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Clinical Anatomy 00:0000 (2014)

REVIEW

Physical Examination of the Female


Internal and External Genitalia With and
Without Pelvic Organ Prolapse:
A Review
AVITA K. PAHWA,1* EVAN S. SIEGELMAN,2
1

AND

LILY A. ARYA1

Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology,
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
2
Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Pelvic organ prolapse, a herniation of pelvic organs through the vagina, is a


common condition in older women. Pelvic organ prolapse distorts vaginal anatomy making pelvic examination difcult. A clinician must accurately identify
anatomic landmarks both in women presenting with symptoms of prolapse and
in women noted to have coincidental prolapse during routine gynecologic
examination. We present a systematic approach to the female pelvic examination including anatomic landmarks of the external genitalia, vagina, and uterus
in women with normal support as well as changes that occur with pelvic organ
prolapse. Knowledge and awareness of normal anatomic landmarks will
improve a clinicians ability to identify defects in pelvic support and allow for
better diagnosis and treatment of pelvic organ prolapse. Clin. Anat. 00:000
000, 2014. VC 2014 Wiley Periodicals, Inc.
Key words: anatomic landmarks; vagina; pelvic organ prolapse; female pelvic
exam

INTRODUCTION
Pelvic organ prolapse is a common condition and its
prevalence is increasing with aging of the US population.
Over 40% of women ages 50 and older have varying
degrees of prolapse on routine gynecological examination. Additionally, pelvic organ prolapse surgery is the
most common surgical procedure in older women in the
United States (Hendrix et al., 2002; Oliphant et al., 2010).
Pelvic organ prolapse refers to the descent or protrusion of pelvic organs through the vagina and is
characterized by compartments of the vagina that are
affected by the prolapse (Bump et al., 1996). Descent
of the anterior vaginal wall is referred as anterior vaginal wall prolapse. Since this usually involves the
descent of the bladder, the term cystocele is commonly used, while descent of the urethra is termed
urethrocele. Descent of the posterior vaginal wall, or
posterior vaginal wall prolapse, may involve protrusion of the rectum, termed rectocele, or small bowel,
termed enterocele. Descent of the apex of the vagina
is termed apical prolapse and includes uterine

C
V

2014 Wiley Periodicals, Inc.

prolapse; the term vaginal vault prolapse is used for


the posthysterectomy vaginal apex.
Pelvic organ prolapse can cause gross distortion of
anatomy, making pelvic examination difcult for clinicians. Familiarity with anatomic landmarks of female
genitalia can orient the examiner to recognizing pelvic
structures in the presence of pelvic organ descent. A
clinician well versed in pelvic anatomic landmarks can
make the diagnosis of pelvic organ prolapse, including
determining the type and severity of prolapse during
bimanual pelvic examination, precluding the need for
radiologic examination even when surgical treatment
*Correspondence to: Avita Pahwa, University of Pennsylvania,
Urogynecology, 1000 Courtyard, Ravdin, 3400 Spruce Street,
Philadelphia, PA 19104, USA.
E-mail: avita.pahwa@uphs.upenn.edu
Received 22 April 2014; Revised 8 August 2014; Accepted 28
August 2014
Published online in Wiley Online Library (wileyonlinelibrary.com).
DOI: 10.1002/ca.22472

Pahwa et al.

Fig. 1. External genitalia in a woman with anterior


vaginal wall prolapse. [Color gure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

is planned (Rogers, 2013). Therefore, it is essential


that the examining clinician be thoroughly familiar
with anatomic landmarks of the pelvic examination of
the female patient with pelvic organ prolapse. The
aim of this review is to describe anatomical landmarks
that are visualized during pelvic examination in a
woman with normal pelvic support and changes that
occur with pelvic organ prolapse.

