vaginal tissues are elevated. The patient is once again asked to strain, and if no further prolapse is noted, a defect of the paravaginal type is strongly suspected (26). Should the midanterior wall continue to descend on strain despite instrumental elevation, the patient is likely to have a central defect. A PVD, however, is not ruled out.

The examiner is then able to grade the severity of any defects with the POPQ or Baden-Walker (27) systems. The POPQ, being quantitative, allows numerical comparisons between preoperative and postoperative and in studying groups of patients in research. Since its measurements are conducted along a linear axis, the POPQ does not include side-to-side (e.g., PVD) parameters. This and any other findings outside of the POPQ system ought to be noted.

Because of the association of occult stress incontinence with anterior prolapse, it is useful to note if the patient shows urinary incontinence during repetitive cough with the prolapse reduced. A TD is diagnosed by observing the anterior cervical fornix. If the normal forniceal indentation is lost between the base of the anterior cervical lip and the anterior vaginal apex, the patient may be said to have a TD.

A thorough history and physical examination in the office setting may be all that are necessary in evaluating patients with anterior vaginal prolapse. The physician should obtain a urine sample to rule out infection in any patient with urinary symptoms. If coexisting urinary incontinence is a problem, appropriate urodynamic testing should be completed prior to treatment. If the patient does not currently complain of voiding dysfunction or urinary incontinence yet the anterior prolapse is grade 3 or greater, urethral function (via urodynamic evaluation) should be carefully assessed with the prolapse reduced. This is very important in that women with severe anterior vaginal prolapse may in fact be continent due to urethral kinking (24). Once the prolapse is effectively reduced, occult or latent stress incontinence may be unmasked. Pessaries (28), large cotton swabs (Scopettes), or ring forcep-type instruments can be used in order to reduce anterior prolapse at the time of urodynamic testing. Care should be taken to ensure that the prolapse-reducing device does not occlude the urethra, causing a false-negative cough stress test. If these maneuvers lead to urinary leakage with cough or Valsalva (occult USI), the surgeon may recommend that an appropriate anti-incontinence procedure be performed
at the time of surgical correction for anterior wall prolapse.