POP Q

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

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)

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

Stage 0 - Stage 4

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)

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

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).

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)

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.

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

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

No prolapse

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

UV prolapse – supravaginal elongation of cervix

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

General prolapse – no supravaginal elongation of cervix (Procidentia)

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

Vault prolapse – D point is not there

Principles of Genital prolapse surgery ...

Supports of uterus

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)

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

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

Case 1 Newborn is born with congenital prolapse of uterus

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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