Fig. 2. Posterior vaginal wall landmarks in a


woman with posterior vaginal wall prolapse. [Color gure
can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

allows the examiner to assess the tone and strength


of the pelvic oor muscles, specically the pubococcygeous and puborectalis muscles located in the lower
third of the vagina. During rectovaginal examination,
a nger in the rectum and another in the vagina
allows the assessment of rectal tone and rectal mass.
While variation in the anatomy of the external and
internal genitalia is common, specic landmarks can
be identied as described below.

PELVIC EXAMINATION
The pelvic examination should be performed in a
systematic manner to include inspection of the external genitalia, speculum exam of the vagina, and bimanual pelvic examination. Inspection of the external
genitalia, including the perineum and external anal
opening is performed rst at rest, then with the
patient performing a pelvic oor contraction, as if to
prevent escape of urine or gas, and nally with the
patient straining, as if bearing down or defecating.
Next, a speculum examination of the cervix and the
vaginal vault is performed. A split-speculum exam
using the posterior blade of the speculum allows the
clinician to examine the anterior and posterior vaginal
walls separately (Figs. 1 and 2). The severity of prolapse of each compartment is quantied using the Pelvic Organ Prolapse Quantication (POP-Q) staging
system that involves exact measurements, or the
Bader-Walker grading system, that requires only visual assessment (Tables 1 and 2) (Bump et al., 1996;
ACOG Committee on Practice Bulletins, 2007). Bimanual examination with one hand in the vagina and
another hand over the lower abdomen allows assessment of size and shape of uterus and any adnexal or
pelvic mass. A single digit in the vagina with the
patient relaxed and with subsequent contraction

EXTERNAL GENITALIA
Vulva
The mons is the hair-bearing area of subcutaneous
fat overlying the symphysis pubis and provides fascial
support to the clitoris and urethra (OConnell et al.,
2008). The shape can be variable, but generally is of
TABLE 1. Pelvic Organ Prolapse Quantication
System (ACOG Committee on Practice Bulletins,
2007)
Stage 0
Stage 1
Stage 2
Stage 3

Stage 4

No prolapse; Aa, Ba, Ap, Bp is 23 cm


and C or D  2 (TVL 2 2) cm
Most distal portion of prolapse 21 cm
(above level of hymen)
Most distal portion of prolapse 21
but  11 cm (1 cm above or below
the hymen)
Most distal portion of prolapse >11 cm
but <11(TVL 2 2) cm (beyond
hymen; protrudes no further than
2 cm less than TVL)
Complete eversion; most distal portion
of prolapse 1 (TVL 2 2) cm

Anatomic Landmarks in Pelvic Organ Prolapse


TABLE 2. Baden Walker Pelvic Organ Prolapse
Grading System (Bump, 1996)
Grade
Grade
Grade
Grade
Grade

0
1
2
3
4

Normal position for each respective site


Descent halfway to hymen
Descent to the hymen
Descent halfway past the hymen
Maximum possible descent for each site

an inverted triangle with the apex at the glans clitoris


(OConnell et al., 2008).

Labia Majora
These two prominent cutaneous vascular fatty folds
of tissue constitute the lateral edges of the vulva. The
outer lateral surfaces display pigmented skin with hair
follicles and glands, while the inner medial surfaces
are smooth and hairless with large sebaceous follicles.
The labia majora unite anteriorly to form the anterior
commissure. Posteriorly the labia major do not join,
but merge with neighboring skin forming a ridge that
overlies the perineal body to form the posterior commissure (Healy, 2008). The round ligament and obliterated processus vaginalis terminate within the labia
majora. In some women, herniation of the bowel into
a patent processus vaginalis can occur and is called
hernia of the canal of Nuck or congenital inguinal hernia (Yavagal et al., 2001; Healy, 2008). Herniation of
ovary, uterus, cysts and endometriosis of the canal of
Nuck have also been reported (Ozel et al., 2009;
Gaeta et al., 2010; Patel et al., 2014).

