Mark D. Walters, M.D.

Professor and Vice Chair of Gynecology

Department of Obstetrics and Gynecology

Cleveland Clinic, USA

Evaluation of Pelvic Evaluation of Pelvic

Organ Prolapse Organ Prolapse

Disclosure of Financial Relationships

American Medical Systems and Boston

Scientific: paid consultant and lecturer

Learning ObjectivesLearning Objectives

At the conclusion of this lecture, At the conclusion of this lecture, participants should be able to:participants should be able to:

1.1. Review epidemiology of pelvic organ Review epidemiology of pelvic organ prolapseprolapse

2.2. Summarize office evaluation and POPQ Summarize office evaluation and POPQ techniques and appraise evidence of techniques and appraise evidence of their utilitytheir utility

Pelvic Organ Prolapse - Pelvic Organ Prolapse - BackgroundBackground

16% of women in US have prolapse 16% of women in US have prolapse Pannu et al. Radiographics 2000;20(6):1567-82Pannu et al. Radiographics 2000;20(6):1567-82

Lifetime prevalence 30-50%, of which 2% are Lifetime prevalence 30-50%, of which 2% are symptomaticsymptomatic Samuelsson EC et al, AJOG 1999;180:299-305Samuelsson EC et al, AJOG 1999;180:299-305

7% lifetime risk of surgery for prolapse7% lifetime risk of surgery for prolapse Olsen et al., Obstet Gynecol 1997;89:501Olsen et al., Obstet Gynecol 1997;89:501

29% of these patients require re-operation29% of these patients require re-operation Olsen et al., Obstet Gynecol 1997;89:501Olsen et al., Obstet Gynecol 1997;89:501

30-39 40-49 50-59 60-69 70-79

0.9%

2.8%

4.7%

7.5%

11.1%

00

22

44

66

88

1010

1212

Age GroupAge Group

Pe

rce

nt

Pe

rce

nt

Lifetime Risk of Single Operation for POP/UI

Olsen et al., Obstet Gynecol 1997;89:501Olsen 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

Uterine prolapseUterine prolapse Anterior vaginal Anterior vaginal prolapseprolapse

Vaginal vault Vaginal vault prolapseprolapse

Pelvic Organ Prolapse Quantification Pelvic Organ Prolapse Quantification System (POP-Q)System (POP-Q)

Adopted by ICS, AUGS and SGSAdopted by ICS, AUGS and SGS Objective, site-specific systemObjective, site-specific system

DocumentingDocumenting ComparingComparing CommunicatingCommunicating

Allows for:Allows for: Precise description of pelvic support without assigning Precise description of pelvic support without assigning

severity valueseverity value Accurate observation of stability or progression of Accurate observation of stability or progression of

prolapse over time by same or different observersprolapse over time by same or different observers

The POP-Q SystemThe POP-Q System

Fixed reference point: hymenFixed reference point: hymen

Two points of measurement eachTwo points of measurement each

Anterior wall (Aa, Ba)Anterior wall (Aa, Ba)

Posterior wall (Ap, Bp)Posterior wall (Ap, Bp)

Apex (C, D)Apex (C, D)

Also measure genital hiatus (gh), perineal Also measure genital hiatus (gh), perineal

body (pb), and total vaginal length (tvl)body (pb), and total vaginal length (tvl)

AaAa BaBa CC

GHGH PBPB TVLTVL

ApAp BpBp DD

Anterior wall

Posterior wall

Cervix or cuff

Posterior fornix

Genital hiatus Perineal body

Total vaginal length

POP-QPOP-Q

Evaluate maximum Evaluate maximum prolapseprolapse ValsalvaValsalva TractionTraction Confirmation by patientConfirmation by patient Standing examStanding exam

Describe other Describe other variablesvariables

Genital Genital HiatusHiatus

Perineal Perineal BodyBody

Midline of anterior vaginal wall 3cm from external urethral meatus

SLIDING POINT

Most distal position of any part of anterior vaginal wall

Anterior points (Aa, Ba)Anterior points (Aa, Ba)

Location of posterior fornix

Most distal edge of cervix or leading edge of vaginal cuff

SLIDING POINT

Most distal position of any part of posterior vaginal wall

Midline of posterior vaginal wall 3cm from hymen

POP-Q StagingPOP-Q Staging

Stage 0 normalStage 0 normal Stage IStage I

< -1 cm from (above) < -1 cm from (above) hymenhymen

Stage IIStage II ++1 cm from hymen1 cm from hymen

Stage III-IV Stage III-IV >+1 cm to complete >+1 cm to complete

prolapseprolapse

Thank you for your attention!