Female Pelvic Examination & POP-Q Staging
A pelvic examination documents support, tissue condition, pelvic floor function, and demonstrable leakage. POP-Q provides a reproducible description of vaginal support; the simplified POP-Q is an acceptable alternative in clinical settings where the full system is impractical.[1][2][3]
Preparation and equipment
Explain the examination, obtain consent, offer a chaperone according to local policy, and agree that the patient can pause or stop. Ask about pain, prior difficult examinations, mobility limitations, and preferred positioning. Use draping, adequate lubrication, and the smallest suitable speculum; adapt the sequence to tolerance.
| Equipment | Purpose |
|---|---|
| Adjustable examination table | Supported lithotomy or another tolerable position |
| Single-blade/Sims or separable bivalve speculum | Assess each vaginal wall without supporting the wall being measured |
| Centimetre ruler or measuring probe | POP-Q measurements |
| Gloves and lubricant | Inspection and gentle palpation |
| Bladder scanner; catheter supplies when indicated | PVR assessment and documentation of stress-test volume |
| Pessary or suitable speculum/swab for reduction | Selected prolapse-reduction testing |
Bladder conditions. Assess prolapse with an empty bladder; perform the cough stress test with an adequately filled bladder. If the patient arrives comfortably full, a stress test followed by voiding and PVR and then POP-Q may be convenient. Record the actual sequence and conditions.[3][4] In women with prolapse and voiding difficulty or an elevated PVR, pessary reduction can be used to reassess emptying; resolution of voiding difficulty during reduction was associated with resolution after repair in one study.[3]
Position. Supine lithotomy is practical for most examinations. Left lateral positioning is an alternative. If the patient's usual bulge is not reproduced, repeat in an upright or standing position when feasible. Document the position and whether the observed prolapse matches the patient's experience; standing-related stage change varies.[3]
Structured examination sequence
External genitalia and urethral meatus
Inspect the vulva, clitoral hood, vestibule, meatus, perineum, and anus. During follow-up after an obstetric anal sphincter injury, inspect the perineal scar and anterior perianal folds during voluntary anal squeeze, and assess resting anal tone and squeeze with a consented digital rectal examination.[17] Document tissue thinning or dryness, inflammation, scarring, architectural change, focal lesions, discharge, and exposed mesh.[2][5] Findings suggestive of lichen sclerosus, an atypical bleeding lesion, or a mass warrant the appropriate diagnostic pathway.[2][5]
- A caruncle commonly arises from the posterior meatal lip; urethral prolapse is circumferential mucosal eversion. An uncertain, indurated, ulcerated, or otherwise suspicious lesion needs further evaluation.
- A suburethral mass may be a diverticulum or another periurethral lesion. Gentle palpation can reveal tenderness or discharge; expression of fluid is neither required nor sufficient for diagnosis. Avoid forceful repeated compression.
- EAU describes a fixed anatomical narrowing, but published calibre definitions vary. Consider pain or guarding, anatomy, prolapse, and prior surgery; assess flow and PVR and investigate suspected obstruction with appropriate endoscopic or imaging studies. Do not force a catheter to establish a diagnosis.[6]
Vaginal compartments and apex
Use a single speculum blade to support the opposite wall while the patient strains. Assess anterior, posterior, and apical support separately, then their interaction. Ask for a sustained maximal strain; coughing may help elicit descent when needed. Avoid pushing the apex or the compartment being measured back into position.[1][3]
| Area | Document | Interpretation limits |
|---|---|---|
| Anterior wall | Leading edge, Aa/Ba, scars, periurethral mass; effect of separately supporting the apex if assessed | Examination does not reliably distinguish central from paravaginal defects. Anterior prolapse commonly includes an apical component |
| Posterior wall | Ap/Bp, distal pocket, perineal descent, relation to bowel symptoms | Posterior prolapse severity correlates poorly with defecatory symptoms |
| Cervix or cuff | C; D when a cervix is present; lesions, bleeding, scarring | A large C−D difference can suggest cervical elongation |
Split speculum. Support the posterior wall to expose the anterior wall; remove or reposition the blade to assess the posterior wall while supporting the anterior wall. Measure the external genital hiatus and perineal body without distorting them with the speculum. Measure TVL separately with the prolapse reduced and without straining.