Labia Minora
The labia minora are two small hairless cutaneous
folds devoid of fat just medial to the labia majora, bordering the vaginal orice (Fig. 1) (Drake et al., 2004).
Normally, the folds are approximated together. The
folds contain erectile tissue and highly sensitive skin.
Rich sebaceous glands are found medial to each labium,
adjacent to the vestibule (Yavagal et al., 2011). The
upper points of the labia converge anterior and over the
clitoris to form the prepuce and frenulum of the clitoris
while the lower points converge to form the frenulum or
posterior commissure of the labia minora (Figs. 1 and
2) (Puppo, 2011). The lengths and widths of both the
labia majora and labia minora widely vary between
women. The labia minora can range from unnoticeable
to protruding beyond the labia majora. Additionally,
anatomic variation can exist between two sides and
appear asymmetric in the same patient (Puppo, 2011).
The hypoestrogen state of menopause causes thinning,
loosening, and decreased elasticity of subcutaneous
skin and adipose tissue that can decrease the width and
length of labia majora and minora (Basaran et al.,
2008). Occasionally an extra labial fold, or labium tertium, can be found on one or both sides between the
labia minora and labia majora (Healy, 2008).

Clitoris
This neurovascular erectile structure consists of a
body that is covered at the distal end by the glans

clitoris. The body is made of the paired corpora


cavernosa that are erectile tissue and taper laterally
to paired crura anchored to the ischiopubic rami.
Suspensory ligaments hold the clitoral body to the
mons and symphysis pubis (Puppo, 2011). The
glans clitoris that covers the distal corpora cavernosa is a round tubercle of spongy erectile tissue
with large nerve trunks and sensory receptors
(Puppo, 2011).
On clinical inspection, the body of the clitoris,
approximately 1 to 2 cm wide and 1 to 3 cm
long, projects outward and away from the patient
(OConnell et al., 1998; Puppo, 2011). The body can
be palpated through the skin as enclosed in dense
brous tissue (Healy, 2008). The anterior portion of
the glans is partially enclosed by the bifurcated anterior ends of the labia minora, or prepuce, as described
above and can vary in size and coverage of the glans
clitoris (Healy, 2008; Puppo, 2011). This inverted
V-shaped skin fold, or hood, of the prepuce joins the
frenulum below the glans to form a near-circular skin
arrangement around the glans (OConnell et al.,
2008). The glans clitoris is 4 to 7 mm in length and
contains cavernous tissue in direct contact with skin
(Puppo, 2011). Like other structures of female genitalia, clitoral anatomy of the clitoris is inuenced by
hormonal status, through pregnancy, menopause, or
exogenous hormones (Verkauf et al., 1992).

Vestibule
The vestibule refers to the triangular shaped space
beneath the glans clitoris, between the labia minora
and contains openings of the vagina, urethra, and
ducts of the greater and lesser vestibular glands
(Fig. 3). Historically known as the vulvar vestibule,
its contents suggest that the term vaginal vestibule
is likely more accurate (Friedman et al., 2004). Supercially, the vestibule can be visualized as the hairless
skin extending from the medial labia minora to the
frenulum of the glans clitoris anteriorly and the
vaginal introitus posteriorly (OConnell et al., 2008).
Given its proximity to the clitoris and other erectile
structures, the vestibule is highly responsive to
direct stimulation and important to female sexuality
(OConnell et al., 2008). In most patients, the shallow
vestibular fossa, also known as the navicular fossa,
can be found midline between the vaginal orice and
posterior frenulum of the labia minora (Fig. 4).
The greater vestibular glands, or Bartholins glands,
are two small structures on either side of the vaginal
ostium with openings through ducts 2 cm in length
within the groove between the hymen and labia
minora (Yavagal et al., 2011). The openings of these
ducts are visualized at the posteriorlateral aspect of
this groove at 4 and 8 oclock and secrete clear-white
mucus with lubricating function during sexual arousal
and moisturizing effect for vulvar surfaces (Fig. 4)
(Marzano and Haefner, 2004; Healy, 2008). Blockage
of these ducts can lead to cysts or abscesses. The
lesser vestibular glands, also known as Skenes glands
or paraurethral ducts, are numerous mucous glands
found in the vestibule that contribute to vulvar lubrication (Fig. 3).

