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

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

3. 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

4. Pelvic Organ Prolapse - Background
16% of women in US have prolapse
Pannu et al. Radiographics 2000;20(6):
Lifetime prevalence 30-50%, of which 2% are symptomatic
Samuelsson EC et al, AJOG 1999;180:
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

5. 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

6. 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

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

8. Anterior vaginal prolapse Vaginal vault prolapse
Uterine prolapse
Anterior vaginal prolapse
Vaginal vault prolapse

10. 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

11. 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

12. 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)

13. 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

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

15. Genital Hiatus
Perineal Body

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

17. Anterior points (Aa, Ba)

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

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

21. 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

22. Thank you for your attention!