1. POP Q

2. POPQ → STAGING SYSTEM Pelvic organ prolapse quantifification
( International continence society) Aa Ba C Gh Pb
TVL Ap Bp D

3. Aa
3cm proximal to external urethral meatus on Anterior vaginal wall approximate location of urethrovesical junction Ba
Most distal postion of upper Ant vaginal wall ( Max prolapsed excursion on Anterior vaginal wall) C
Most distal edge of cervix or vaginal cuff AP
3cm proximal to hymen on posterial vaginal wall Bp
Max prolapsed excursion on posterior vaginal wall D
Location of posterior vaginal fornix
Represents the level of uterosacral ligament attachment to the posterior cervix gh
Diameter of genital hiatus
Middle of external urethral meatus to the posterior hymen Pb
Width of perineal body
Posterior margin of genital hiatus to midanal opening
TVL
Total vaginal length
Proximal to hymen → measurements – recorded as negative numbers (inside the vagina)
Distal to hymen → Positive numbers ( out side the vagina)

4. POP-Q D C Ba Aa Bp
tvl Ap gh pb

5. Stage 0 - Stage 4

6. Stage 0 No prolapse is demonstrated
Points Aa, Ap, Ba, and Bp are all at -3cm
Point C is <TVL – 2cm
Point D is equal to TVL(total vaginal length)

7. The criteria for stage 0 are not met
The most distal portion of the prolapse is > 1cm above the level of the hymen

8. Stage 2
The most distal portion of the prolapse is 1cm proximal to or distal to the plane of the hymen(i.e., its quantitation value is -1cm to +1cm).

9. Stage 3
The most distal portion of the prolapse is >1cm below the plane of the hymen but protrudes no further than 2cm less than the total vaginal length in centimeters (i.e., its quantitation value is >+1cm but <+[TVL -2]cm)

10. Stage 4
Essentially, complete eversion of the total length of the lower genital tract is demonstrated.
The distal portion of the prolapse protrudes to at least (TVL -2)cm (i.e., its quantitation value is >TVL -2cm.

11. How to do POP Q? With prolapse reduced mark 2 fixed points Aa and Ap
Measure 3 things GH, PB and TVL
With maximal excursion of prolapse
mark remaining 4 floating points
measure all 6 points with hymen as the reference point

12. Case 1
Aa - 3
Ba -3
C -7
Gh 4
Pb 4
TVL 9
Ap -3
Bp -3
D -9

13. No prolapse

14. Case 2
Aa -3
Ba +4
C +7
Gh 5
Pb 2
TVL 10
Ap +3
Bp +1
D +2

15. UV prolapse – supravaginal elongation of cervix

16. Case 3
Aa +3
Ba +7
C +8
Gh 6
Pb 1.5
TVL 9
Ap +3
Bp +3
D +7

17. General prolapse – no supravaginal elongation of cervix (Procidentia)

18. Case 4
Aa +3
Ba +5
C +8
Gh 6
Pb 2.5
TVL 9
Ap +3
Bp +2

19. Vault prolapse – D point is not there

20. Principles of Genital prolapse surgery
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21. Supports of uterus

22. Primary supports Uterine axis – flexion 90⁰ and version 120 ⁰
Vaginal supports – De Lancy
Ligamentary – Level 1(suspension)
Fascial – Level 2 (attachment)
Muscular – Level 3 (fusion)

23. Secondary supports
Endopelvic fascia contained in leaves of broad ligament
Anteriorly – UV fold of peritoneum
Posteriorly – RV fold of peritoneum
Laterally – Broad ligament

24. Attachment of fasciae Vesicovaginal Superior – pericervical ring
Lateral ATFP (white line)
Inferior – Urogenital diaphragm
Rectovaginal (Denonvillier)
Lateral ATRV
Inferior – Perineal body

26. Case 1 Newborn is born with congenital prolapse of uterus

27. Where is the defect?
What is the cause?
All 3 levels
Severe congenital weakness of connective tissue

28. Case 2
26 year old unmarried nulligravid girl presents with 3 degree uterine descent wth no vaginal descent

29. Where is the defect?
What is the cause?
How do you correct?
Level 1 support
Moderate degree of congenital weakness of connective tissue
Conventional – Sling surgeries
Modern – Sacrohysteropexy

30. Case 3
30 year old primiparous who had very easy vaginal delivery presents with 3rd degree uterine descent with cystocele, enterocele and deficient perineum (general prolapse – cervix normal length)

31. Where is the defect?
What is the cause?
How do you correct it?
Level 1 , 2 and 3 supports
Mild degree of congenital weakness of connective tissue
Conventional – Extended Manchester surgery
Modern – sacrohysteropexy with perineorrhphy

32. Shirodkar’s extended Manchester
Original fothergill
pod not opened
Modified fothergill
pod opened and uterosacrals stiched infront of cervix
Shirodkar’s extended Manchester
cervix not amputated
Fothergill points
imaginary points to harvest vaginal flaps
Fothergill stitch
suturing uterosacrals infront of cervix
Sturmdorf stitch
reformation of crvical lips

33. Case 4
P3 L3, 38yr, all home deliveries presented with 2nd degree uterine descent with cystocele, enterocele, rectocele and deficient perineum (UV prolapse)

34. Where is the defect?
What is the cause?
How do you correct it?
Level 2 and 3 supports
Child birth injury
Conventional – Modified Fothergill surgery
Modern – Sacrohysteropexy with perineorrhphy

35. Case 5
60 year old postmenopausal lady presents with 3rd degree uterine descent with cystocele, enterocele, rectocele and deficient perineum (General prolapse)

36. Where is the defect?
What is the cause?
How do you correct it?
Level 1, 2 and 3 supports
Estrogen deficiency
Conventional – Ward Mayo surgery ( Levator myorrhaphy)
Modern – Vaginal hysterectomy with site specific repair

37. Same lady not fit for surgery, uterine pathology ruled out and sexually not active
What do you do?
Sexually active?
Not willing for surgery ?
Pessary not fitting?
Leforts
Goodall power modification
Pessary
Dannis stitch

38. Cystocele repair Central repair fascial defect / mesh Lateral
Conventional – paravaginal defect repair
Modern – apical fixation

39. Enterocele Abdominal – Moscovitz and Halban
Vaginal McCall (rectovaginal fascia is attached to pericervical ring)

40. Rectocele repair Central defect – repair of the defect/mesh
Laterally – attach to ATRV
Inferiorly to PB

41. Perineorrahphy
Approximation of bulbospongiosus, superficial and deep transverse perinei
Levator myorrhaphy – wide genital hiatus not sexually active – dumbell shaped vagina - dyspareunia