Female Pelvic Examination & POP-Q Staging
A pelvic examination documents support, tissue condition, pelvic floor function, and demonstrable leakage. Interpret these findings alongside the patient's symptoms and goals: prolapse stage alone does not establish treatment need, and a normal examination does not exclude every cause of urinary or pelvic symptoms. 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 |
Separate the bladder conditions for the two principal tests: 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/PVR and then POP-Q may be convenient. Record the actual sequence and conditions.[3][4]
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; there is no universal percentage by which standing changes stage.[3]
Structured examination sequence
External genitalia and urethral meatus
Inspect the vulva, clitoral hood, vestibule, meatus, perineum, and anus. Document tissue thinning/dryness, inflammation, scarring, architectural change, focal lesions, discharge, and exposed mesh. Findings suggestive of lichen sclerosus, an atypical bleeding lesion, or a mass warrant the appropriate diagnostic pathway rather than an assumption of uncomplicated atrophy.[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.
- Difficult catheter passage is not pathognomonic for female urethral stricture. EAU describes a fixed anatomical narrowing, but published calibre definitions vary. Consider pain/guarding, anatomy, prolapse, and prior surgery; assess flow/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 | The bulge does not establish which organ lies behind it; 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 but does not prove it or exclude concomitant apical descent |
Split speculum: support the posterior wall to expose the anterior wall; remove/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/mobility, masses, and tenderness. A rectovaginal examination can help characterize a posterior defect or suspected enterocele, but cannot reliably confirm or exclude an enterocele. Selected symptomatic patients may benefit from defecography or other targeted imaging; routine imaging of uncomplicated prolapse is unnecessary. Cervical traction and examination under muscle relaxation can exaggerate apical descent and should not replace the awake examination when deciding what is symptomatic.[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. Negative values do not by themselves establish normal support. The remaining three measurements—GH, PB, and TVL—are lengths, recorded as positive values.[1][2]
Record maximal descent with straining/coughing and an empty bladder. Include GH/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 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 |
A wide GH, short PB, or short TVL may be clinically relevant, but none is a stand-alone diagnosis of avulsion, obstetric injury, or an indication for reconstruction. Interpret the measurements in context.[1][3]
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.
Pelvic floor muscle assessment
Assess resting resistance/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. Abdominal coactivation can occur normally; it is not automatically an incorrect contraction. Inability to relax on one attempt does not establish a complete pain or non-relaxing pelvic floor diagnosis.[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. Later adaptations use different expansions; identify the version rather than mixing them.[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. It does not mean four 10-second holds. 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. The original paper evaluated measurement properties and proposed individualized exercises; it did not establish one optimal exercise prescription for all patients.[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. Asymmetric strength alone is not a structural avulsion diagnosis, and digital assessment can miss defects. 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.
Q-tip testing is not a required routine test. NICE recommends against its use in the assessment of urinary incontinence. 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. The result alone should not select sling route or exclude surgical options.[5][9]
A suspicious periurethral mass requires targeted evaluation. Pelvic MRI can help characterize a diverticulum or other lesion; a negative “milking” response does not exclude a diverticulum. Suspected anatomical obstruction requires a broader assessment than catheter calibre alone.[6]
Cough stress test
ICS-Uniform Cough Stress Test
- Explain that the test aims to reproduce leakage and obtain consent.
- Use a supine/lithotomy position with approximately 200–400 mL in the bladder, appropriate to the patient's usual capacity and comfort. Do not force painful overfilling.
- Record how volume was established: bladder scan, measured filling, or subsequent voided volume plus PVR. Time since last void alone does not establish an adequate volume.
- 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]
A negative test does not exclude SUI. If the history remains suggestive, consider an accessory upright test with adequate filling, or further testing when it would change management. Record the accessory result separately. Delayed or persistent leakage after coughing can suggest cough-associated detrusor activity, but visual observation alone does not confirm urodynamic detrusor overactivity. Leakage with an almost empty bladder is also not, by itself, proof of intrinsic sphincter deficiency.[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/swab that reduces the prolapse without compressing the urethra. Record the method and unreduced/reduced results.[3]
Occult SUI is stress leakage revealed with prolapse reduction in a patient without reported incontinence. It informs counseling but does not mandate a concurrent sling. Discuss the probability of postoperative leakage alongside the added risks of a continence procedure and the option of staged treatment. In the 2023 International Urogynecology Consultation review, median positive predictive value for de novo SUI was about 40% and negative predictive value about 91%, with wide variation in study populations, tests, operations, and outcome definitions. These are not individualized risk estimates.[3][5]
Urodynamics is not automatically required after every positive office stress test. Use the broader clinical picture, especially diagnostic uncertainty, previous continence surgery, significant prolapse, or voiding dysfunction, to determine whether it is likely to change management.[3][5]
Focused neurological examination
When indicated, assess perineal/perianal sensation, voluntary anal contraction, and sacral reflexes, with the patient's consent. Document right/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 response on one examination can reflect technique or normal variation; it does not by itself prove pudendal injury, a sacral lesion, or the level of a lesion. An intact reflex does not exclude a suprasacral neurological disorder. New saddle sensory loss, new urinary retention, or progressive neurological deficits require urgent assessment for a compressive spinal/cauda equina process rather than reassurance from a single normal reflex.[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.