Pahwa et al.
vestibule, approximately 2.5 cm below the clitoris and
above the vaginal opening. The external urethral meatus is a short sagittal cleft with slightly raised and distensible margins found under the pubic arch, outside
the hymenal caruncles (Kovac and Zimmerman,
2007). Its shape can vary ranging from rounded to
slit-like to crescent-like (Healy, 2008). This most distal and visible portion functions to aim the stream of
urine (McBride et al., 2003). The openings of the
Skenes glands, or paraurethral ducts, are found at
the bilateral margins of the urethral meatus and provide secretion during sexual arousal. A reddish soft
mucosal-covered exophytic mass protruding from the
posterior distal urethral meatus is often visible in
postmenopausal women and is a benign inammatory
lesion known as a urethral caruncle (Wein, 2012).
Commonly asymptomatic, it should be distinguished
from urethral prolapse, which is a circumferential
eversion of the urethral mucosa at the urethral
meatus (Wein, 2012).

Fig. 3. Anatomic landmarks around urethra. [Color


gure can be viewed in the online issue, which is available
at wileyonlinelibrary.com.]

Urethra
The urethra is embedded in the anterior vaginal
wall and surround by erectile tissue (OConnell et al.,
1998) (Fig. 3). Its midline opening is visible within the

Introitus of the Vagina


The vaginal opening varies in size and has great
elastic potential, allowing for distention during childbirth and intercourse. Normally at rest it is approximately 3 to 4 cm in the anterior-posterior dimension
(Fig. 1) (OConnell et al., 2008). With pelvic organ
prolapse, the introitus, or genital hiatus, can widen
and allow pelvic organs to descend caudally into the

Fig. 4. Anterior vaginal suclus (A) and posterior vaginal sulcus (B) (x 5 Bartholins
glands). [Color gure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

Anatomic Landmarks in Pelvic Organ Prolapse


vaginal lumen or completely through the vaginal
opening (Kovac and Zimmerman, 2007).

Hymen
The hymen is a thin mucous membrane fold found
just within the vaginal introitus. Like other vulvar
structures, the hymen has normal anatomic variation
in shape, ranging from ring-like to semi-lunar to completely absent. When present, its internal surfaces are
normally in contact with each other. After rupture, its
small skin elevations are usually found in a circumferential pattern and referred as hymenal remnants,
hymenal tags, or carunculae myrtiformis (Fig. 2)
(Healy, 2008; OConnell et al., 2008). The hymen
serves no physiologic functional purpose; however, it
is used as a xed point of reference during the POP-Q
exam for assessing the severity of prolapse (Bump
et al., 1996).

