Pelvic organ prolapse (POP) is traditionally evaluated using objective anatomic measures obtained during pelvic examination [1]; however, symptom burden, as captured by patient-reported outcomes like the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6), often demonstrates discordance with exam findings [2]. Current literature highlights the complex interplay among prolapse, pelvic pain, and pelvic floor dysfunction, suggesting that symptom severity may not be fully explained by anatomic stage alone [3]. 

This study investigates the relationship between objective pelvic examination findings and patient-reported distress according to the POPDI-6. We hope to determine whether pelvic examination findings of prolapse versus high tone/tender levator muscles (or both) correlated with POPDI-6 scores in women with pelvic organ prolapse.

This study is a retrospective cross-sectional analysis of patients presenting to 1) subspecialized urology, urogynecology, genitourinary reconstruction and 2) multidisciplinary pelvic pain clinic. Patients completed a standardized electronic intake questionnaire. Data were de-identified in accordance with institutional review board (IRB) approval. 

A total of over 259 patient charts from January 2023 through March 2025 were screened. Patients were eligible for inclusion if they reported any pelvic symptoms and completed the responsive intake questionnaire, and had documented prolapse and levator muscle exams. Exclusion criteria included denial of pelvic symptoms, completion of a paper intake form, and incomplete exam documentation. 

A final cohort of 71 patients met inclusion criteria and were included in the analysis. Demographic variables, patient-reported outcome measures (including POPDI-6), and clinical data were extracted for analysis.

One-third of patients who self-identified prolapse symptoms were found to have high-tone levator musculature in the absence of prolapse on examination. POPDI-6 score demonstrated a strong association with levator pain in the absence of prolapse; in multivariable modeling, POPDI-6 composite score was the best predictor of levator tenderness when compared across the six questions in the instrument. 

Patient-reported prolapse distress was significantly associated with objective prolapse. For every 10-point increase in POPDI-6 score, the odds of prolapse increased by 30%. Among individual symptom items, splinting for urination was a particularly strong predictor; patients endorsing this symptom were nearly five times more likely to have prolapse. POPDI-6 elements were not predictive of post-void residual (PVR) in this population.

These findings demonstrate a complex relationship between patient-reported prolapse symptoms and objective pelvic examination findings. Symptom burden in pelvic floor disorders is not solely driven by anatomic descent—levator hypertonicity may contribute significantly to patient-reported distress. The strong association between splinting for urination and objective prolapse supports its utility as a high-yield screening question. However, patient-reported prolapse distress does not reliably reflect objective measures of bladder emptying, as evidenced by the lack of association with PVR.

These findings underscore the multifactorial nature of pelvic floor disorders and highlight limitations of relying on either patient-reported symptoms or anatomic findings in isolation. While higher POPDI-6 scores are associated with increased odds of prolapse, they also reflect overlapping domains of pelvic floor dysfunction, including myofascial pain, not specific to anatomy alone.  

Importantly, symptom-based questions (such as splinting for urination) demonstrate strong predictive value and serve as practical screening tools, particularly applicable for patients who have their initial evaluations online. This supports a patient-centered approach that can help individuals recognize behaviors or experiences they may have normalized. For example, patients who identify that they are splinting may be counseled to that this reflects an underlying pelvic floor disorder and represents an opportunity for intervention rather than a condition to be passively managed.

Incorporating predictive screening questions into both clinical practice and patient education may empower patients to more effectively communicate symptoms, facilitate earlier recognition of pelvic floor disorders, and ultimately improve access to appropriate evaluation and treatment.

Bump, R. C., Mattiasson, A., Bø, K., Brubaker, L. P., DeLancey, J. O., Klarskov, P., ... & Smith, A. R. (1996). The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. American journal of obstetrics and gynecology, 175(1), 10-17.
The Incidence of Pelvic and Low Back Pain in Patients with Pelvic Organ Prolapse Katelyn Donaldson 1 2, Julia Meilan 3, Tiquez Rivers 3, Kelly Rutherford 3, Kayla Shine 3, Valentín Manríquez 4, G Alessandro Digesu 5, Autumn Edenfield 3, Steven Swift 3 Affiliations Expand PMID: 38265453 DOI: 10.1007/s00192-024-05732-4
M.R. Meister, S. Sutcliffe, A. Badu, C. Ghetti, J.L. Lowder Pelvic floor myofascial pain severity and pelvic floor disorder symptom bother: is there a correlation?Am J Obstet Gynecol, 221 (2019), pp. 235.e1-235.e15