Evaluation of Pelvic Organ Prolapse Mark D. Walters, M.D. Professor and Vice Chair of Gynecology Department of Obstetrics and Gynecology Cleveland Clinic, USA

Disclosure of Financial Relationships American Medical Systems and Boston Scientific: paid consultant and lecturer

Learning Objectives At the conclusion of this lecture, participants should be able to: Review epidemiology of pelvic organ prolapse Summarize office evaluation and POPQ techniques and appraise evidence of their utility

Pelvic Organ Prolapse - Background 16% of women in US have prolapse Pannu et al. Radiographics 2000;20(6):1567-82 Lifetime prevalence 30-50%, of which 2% are symptomatic Samuelsson EC et al, AJOG 1999;180:299-305 7% lifetime risk of surgery for prolapse Olsen et al., Obstet Gynecol 1997;89:501 29% of these patients require re-operation Clinical examination either underestimates or inaccurately diagnoses the site of prolapse in a significant proportion of patients, and preoperative imaging has assumed a prominent role because of this Goh et al., AJR:174, 661-6;2000

Lifetime Risk of Single Operation for POP/UI 30-39 40-49 50-59 60-69 70-79 0.9% 2.8% 4.7% 7.5% 11.1% 2 4 6 8 10 12 Age Group Percent Lifetime Risk of Single Operation for POP/UI Olsen et al., Obstet Gynecol 1997;89:501

Outcomes for Pelvic Organ Prolapse Vaginal anatomy; bulge, pressure, mass Visceral symptoms: Urinary and bowel symptoms Sexual activity and expectations Future surgical procedures or medicines to manage failures or complications

Vaginal Prolapse Exam Vaginal apex Enterocele Anterior wall Bladder neck Posterior wall Perineum

Anterior vaginal prolapse Vaginal vault prolapse Uterine prolapse Anterior vaginal prolapse Vaginal vault prolapse

Pelvic Organ Prolapse Quantification System (POP-Q) Adopted by ICS, AUGS and SGS Objective, site-specific system Documenting Comparing Communicating Allows for: Precise description of pelvic support without assigning severity value Accurate observation of stability or progression of prolapse over time by same or different observers position type of exam table type of specula or retractor diagram of customized device type of straining fullness of bladder contents of rectum methods of quantitative measurements

Description of POP-Q Exam Confirm that prolapse is maximal Avoid terms of cystocele, rectocele, etc. Specify position of patient, exam chair or table Specify if bladder and rectum full or empty Describe any instruments used in examination

The POP-Q System Fixed reference point: hymen Two points of measurement each Anterior wall (Aa, Ba) Posterior wall (Ap, Bp) Apex (C, D) Also measure genital hiatus (gh), perineal body (pb), and total vaginal length (tvl)

Aa Ba C GH PB TVL Ap Bp D Anterior wall Cervix or cuff Genital hiatus Perineal body Total vaginal length Posterior wall Posterior fornix

POP-Q Evaluate maximum prolapse Describe other variables Valsalva Traction Confirmation by patient Standing exam Describe other variables

Genital Hiatus Perineal Body

SLIDING POINT Most distal position of any part of anterior vaginal wall Midline of anterior vaginal wall 3cm from external urethral meatus

Anterior points (Aa, Ba)

Most distal edge of cervix or leading edge of vaginal cuff Location of posterior fornix

SLIDING POINT Most distal position of any part of posterior vaginal wall Midline of posterior vaginal wall 3cm from hymen

POP-Q Staging Stage 0 normal Stage I Stage II Stage III-IV < -1 cm from (above) hymen Stage II +1 cm from hymen Stage III-IV >+1 cm to complete prolapse

Thank you for your attention!