Perineal Body
The perineal body refers to the pyramidal bromuscular elastic structure midline between the posterior
fourchette of the vaginal opening and the anus (Fig.
2). The base of pyramid faces the examiner with the
apex in the cephalad direction (OConnell et al., 2008;
Sokol and Shveiky, 2008). This area contains a conuence of supercial and deep connective tissue and
muscle. The bulbocavernosus, supercial, and deep
transverse perineal, and external anal sphincter
muscles provide supercial support, while the perineal
membrane and some bers of the pubococcygeus,
and puborectalis portion of the levator ani muscles
provide deeper support (Kovac and Zimmerman,
2007; OConnell et al., 2008; Sokol and Shveiky,
2008; Hoffman et al., 2012). There exists individual
variation in tone, thickness, and composition, with an
average height of 3 to 4 cm and thickness of 2 to
4 cm (Kovac and Zimmerman, 2007; Sokol and
Shveiky, 2008; Hoffman et al., 2012). The perineal
body is an elastic zone that can stretch during delivery
and incur permanent damage from obstetric trauma
(OConnell et al. 2008).
During pelvic examination, the position of the perineal body should be noted at rest, during a contraction, and with straining.
Normally in nulliparous women, the perineal body
rests 1 to 2 cm superior to the plane of the ischial
tuberosities. It appears slightly concave at rest, supported upward toward the ischial tuberosities due to
pull from the distal rectovaginal septum on its apex
(Kovac and Zimmerman, 2007).
When the woman is asked to contract her pelvic
oor muscles, as if to prevent urine or gas from
escaping, ventral and cranial movement of the perineal body will be observed (Messelink et al., 2005).
Similarly, when the patient coughs, the perineal
body should show no downward movement; ventral
movement may occur because of the guarding action
of the pelvic oor muscles (Messelink et al., 2005).
Perineal descent is the outward or caudal movement
of the vulva, perineal body, and anus. Perineal descent

will occur when a woman is asked to strain, as if defecating or bearing down, however, should normally not
descend below the level of the ischial tuberosities.
The perineal body with its surrounding muscles and
connective tissue collectively support the distal
vagina, introitus, and anal canal. Damage to these
structures can lead to perineal descent, a gaping
introitus, and posterior vaginal wall prolapse (Fig. 2)
(Hoffman et al., 2012). A tear along the rectovaginal
septum, bulbocavernosus muscles, supercial and
deep transverse perineal muscles, or external anal
sphincter muscles may lead to a descent of the perineal body below the level of the ischial tuberosities
and stool trapping (Kovac and Zimmerman, 2007).

External Anal Opening


The external anal opening is typically tightly closed
and is surrounded by radial striations that are most
prominent posteriorly. These striations represent an
intact external anal sphincter. Following child birth
injury to the external and internal anal sphincters, the
external anal opening may appear patulous and the
retracted ends of the torn external anal sphincter can
be seen as dimples on either side of the external anal
opening often referred to as the dove-tail sign (Hoffman et al., 2012). Visual inspection of the perianal
area commonly shows protuberant tissue suggestive
of hemorrhoids or sentinel pile suggestive of anal
ssure (Hoffman et al., 2012). Rectal prolapse of the
rectal mucosa or muscle may be visible with straining.
Digital rectal exam is used to assess for strength
and contour of the anal sphincter and levator ani
muscles. The exam is performed with the patient at
rest, squeezing around the digit, and straining. The
smooth internal anal sphincter muscle provides resting tone while striated external anal sphincter muscle
provides voluntary contraction and relaxation. The
striated external anal sphincter muscle is specically
evaluated by asking the patient to squeeze around the
rectal digit. Poor sphincter tone or defects in the circumferential anatomy of the muscle can be palpated.
The patient is also asked to bear down during examination to stimulate defecation and assess for pelvic
oor relaxation. Anal continence is in part maintained
by the levator ani muscles, the iliococcygeus, pubococcygeus, and puborectalis muscles, which specically form a U-shaped, loop that slings behind the
rectum and attaches to the pubic bones (Bailey et al.,
2012).

VAGINA
The vagina is a rugated bromuscular tube of nonkeratinized stratied squamous epithelium absent of
glands. Physiologic vaginal lubrication is provided by
transudate from blood vessels and secretion from the
Bartholins, Skenes or lesser vestibular, and cervical
glands (Sokol and Shveiky, 2008). In the lithotomy
position during pelvic examination, the vaginal axis is
horizontal for approximately 3 cm at its lower end,
after which it continues toward the ischial spines at a
45 angle posteriorly. A sagittal view of a standing

Pahwa et al.

