Pelvic organ prolapse quantification

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Is POP-Q quantification really time consuming?? ElisabettaCostantini ElisabettaCostantini 8 100 Jun 20, 2016 by harveym1 harveym1
Pelvic organs prolapse quantification

Editor: Jeanette Matouskova, jeanette.matouskova@gmail.com
Consultant: Martin Huser, martin.huser@gmail.com
Wiki committee:Chendrimada Madhu
April, 2016
Pelvic organs prolapse (POP) is a condition in women that signify an anatomical change referring to falling, slipping or downward displacement of female pelvic organs. The symptoms vary according to the impairment of particular organ but generally it is departure from normal sensation, structure or function experienced by woman in reference to the position of her pelvic organs. POP has prevalence of 3-6%.


Pelvic organs prolapse quantification (POP-Q) is a standardised tool for documenting the examination findings and is recognised by International Continence Society (ICS) and International Urogynecological Association (IUGA). In 2010 the POP-Q system was ratified by IUGA and ICS and published in both Neurourology and Urodynamics (NAU) and International Urogynecology Journal (IUJ) (1). In 2015 the POP-Q classification system was revised by IUGA / ISC working group for female POP terminology. The revised joint report on the terminology for female POP published in 2016 in IUJ and NAU contains besides standard POP-Q also new simplified POP-Q classification and furthermore some new concepts and alternatives for POP description (2).
Controversies
The pop-Q System is considered a valid and reproducable measurement system of pelvic organ prolapse POP.
This scoring system is however, not widely used by urologists as it is a bit more difficult to learn and the practical reason that you need a ruler to measure the distant of the different reference points. In addition, many urologists believe that simply writing down that there is a significant prolapse (for example cyctocele beyond the hymenal ring) is more than accurate enough and that the pop-q does not add any clinical relevance to the description of physical examination. How ever many gynaecologist would disagree and think that the specific description of the exact pop-q is essential for the choice of the right treatment.
Moreover, the choice of the treatment (operative versus pessarium or even pelvic floor physiotherapy ) is a matter of debate.
Would we help reduce patients bother ( their urinary urgency or incontinence) by POP treatment or should we first try medication or in case of stress incontinence a vaginal tape?
These and many other aspects of POP diagnosis and treatment are the aim of many studies and can be the subject of debate on the ICS wiki page on POP.
This document includes the summary of standard POP-Q classification based on the document from year 2010, new simplified pop-q classification and latest available parameters for POP description which needs to be validated in clinical practice.
A. Standard POP-Q classification
In POP-Q system six principle landmarks are defined to describe the quantity of pelvic organ prolapse. These points are located on vaginal walls and are related to hymen which is fixed point of reference. Other three landmarks are defined for more detailed description. Stages of prolapse are defined according to the evaluation of these points. All nine points are shown in figure below (Fig.2) and summarized in the grid. (Fig. 1)
Anatomical landmarks
Anterior vaginal wall
  1. 1. Point Aa: This point is located in the middle of anterior vaginal wall proximal to the external urethral meatus (3cm). The range of its position relative to hymen is from -3 to +3cm.
  2. 2. Point Ba: This point represents the most distal position of any part in upper vaginal anterior wall from the vaginal cuff or anterior vaginal fornix to Point Aa. In absence of prolapse, this point is at -3cm and in women with total uterine prolapse or post hysterectomy vaginal eversion would have a positive value equal to position of Point C-vaginal cuff.
Superior vaginal wall
  1. 3. Point C: A point that has two representations. It could be a point represented the most distal edge of the cervix or leading edge of vaginal cuff (hysterectomy scar) after total hysterectomy.
  2. 4. Point D: This point is determining in women who still has cervix and it represents the location of posterior vaginal fornix. It is also a point of measurement for differentiation a suspensory failure of uterosacral-cardinal ligament “complex” from cervical elongation. In absence of cervix Point D is omitted.
Posterior vaginal wall
  1. 5. Point Ap: This point is located in the middle of posterior vaginal wall proximal to the hymen (3cm). The range of its position relative to hymen is from -3 to +3cm.
  2. 6. Point Bp: This point represents the most distal position of any part in upper vaginal posterior wall from the vaginal cuff or anterior vaginal fornix to Point Aa. In absence of prolapse, this point is at -3cm and in women with total uterine prolapse or post hysterectomy vaginal eversion would have a positive value equal to position of Point C-vaginal cuff.
Other landmarks and measurements
  1. 7. Genital hiatus (GH): A distance between external urethral meatus and posteriori margin of the hymen.
  2. 8. Total vaginal length (TVL): A length of vagina (cm) measured from posterior fornix to hymen when Point C and D are reduced to its full normal position.
  3. 9. Perineal body (PB): A distance measured from posterior margin of the hymen to the mid-anal opening.
Figure 1
Grid presentation of POP-Q measurements
figure 1.jpg

