In order to elucidate the concrete manifestations of pelvic organ prolapse, specific questions should be asked: a sensation of “heaviness” or “descent” and a feeling of a “foreign body” or “bulge” between the labia or in front of the vulva. Further questions are aimed at elucidating how often and at what times of the day these symptoms are noted by the patient. Symptoms of pelvic organ prolapse typically appear during the day and get worse with physical labor and towards the afternoon and evening.

The next question is how these symptoms affect daily activities and quality of life. Finally the patient is asked about urinary incontinence, anal and fecal incontinence and implications on sexual function. It is important to ask whether a bulge prevents complete emptying of the bladder and the rectum and whether the patient has to manually replace the prolapse in order to be able to pass urine or stool.

Although time is often a problem, the main points of pelvic organ prolapse can be elucidated with a few questions as outlined above. Ideally, the history taking has the form of a structured interview. Alternatively, questionnaires can be used. In the mind of the doctor, while taking a history, the outlines of a possible treatment strategy already takes shape. Severe symptoms or the presence of a marked bulge are points in favor of surgery.

For the clinical examination, the patient must be placed in a comfortable position, and the examiner must be able to see the vulva and the prolapse. There might be cultural inhibitions to let a doctor see the external genitalia, but if at all possible, an effort should be made to visualize the prolapse. This is important to see the extent of the prolapse and the movement of the prolapse on Valsalva and to see whether the skin and the epithelium are intact.

For the examination, the patient can be in the dorsal or lateral supine position. The patient should also be asked to stand up so that the prolapse can be evaluated in the standing position. The dorsal lithotomy position with the knees apart offers the examiner the best access to the external genitalia and the prolapse and allows the easy use of specula and ultrasound probes. Many women will tolerate this position when a light blanket or bed sheet is placed over their knees and lower abdomen.

The next step is a thorough clinical examination of the patient with the help of speculum and palpation. It is preferable to use two separate specula in order to better visualize the anterior and posterior vaginal wall. Only a gynecological examination with speculum allows for a differentiation between the various forms of a prolapse (anterior, posterior, apical) and the extent of the prolapse (stage). The patient is asked to do a Valsalva maneuver or to cough so that the physician can see the extent of the prolapse (Figs. 12.1, 12.2, 12.3, 12.4, and 12.5). The pelvic organ prolapse quantification (POPQ) system is utilized to objectively assess the severity of POP.

It is important to keep in mind that a pelvic organ prolapse almost always can be manually replaced into the small pelvis. This means that the picture of how a pelvic organ prolapse presents itself is never stable and very often cannot be completely reproduced during a clinical examination and even with good Valsalva maneuvers. The most important anatomical information for further treatment planning is knowledge about compartment and level, which are involved in the POP.

For several reasons, it is very important that the result of a clinical examination of pelvic organ prolapse is clearly described and recorded. Every medical diagnostic or therapeutic intervention must be documented. It becomes part of the patient record, which allows comparison with subsequent examinations or assessments by other health care providers. Over time, it allows the evaluation of changes during the natural course or in conjunction with treatments. Last but not least, it is important to document pelvic organ prolapse for quality control measures and for research.

For these reasons, the need became apparent for a standardized description and documentation of pelvic organ prolapse and in 1996, the result of the combined efforts of several working groups was published as The Standardization of Female Pelvic Organ Prolapse and Pelvic Floor Dysfunction [1]. The system quickly became known as the POPQ system – pelvic organ prolapse quantification system – and is now the preferred system to describe and document pelvic organ prolapse. Clinical research on pelvic organ prolapse requires the use of POPQ, but over the years, many clinicians have familiarized themselves with the POPQ and use it in their daily practice [2].