Fig. 5. Sagittal MRI of the pelvis demonstrating the axis of the vagina (A). The
lower vagina is vertical while the proximal vagina is curves to a 45 angle towards
the hollow of the sacrum (B). [Color gure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

patient would demonstrate the lower third of the


vagina as relatively vertical, followed by a steep angulation into a horizontal plane for the upper vagina
(Fig. 5). The vaginal caliber is most narrow at the introitus and becomes progressively larger toward its apex
with the largest dimension in the middle and upper third
(Sokol and Shveiky, 2008). In the normal relaxed state,
the walls of the vagina are approximated.
The vagina is H-shaped in cross-section where the
anterior and posterior walls are coapted, forming a attened, longitudinal potential space (Kovac and Zimmerman, 2007). The side walls are suspended by
attachments to paravaginal lateral connective tissue
from which they receive their blood supply. These lateral attachments x the vagina in a side to side position,
lending to its H-shape. (Sokol and Shveiky, 2008).
Additionally, these points of suspension create visible
paravaginal sulci. The anterolateral sulci are formed by
attachment of the anterior vaginal walls to the medial
surface of the iliococcygeus muscles at the arcus tendineus fascia pelvis or White lines (Figs. 3 and 4) (Barber, 2014). The posteriolateral sulci are formed by
attachment of the distal half of posterior vaginal wall to
the aponeurosis of the levator ani muscles along a
line known as the arcus tendineus fascia rectovaginalis
(Fig. 4) (Kovac and Zimmerman, 2007).

Vaginal Support
The vagina is supported by a combination of muscular and ligamentous support. Three levels of support
are described by DeLancey (Rock and Jones, 2008).
Level I support refers to support of the proximal or
upper vagina or vaginal apex by the uterosacral ligaments, cardinal ligaments, and anterior endopelvic
fascia or pubocervical fascia. The uterosacral ligaments contribute to maintenance of vaginal length
and the horizontal axis of the upper vagina. These

ligaments originate from the posterior cervix and


upper vagina to attach to the presacral region, allowing the cervix to be positioned just superior to the
level of the ischial spines. The uterosacral ligaments
can be palpated in the posterior fornix, fanning posteriorly and cephalad. The cardinal ligaments attach the
cervix laterally to the pelvic walls to the obturator,
providing support to the cervix, upper vagina, and
uterus (Rock and Jones, 2008). Defects in level I support lead to prolapse of the uterus or the vaginal vault
in a woman who has undergone hysterectomy and
also contribute to anterior and posterior vaginal wall
descent (cystocele and rectocele, respectively).
The midportion of the vagina is supported by lateral
attachments to the medial levator ani muscles, known
as Level II support (Hoffman et al., 2012). The anterior mid-vagina is suspended laterally to the levator
ani and obturator internus muscles at the arcus tendineus fascia pelvis or the White line as described
above. Detachment of these lateral supports can lead
to paravaginal defects and prolapse of the anterior
vaginal wall, or cystocele. The attachments of the
posterior vaginal walls are more complex than the
anterior vaginal walls. The distal half of the posterior
vagina is densely attached to the aponeurosis of the
levator ani muscle at the arcus tendineus rectovaginalis as described above. The arcus tendineus converges
with the arcus tendineus rectovaginalis at a point midway between the pubic symphysis and the ischial
spine. Defects in the posterior vaginal wall support
result in prolapse of the posterior vaginal wall, or
rectocele.
Level III support refers to support of the distal third
vagina by the following surrounding structures: the
urethra anteriorly, the pubovaginalis muscle and perineal membrane laterally, and perineal body posteriorly
(Hoffman et al., 2012). Defects in level III support
lead to distal rectocele, perineal descent, and gaping
introitus.