Perform bimanual examination when indicated to assess uterine size and mobility, masses, and tenderness. A rectovaginal examination (index finger in the vagina, middle finger in the rectum) can help characterize a posterior defect or suspected enterocele, but cannot reliably confirm or exclude an enterocele. An enterocele may be felt as a peritoneal sac, sometimes with bowel loops, between the two fingers. A rectocele is felt as rectal bulging into the vagina, and a perineocele as perineal body deficiency with the rectal wall bulging posteriorly. Selected symptomatic patients may benefit from defecography or other targeted imaging; routine imaging of uncomplicated prolapse is unnecessary.[3][5] Cervical traction and examination under muscle relaxation can exaggerate apical descent.[3][5]
POP-Q system
Reference plane and measurement conditions
Record the six vaginal points in centimetres relative to the hymen: negative values lie proximal to it, zero lies at it, and positive values lie distal to it. The remaining three measurements (GH, PB, and TVL) are lengths, recorded as positive values.[1][2]
Record maximal descent with straining or coughing and an empty bladder. Include GH and PB on strain; optional resting measurements should be labelled separately. TVL is measured at rest with the prolapse reduced. Document limitations such as pain or an ineffective strain.[1][3][11]
Six vaginal points and three lengths
Definitions follow the original POP-Q framework of Bump and colleagues (1996) and the ICS educational module.[1][11]
| Point | Definition | Practical note |
|---|---|---|
| Aa | Fixed point on the anterior vaginal wall, originally defined 3 cm proximal to the external urethral meatus | Its POP-Q position ranges from −3 to +3 cm |
| Ba | Most distal point of the upper anterior wall, between the anterior fornix/cuff and Aa | It is not the segment between Aa and the hymen. In the absence of anterior prolapse, Ba is −3 |
| C | Most distal edge of the cervix, or vaginal cuff after hysterectomy | Record even when the anterior/posterior wall leads |
| D | Posterior vaginal fornix when the cervix is present | Omit when there is no cervix; C−D is an imperfect estimate of cervical length |
| Ap | Fixed point on the posterior vaginal wall 3 cm proximal to the hymen | Its POP-Q position ranges from −3 to +3 cm |
| Bp | Most distal point of the upper posterior wall, between the posterior fornix/cuff and Ap | It is not the segment between Ap and the hymen. In the absence of posterior prolapse, Bp is −3 |
| GH | Middle of external urethral meatus to posterior midline hymen | Measure on strain; separately label any resting value |
| PB | Posterior midline hymen to middle of anal opening | Measure on strain; separately label any resting value |
| TVL | Greatest vaginal depth with apex/prolapse reduced, without straining | Provides the reference for near-complete eversion |
POP-Q grid
| Aa | Ba | C |
|---|---|---|
| GH | PB | TVL |
| Ap | Bp | D (or omitted) |
Staging
Stage follows the most distal prolapsing portion, with the specific stage-0 criteria considered first.[1]
| Stage | Definition |
|---|---|
| 0 | No prolapse: Aa, Ba, Ap, and Bp are −3 cm, and C or D lies between −TVL and −(TVL−2) |
| I | Does not meet stage 0; leading edge remains more than 1 cm above the hymen (<−1 cm) |
| II | Leading edge lies from −1 to +1 cm, inclusive |
| III | Leading edge is >+1 cm but <+(TVL−2) cm |
| IV | Complete or nearly complete eversion: leading edge ≥+(TVL−2) cm |
Example. Aa +1, Ba +2, C −5, GH 4, PB 3, TVL 9, Ap −2, Bp −2, D −7 describes stage III, led by the anterior wall. TVL−2 = 7 cm is the lower boundary of stage IV, not an upper limit of prolapse. This grid documents anatomy; symptom burden and the patient's preferences determine whether treatment is appropriate.
Example. After hysterectomy, Aa +3, Ba +8, C +8, GH 6, PB 2, TVL 8, Ap +3, Bp +8 and D omitted describes stage IV vault prolapse, because C ≥ TVL−2 = 6 cm. The wide genital hiatus (GH 6) and short perineal body (PB 2) are recorded but do not enter the staging.
