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REVIEW
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
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
Pahwa et al.
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
0
1
2
3
4
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
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).
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
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.]
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).
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.]
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
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.
Pahwa et al.
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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