Sydney Pelvic Floor Health

Clinical Examination

There are six main components to a clinical examination for pelvic floor dysfunction in women:

1.) Inspection for urogenital atrophy, skin changes and asymmetry/ distorttion/ scarring, eg at the perineum, and to detect a urethral caruncle (extrusion of urethral mucosa from the external meatus).

2.) Clinical stress test or CST: ask the patient to cough and Valsalva while watching the external meatus for urine loss. 

After voiding: 

3.) POP-Q prolapse quantification as shown in Figure 1. Maximal descent of anterior, central and posterior compartments are determined against the hymenal remnant on maximal Valsalva of at least six seconds' duration. Try and ascertain that the patient is not contracting the levator (evident as cranial displacement of the anus and dorsal displacement of the clitoris. Do not use the ICS staging as it is clearly inappropriate: a (stage 1) Ba or Bp of up to -1.5 is normal, but a (stage 1) uterine descent to -4 clearly is not. We consider Aa and Ap superfluous. TVL is measured on maximal Valsalva as demonstrated in Figure 2 in a comparison with hiatal area on US. Also watch the anus for signs of rectal prolapse, and the perineum for excessive perineal descent and asymmetry indicating avulsion (Figure 3). Figures 4-6 show clinical appearances, POPQ coordinates and ultrasound images for anterior, central and posterior compartment descent.

4.) Bimanual examination to exclude pelvic masses, stool and urinary retention, to palpate the urethra for implants, scarring, diverticula, and to detect vaginal meshes, mesh-related pain and mesh exposure. Palpation on Valsalva will show mesh dynamics (eg problems with anchor failure) and may allow the diagnosis of intususception (palpate the posterior vaginal wall to detect splaying of the anal canal). 

5.) Palpation of the levator ani for thinning, avulsion and Oxford grading (0-5), see Figure 7. Resting tone may also be assessed on a scale from 0-5. Figure 8 shows a proforma that can be used for documentation. One should start by palpating the urethra, then the anterior fornix bilaterally, ie., the gap between the urethra and levator ani. Normally this just fits one finger. The finger should then be placed on the inferior pubic ramus lateral to the urethra and moved laterally while asking the patient to perform a pelvic floor muscle contraction. A full avulsion is diagnosed if there is no contractile tissue palpated on the inferior pubic ramus or the body of the os pubis itself. Make sure that you don't mistake the bulbocavernosus muscles (which are lower and not directly connected to the inferior pubic ramus) for the levator. Figure 9 shows a comparison of ultrasound images of a normal and abnormal levator ani muscle plus a palpation model developed by our unit for teaching of digital palpation of levator trauma.

6.) Digital rectal examination for resting tone of anal canal and external sphincter and squeeze pressure. Sometimes it is possible to palpate scarring and EAS defects. Then ask patient to Valsalva while palpating the anterior wall of the rectal ampulla for rectocele. In a patient with true rectocele the superior margin of the rectovaginal septum can usually be palpated as a well- defined discontinuity. Finally, check whether anything descends towards the palpating fingertip on Valsalva. If the finger is pushed back by tissue (rather than stool) there likely is an intussuception.   

Figure 8: Proforma for documentation of levator palpation. From Dietz HP, Shek KL. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J. 2008;19:1097-101. 

Figure 1: POPQ graph and coordinates. From Bump, R. C., et al. (1996). "The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction." Am. J. Obstet. Gynecol. 175(1): 10-17.

Figure 2: Measurement of Gh+Pb on Valsalva and equivalent measurement on translabial ultrasound, demonstrating the levator hiatus. From Khunda A, Shek K, Dietz H. Can ballooning of the levator hiatus be determined clinically? Am J Obstet Gynecol. 2012;206(3):246.e1-4.

Figure 3: Marked asymmetry on Valsalva due to typical right-sided levator avulsion. 

Figure 4: Cystocele on clinical examination (A), on POPQ drawing (B; Ba= +2, C= -3, Bp= -3) and on ultrasound (C). From Dietz H. Female Pelvic Organ Prolapse- a review. Australian Family Physician. 2015;44(7):446-52. 

Figure 5: Vault prolapse on clinical examination (A), on POPQ drawing (B; Ba= -3, C= +2, Bp= -1) and on ultrasound (C). From Dietz H. Female Pelvic Organ Prolapse- a review. Australian Family Physician. 2015;44(7):446-52. 

Figure 6: Rectocele on clinical examination (A), on POPQ drawing (B; Ba= -3, C= -4, Bp= +1) and on ultrasound (C). From Dietz H. Female Pelvic Organ Prolapse- a review. Australian Family Physician. 2015;44(7):446-52. 

Figure 7: Palpation of the puborectalis muscle for avulsion defects (normal situs on left, avulsion on right). From: Dietz HP, Shek KL. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J 2008; 19: 1097-1101

Figure 8: Proforma for documentation of levator palpation. From Dietz HP, Shek KL. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J. 2008;19:1097-101. 

Figure 9: Normal muscle and right-sided avulsion on ultrasound; palpation model for the teaching of the digital diagnosis of avulsion.