Compartments and the operations commonly considered
| Compartment | Points | Typical finding | Operations commonly considered |
|---|---|---|---|
| Anterior | Aa, Ba | Cystocele (central or paravaginal) | Anterior colporrhaphy, paravaginal repair |
| Apical | C, D | Uterine descent, vault prolapse | Uterine-preserving hysteropexy for eligible patients with uterine descent[16]; sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament fixation |
| Posterior | Ap, Bp | Rectocele, enterocele, perineal defect | Posterior colporrhaphy, perineorrhaphy, enterocele repair |
| Hiatus and perineum | GH, PB | Wide hiatus, perineal injury | Perineal repair (perineorrhaphy) for a perineal-body defect; selected levator ani plication to narrow the hiatus, relatively contraindicated when receptive vaginal intercourse is current or desired because of dyspareunia risk.[12] |
Choice of operation depends on symptoms, the leading compartment, apical support, prior surgery and patient preference.
Pelvic floor muscle assessment
The levator ani comprises the pubovisceral (pubococcygeal, including pubovaginalis), puborectalis and iliococcygeus muscles; the coccygeus is a separate pelvic-floor muscle.[13][14] The pubovisceral muscle is the main support component and the muscle most often injured at vaginal delivery. Assess resting resistance or tenderness, voluntary contraction, sustained contraction, and relaxation after contraction. Ask the patient to squeeze and lift around the examining finger while breathing normally. Record whether there is inward lift, bearing down instead of contraction, pain, or substitution by other muscles.[7][8] Abdominal coactivation can occur normally.[7][8]
Modified Oxford scale
| Grade | Digital finding |
|---|---|
| 0 | No discernible contraction |
| 1 | Flicker |
| 2 | Weak squeeze without appreciable lift |
| 3 | Moderate squeeze with lift |
| 4 | Good squeeze/lift against resistance |
| 5 | Strong squeeze/lift against strong resistance |
These are examiner-dependent ordinal grades. Record endurance separately; grade 5 does not itself imply a particular hold duration. Weakness, tenderness, and increased resting resistance can coexist.[7][8]
PERFECT scheme
The original Laycock–Jerwood 2001 scheme uses P/E/R/F with ECT (Every Contraction Timed).[7] Later adaptations use different expansions.[7]
| Component | What to record |
|---|---|
| P — Power | Modified Oxford grade 0–5; this is a clinical strength estimate |
| E — Endurance | Seconds that the chosen maximal contraction can be maintained before appreciable fatigue, up to 10 |
| R — Repetitions | Number of contractions of that patient's measured duration, up to 10; the original scheme used 4 seconds of rest between them |
| F — Fast contractions | Number of short maximal contractions, up to 10, after adequate rest |
| ECT | Time and record each part of the assessment |
For example, 3/5/4/7 means a grade-3 contraction held for 5 seconds, repeated four times, followed by seven fast contractions.[7] There is no universal “normal PERFECT” threshold that diagnoses pelvic floor dysfunction or predicts continence. Tailor training to function and symptoms; pain or poor relaxation may require a different initial emphasis from strengthening.[5][7][8]
Suspected levator avulsion
Palpate the levator attachment beside the urethra at the inferior pubic ramus, at rest and with contraction, if relevant to the assessment. Describe an apparent gap, reduced bulk, asymmetry, or uncertainty. Specialist translabial ultrasound or MRI can clarify anatomy when the result would affect counseling or management. Neither a palpated defect nor a wide hiatus automatically determines the repair route or justifies mesh use.[8]
Urethral mobility and periurethral pathology
Observe urethral movement during strain and document prior continence surgery, scarring, masses, and tissue quality. Mobility and sphincter function are related but distinct; neither urethral hypermobility nor a fixed urethra independently diagnoses stress incontinence or intrinsic sphincter deficiency.
NICE recommends against using the Q-tip test in the assessment of urinary incontinence (recommendation 1.3.17). If used in a selected specialist setting, report the technique, position, resting angle and maximum straining angle relative to horizontal, and the calculated excursion separately. A commonly used threshold is a maximum straining angle of 30° from horizontal, but definitions differ between studies; do not silently substitute a 30° change from rest.[5][9]
Urethral diverticulum classically presents with dysuria, dyspareunia and post-void dribbling, although many are asymptomatic or present with recurrent urinary tract infection. The differential diagnosis of an anterior vaginal wall or periurethral mass includes the following.
| Diagnosis | Features |
|---|---|
| Urethral diverticulum | Tender, fluctuant suburethral mass, most often mid-urethral; discharge may be expressed |
| Skene's gland cyst | Periurethral, lateral to the meatus, usually asymptomatic |
| Gartner's duct cyst | Anterolateral vaginal wall along the lateral sulcus, usually nontender |
| Bartholin's gland cyst | Posterolateral at the introitus, not on the anterior wall |
| Paraurethral leiomyoma | Firm and rubbery, not fluctuant; MRI helps confirm |
| Urethral carcinoma | Firm and irregular, may bleed; biopsy is required |
A suspicious periurethral mass requires targeted evaluation. Pelvic MRI can help characterize a diverticulum or other lesion.