Anatomic Landmarks in Pelvic Organ Prolapse

cephalad to the hymen to the area of the submeatal


sulcus. Although of unknown signicance, it can be a
prominent fold encountered during pelvic examination
and is often asymmetric. Continuing toward the vaginal apex, the second well-dened sulcus, the transverse vaginal sulcus, is visible as a slightly convex
groove representing the approximate position of the
urethral-bladder junction (Fig. 7). The nal sulcus is
noted at the most proximal portion of the anterior
vaginal wall as a concave groove called the bladder
sulcus (Fig. 7) (Shaw, 1947). These notable anterior
vaginal wall landmarks are due to attachments of the
vaginal wall to underlying fascial planes. An area of
smooth mucosa with minor resistance can be identied along the middle third of the anterior vaginal wall,
known as Pawliks Triangle. This area corresponds
to the area under the bladder trigone (Kovac and
Zimmerman, 2007; Puppo, 2011).

Fig. 6. Uterine prolapse and cystocele. [Color gure


can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

Weakness of the muscular and ligamentous supports of the vagina can allow organs overlying the
anterior vaginal walls, such as the urethra and bladder, and structures underlying the posterior vaginal
wall, anal canal, rectum, and rectouterine pouch, to
prolapse into and through the vaginal canal.

Vaginal Wall Rugations


Vaginal wall rugations are formed by epithelial
ridges arranged in an accordion like manner that
allows for stretching and expansion without laceration
(Sokol and Shveiky, 2008; Yavagal et al., 2011). Starting at the introitus and traveling cephalad toward the
apex, the vaginal rugae are arranged in a typical transverse orientation. Similar to other pelvic structures,
these rugae change in prominence with the hormonal
changes of menopause, leading to decreased rugations
in the hypoestrogen state. Additionally, appearance of
rugations can dissipate with prolapse as traction from
vaginal descent will smoothen these folds (Fig. 6).
In addition to vaginal rugations, discrete sulci,
ridges, and grooves offer landmarks in patients whose
pelvic organ prolapse may cause distortion of normal
anatomy (Shaw, 1947). In particular, three midline
sulci can be identied along the anterior vaginal wall.
The rst sulcus is found just cephalad to the urethra
as a midline groove, known as the submeatal sulcus,
demarcating the posterior margin of the urogenital
diaphragm (Fig. 7). The bilateral paraurethral recesses
are found laterally and cephalad to the submeatal sulcus, however are most well dened in nulliparous
women (Fig. 7). Further cephalad, a transverse projection, or fold, of the anterior vaginal wall epithelium
can be visualized and palpated in most premenopausal women, known as the oblique vaginal
fold (Fig. 7). This passes from the lateral vaginal wall

Changes in Anatomic Landmarks With


Vaginal Prolapse
With the patient straining during the split speculum
exam, the examiner can observe for descent apically,
anteriorly, and posteriorly in an isolated manner
(Fig. 4) (Kovac and Zimmerman, 2007). Often normal
rugae will be absent or attenuated in pelvic organ prolapse (Hoffman et al., 2012). Because vaginal wall
rugations are due to lateral and midline suspension of
the vaginal epithelium to supporting structures, loss
of rugae imply underlying connective tissue disruption
(Kovac and Zimmerman, 2007).
In anterior prolapse, or cystocele, a bulge of the
anterior vaginal wall will be noted during split speculum exam while displacing the posterior vaginal wall
(Fig. 4). Sagging lateral vaginal sulci in the presence

Fig. 7. Anterior vaginal wall landmarks. [Color gure


can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

Pahwa et al.