Figure. 2
The six sites (Aa, Ba, C, D, Bp and Bp), the genital hiatus (gh), perineal body (pb) and total vaginal length (tvl) used cm above or proximal to the hymen (negative number) or cm below or distal to them hymen (positive number) with the plane of the hymen being defined as zero (0). Alternatively, a three by three grid can be used to organize concisely the measurements as noted in Fig. 1
figure 2.jpg

Pelvic organs prolapse definition and staging
Pelvic organ prolapse is anatomically defined as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault or cuff scar after hysterectomy).
The presence of POP should be correlated with relevant POP symptoms. Syndromes related to POP are bulge sensation, pelvic pressure and sacral backache. Frequent, incomplete emptying or urinary retention can appear. Patients may also suffer from incomplete defecation, urinary incontinence or bladder storage.

During examination woman’s bladder must by empty (and if possible an empty rectum). They examine in standing or lithotomy position with patient forcefully bearing down, performing Valsalva or coughing. According to the anatomical landmarks defined above, pelvic organs prolapse can be divided into the following five stages (0-IV) shown on Figure 3.
Stage 0: No prolapse is demonstrated
Stage I: Most distal portion of prolapse is more than 1 cm above the level of hymen.
Stage II: Most distal portion of the prolapse is situated between 1 cm below or above hymen.
Stage III: The most distal portion of prolapse is more than 1cm blond the plane of hymen but everted at least 2 cm less then total vaginal length.
Stage IV: Complete eversion or eversion at least within 2 cm of the total length of the lower genital tract is demonstrated.


Figure 3
figure 3.jpg

Figure shows prolapse staging 0, I, II, III, IV.

B. Simplified POP-Q

This quantification is based on POP-Q with similar ordinal staging but with only four points measured instead of nine. There is no Stage 0; it is combined with Stage I. It is undertaken in the dorsal lithotomy position with patient forcefully bearing down, performing Valsalva or coughing.
Points
1) Anterior vaginal segment: point Ba (estimated around 3 cm proximal to hymenal remnants).
2) Posterior vaginal segment: point Bp (estimated around 3 cm proximal to hymenal remnants).
3) Cervix point C
4) Apex/posterior fornix: point D (non-hysterectomized);
point C (hysterectomized)
Staging
I, II, III, IV as for POP-Q above.
C. New concepts and available measurements for POP description
The IUGA/ ISC working group on female POP terminology also introduced the following new concepts and available measurements for POP description including vaginal anatomical levels and lengths, perineal measurements and vaginal measurements. These additional might be possibly used in clinical practice, but they are still waiting to be validated.
1. Subdivision of Stage II POP-Q:
Stage II mentioned in article above is according to the new concept divided in two parts. St. IIA when the portion is 1 cm above hymen and St. IIB when the portion is 1 cm below hymen
2. Vaginal Anatomical Levels and Lengths:


Level I: A distance 2.5 cm long measured from uterine cervix to vagina.
Level II: A distance between distal end of level I to the hymen (about 5 cm)
Level III-Vaginal vestibule: A distance measured from hymenal ring to just below the clitoris anteriorly, labia minora laterally and anterior perineum posterior.
Posterior vestibule: A distance between posterior hymenal ring and anterior perineum.
Total vaginal length: A length including Level I and Level II posteriorly.
Total posterior vaginal lenght: length including Level I, Level II and Level III a posteriorly
Anterior vaginal length: A distance between anterior hymenal ring and anterior vaginal vault


3. Additional available intraoperative measurements.


Perineorrhapy Width (PW) and Depth (PD): These terms present a width and depth of excised perineum.
Perineal Length (PL): A distance from posteriori margin of vestibule to anterior anal verge
Mid-perineal thickness (MPT): A thickness (cm) of perineum in midline.
Perineal Gap (PG): Thinned out medial area (cm) between Moynihan forceps placed bilaterally where the labia minora meet perineum.
Perineorrhaphy Commencement Position (PCP): In Level III perineorrhapy should commence.
Posterior Vaginal Vault Descent (PVVD): Descent of the posterior vaginal wall towards the perineal gap obtained by subtracting the inferiorly displaced vaginal wall and anterior perineum (second figure) from the posterior vaginal length (TPVL-first figure-posterior vaginal vault to anterior perineum)
Mid-Vaginal Laxity (MVL): Laxity of vaginal mucosa (anterior traction) midpoint in the vagina super- posteriori and in the midline with the vaginal vault held in an undisplaced position (similar to that after vault fixation)
Recto-Vaginal Fascial Laxity (RVFL): Laxity of the recto-vaginal fascia (anterior traction) midpoint in the vagina super- posteriori (mucosa opened) and in the midline with the vaginal vault held in an undisplaced position.
References:
1. Haylen BT, De Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al (2010) An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 21:5–26

  1. 2. Haylen BT, Mahen CHF, Barber MD, Camargo S, Dandolu V, Digesu A, et al (2016) An International Urogynecological Association (IUGA) /International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J 27:165–194