Cough stress test
ICS-Uniform Cough Stress Test
- Explain that the test aims to reproduce leakage and obtain consent.
- Use a supine or lithotomy position with approximately 200–400 mL in the bladder, appropriate to the patient's usual capacity and comfort.[4] Do not force painful overfilling.
- Record how volume was established: bladder scan, measured filling, or subsequent voided volume plus PVR.
- Visualize the urethral meatus directly without compressing or obstructing it. Ask for one forceful cough; if negative, repeat up to a total of four.
- Urine escaping synchronously with the cough is a positive stress test. Record position, volume, and whether prolapse was reduced.[4]
In women with symptoms of SUI being evaluated before primary midurethral sling surgery, ACOG/AUGS recommends repeating a negative supine cough stress test while standing with a full bladder (or at least 300 mL when tolerated); if leakage remains absent despite adequate filling, it recommends multichannel urodynamic testing.[9] Record the accessory result separately. Delayed or persistent leakage after coughing can suggest cough-associated detrusor activity.[4]
Prolapse reduction and occult SUI
Prolapse can mask leakage. In women undergoing assessment for prolapse treatment, perform selected reduction stress testing with at least 200 mL when tolerable, using a pessary or speculum or swab that reduces the prolapse without compressing the urethra. Record the method and unreduced and reduced results.[3]
Occult SUI is stress leakage revealed with prolapse reduction in a patient without reported incontinence. In women with occult SUI undergoing vaginal prolapse repair, five randomized trials (369 women) showed that adding a midurethral sling probably reduced postoperative subjective SUI versus repair alone (RR 0.38, 95% CI 0.26–0.55; moderate-certainty evidence).[15] Discuss the probability of postoperative leakage alongside the added risks of a continence procedure and the option of staged treatment. Across 25 heterogeneous studies using varied occult-SUI tests, including urodynamics, before prolapse surgery without a concurrent continence procedure, the 2023 International Urogynecology Consultation reported median positive and negative predictive values of 40% (range 0–79%) and 91% (range 51–100%) for de novo SUI, respectively; operations and outcome definitions also varied.[3]
Before surgery for SUI, NICE NG123 recommends multichannel filling and voiding cystometry after a detailed history and examination if a woman has urge-predominant mixed incontinence or incontinence of unclear type, symptoms suggestive of voiding dysfunction, anterior or apical prolapse, or prior SUI surgery.[5] In a retrospective study of 316 women with prolapse referred for urodynamics because of OAB, mixed or insensible incontinence, or voiding difficulty, management or counseling changed in 11 (3%), mainly when SUI and voiding difficulty coexisted.[3]
Focused neurological examination
When indicated, assess perineal or perianal sensation, voluntary anal contraction, and sacral reflexes, with the patient's consent. Document right and left differences, the stimulus used, and whether a response is present, absent, or uncertain. Interpret findings with lower-limb examination and the neurological history.[8][10]
| Test | Technique and interpretation |
|---|---|
| Sensation | Compare light touch and, where indicated, sharp/dull sensation across relevant perineal and perianal areas; the perianal S4–S5 sensory test is distinct from the reflex arc |
| Bulbocavernosus/clitoroanal reflex | Gentle clitoral or adjacent labial stimulation while observing/palpating an anal contraction; avoid a forceful pinch |
| Anal reflex/wink | Warn the patient before appropriate brief perianal pinprick stimulation; observe contraction and distinguish it from voluntary withdrawal |
| Voluntary anal contraction | Ask for a squeeze and record contraction and any asymmetry or uncertainty; this assesses voluntary motor function separately from reflexes |
The sacral reflex arcs are predominantly S2–S4. An absent bulbocavernosus response on one examination can reflect technique or normal variation (the reflex was detectable in 81% of able-bodied women in a series cited in reference 10).[10] New saddle sensory loss, new urinary retention, or progressive neurological deficits require urgent assessment for a compressive spinal or cauda equina process.[8][10]
Documentation checklist
Document only findings actually assessed; leave unperformed components explicit.