of anterior wall rugae suggest a paravaginal defect, or


loss of lateral support. On the other hand, a central
bulge with loss of vaginal rugae suggests a midline or
central defect. Replacing support at these defective
areas during examination with the speculum, digit, or
instrument can reduce the defect and provide information to routes of surgical repair (Hoffman et al.,
2012). Of note, vaginal wall and urethral masses such
as Gartner duct cysts, Skenes gland cysts, and urethral diverticula may be mistaken for pelvic organ prolapse. Careful vaginal inspection will characterize the
origins and boundaries of these masses and distinguish them from true anterior vaginal wall prolapse.
In assessing for posterior prolapse, or rectocele,
the split speculum isolates the anterior wall while the
patient bears down (Fig. 2). Occasionally, small bowel
peristalsis is noted behind a thinned posterior vaginal
wall and enterocele is diagnosed. If the bulge is noted
in the distal cephalad posterior wall, a rectocele is
diagnosed. Further distinction can be found during the
rectovaginal exam, when the examiners digits are
placed along the rectum and posterior vaginal wall.
Small bowel can be palpated sliding between these
ngers to conrm enterocele and distinguish from rectocele (Kovac and Zimmerman, 2007).
Uterine prolapse is identied by the descent of the
external os of the cervix (Fig. 6). Descent of the vaginal vault in a patient who has undergone hysterectomy constitutes vault prolapse.

are in contact forming a transverse slit, except at the


apex where the cervix keeps them apart (Healy,
2008; Sokol and Shveiky, 2008; Yavagal et al., 2011).
The cervix is visually assessed during the speculum
exam. The pale smooth appearance of the external
surface of the cervix (ectocervix) is due to nonkeratinized stratied squamous epithelium similar to
and continuous with the vagina (Healy, 2008). The
central cervical canal, or endocervix, is lined by deeply
folded mucosa with epithelium of columnar mucous
cells that produce alkaline mucus (Healy, 2008). The
openings of these mucous glands can form physiologic
1 to 2 cm Nabothian cysts when blocked (Healy,
2008). The os has a typical appearance based on a
womans history of vaginal birth. In the nulliparous
woman, the external os appears a circular aperture,
while after parity, it appears as a transverse slit
(Healy, 2008). During speculum examination, the
patient is asked to strain while gently retracting the
speculum to allow for visualization of apical prolapse.
In apical or uterine prolapse, the cervix, or posterior
fornix can be noted to descent toward the hymen with
valsalva. Of note, cervical elongation, dened as
lengthening of the cervix independent of prolapse, can
confound the diagnosis of apical prolapse. There
exists no current consensus denition of cervical elongation, however various studies describe the length of
an elongated cervix as ranging from 5 to 8 cm
on POP-Q measurement between points C and D
(Finamore et al., 2009; Dancz et al., 2014).

UTERUS AND CERVIX


Uterus
The body of the uterus is slightly attened anterior
posteriorly with a rounded superior end, known as the
fundus. The position of the uterus can vary in women
and is described by the relation of the axis of the uterine body to the axis of the vagina, known as anteversion or retroversion (Healy, 2008). In the adult
nulliparous state, the uterus tilts forwards relative to
the axis of the vagina (anteversion). In 10 to 15% of
women the whole uterus leans backwards at an angle
to the vagina and is said to be retroverted (Healy,
2008). The angle of the body of the uterus relative to
the cervix, either anteexion or retroexion, cannot
be appreciated on clinical examination.

Cervix
The cervix projects into the apex of the vagina. The
fornix is an annular recess between the cervix and
vagina and is described as the anterior, posterior, right
and left lateral fornices, although all are continuous
with each other. Because the cervix projects to a
greater extent into the anterior than the posterior
vagina, the posterior vaginal length is 1.5 to 2 cm longer than the anterior vaginal length (Krantz, 1959;
Healy, 2008). Vaginal length has normal anatomic
variation, with a mean length of 9.6 cm in one study
(Lloyd et al., 2005). Vaginal length decreases in postmenopausal women (Basaran et al., 2008). In its
relaxed state, the anterior and posterior vaginal walls

CONCLUSION
Systematic examination of the pelvic genitalia can
provide considerable information of the normal anatomy as well as changes that occur in a woman with
pelvic organ prolapse. Knowledge and awareness of
normal anatomic structures and landmarks will
improve a clinicians ability to identify anatomic
defects of pelvic organ prolapse and allow for better
diagnosis and treatment.

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