Assessment of Vaginal Bulge

Initial Clinical Assessment

The American College of Radiology recommends that the initial evaluation of a vaginal bulge begins with a comprehensive physical examination to identify the type and extent of pelvic organ prolapse (POP) 1, 2
Pelvic organ prolapse may involve various compartments of the pelvic floor, including the anterior compartment (cystocele and/or urethrocele) 3, apical compartment (uterine/cervical and/or vaginal prolapse) 1, and posterior compartment (rectocele) 1, 3
The posterior cul-de-sac may herniate into the rectovaginal space, containing peritoneal fat (peritoneocele) 1, small bowel (enterocele) 3, or sigmoid colon (sigmoidocele) 1, 3

A thorough external genital examination should assess for the presence of any lesions, signs of trauma or laceration, and Bartholin and Skene glands for signs of infection 4
A speculum examination should inspect vaginal walls for discharge and lesions, visualize the cervix completely, and assess for a bluish hue (Chadwick sign) which may indicate pregnancy 4

The American College of Radiology recommends considering imaging studies when clinical evaluation is difficult or inadequate, or for patients with persistent symptoms after treatment 1, 2
Dynamic Cystocolpoproctography (CCP) is one of the imaging tests of choice for evaluation of vaginal bulge or suspected POP, and involves fluoroscopic imaging during defecation with the patient sitting in an upright position 1, 3
CCP shows good agreement with surgical findings for detection of full-thickness rectal prolapse 1, posterior colpocele 5, rectocele 3, and peritoneocele 1, 5
MR Defecography provides high soft-tissue contrast resolution for direct visualization of pelvic organs and floor muscles, and allows for assessment of pelvic floor muscles and fascia, as well as postsurgical changes in the pelvic floor 3, 5
Transperineal Ultrasound (TPUS) can be used for anatomic and functional evaluation of the pelvic floor, and can detect levator muscle avulsion, a predictor of prolapse recurrence after surgical repair 6

The American College of Radiology recommends differentiating between cul-de-sac hernias and anterior rectoceles, both of which can present with posterior vaginal bulge, and evaluating for occult pelvic floor disorders in compartments other than those apparent on physical examination 1