Consent/chaperone; tolerance and examination limitations:
Position(s); bladder empty for POP-Q; usual bulge reproduced:
Vulva/meatus/vaginal tissues/scars/lesions:
POP-Q (cm; maximal strain unless noted):
Aa ___ Ba ___ C ___
GH ___ PB ___ TVL ___ (reduced, at rest)
Ap ___ Bp ___ D ___ / omitted (no cervix)
Stage ___; leading compartment ___
Optional resting GH/PB recorded separately:
Pelvic floor: resting resistance, tenderness, contraction, relaxation:
Modified Oxford ___/5; side-specific findings if assessed:
PERF (original scheme): ___ / ___ seconds / ___ / ___
Suspected structural defect or uncertainty; imaging if indicated:
Cough stress test: volume ___ mL; method of volume assessment:
Supine result; synchronous versus delayed leakage:
Accessory upright test if performed:
Prolapse-reduction method and result if performed:
Urethral mobility/mass; additional tests only if performed:
Focused neurology if indicated:
Sensation; voluntary anal contraction; reflex/stimulus/result:
Symptom–examination concordance; findings needing investigation:
References
1. Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–17. doi:10.1016/S0002-9378(96)70243-0. PMID: 8694033.
2. Haylen BT, de Ridder D, Freeman RM, et al. An IUGA/ICS joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29:4–20. doi:10.1002/nau.20798. PMID: 19941278.
3. Barbier H, Carberry CL, Karjalainen PK, et al. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction. Int Urogynecol J. 2023;34:2657–2688. doi:10.1007/s00192-023-05629-8.
4. Guralnick ML, Fritel X, Tarcan T, Espuña-Pons M, Rosier PFWM. ICS Educational Module: Cough stress test in the evaluation of female urinary incontinence: Introducing the ICS-Uniform Cough Stress Test. Neurourol Urodyn. 2018. doi:10.1002/nau.23519.
5. NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). Recommendations on assessment, pelvic floor therapy, and concurrent surgery. Current recommendations.
6. EAU. Urethral Strictures Guidelines. 2026. Definition and diagnosis/management in females.
7. Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy. 2001;87:631–642. doi:10.1016/S0031-9406(05)61108-X.
8. Frawley H, Shelly B, Morin M, et al. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodyn. 2021;40:1217–1260. doi:10.1002/nau.24658.
9. ACOG/AUGS. Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. Committee Opinion 603. 2014. Clinical guidance.
10. Kirshblum S, Eren F. Anal reflex versus bulbocavernosus reflex in evaluation of patients with spinal cord injury. Spinal Cord Ser Cases. 2020. Full text.
11. Madhu C, Swift S, Moloney-Geany S, Drake MJ. How to use the Pelvic Organ Prolapse Quantification (POP-Q) system? Neurourol Urodyn. 2018;37(S6):S39–S43. doi:10.1002/nau.23740.
12. Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. "Joint report on terminology for surgical procedures to treat pelvic organ prolapse." Int Urogynecol J. 2020;31(3):429–463. doi:10.1007/s00192-020-04236-1
13. Betschart C, Kim J, Miller JM, Ashton-Miller JA, DeLancey JOL. "Comparison of muscle fiber directions between different levator ani muscle subdivisions: in vivo MRI measurements in women." Int Urogynecol J. 2014;25(9):1263–1268. doi:10.1007/s00192-014-2395-9
14. Yavagal S, de Farias TF, Medina CA, Takacs P. "Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerations." Semin Plast Surg. 2011;25(2):121–129. doi:10.1055/s-0031-1281481
15. Baessler K, Christmann-Schmid C, Haya N, et al. "Surgery for women with pelvic organ prolapse with or without stress urinary incontinence." Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2
16. Chang OH, Carter Ramirez A, Edwards A, et al. "The role of uterine preservation at the time of pelvic organ prolapse surgery." Urogynecology (Phila). 2025;31(5):482–495. doi:10.1097/SPV.0000000000001667
17. Sultan AH, Okeahialam NA, De Leeuw J, et al. "IUGA International Guidelines on Obstetric Anal Sphincter Injuries." Int Urogynecol J. 2026;37(8):2223–2280. doi:10.1007/s00192-026-06642-3