Pelvic Organ Prolapse

Abstract

Pelvic organ prolapse (POP) is one of the most common problems faced by every gynecologist. Understandably, terminology is very important when describing vaginal or uterine descent, for two reasons. First, the physician's notes must represent the clinical problem and be able to communicate it to another colleague exactly as it has been seen. The second reason is quality assurance in research, where exact terminology is needed to accurately describe changes in pelvic organ prolapse and to allow comparisons between institutions and studies.Urogenital prolapse has traditionally been classifi ed according to the degree of anatomical descent, the site of the defect and the presumably involved pelvic viscera. The large number of different grading systems that have been used refl ects the diffi culty in designing an objective, reproducible system for grading prolapse. Intraand interobserver variability is often of importance and may lead to confusion. This makes diffi cult comparing successive examinations over time in the same woman or between different women. The Baden-Walker halfway system is one of the most used for POP classifi cation. It consists of a simple 0-4 grading scale which classifi es prolapse according to the defect site (urethra, bladder, cervix, or cuff, pouch of Douglas, rectum, and perineum) and descent above or below the vaginal introitus. For its simplicity, the Baden-Walker system has maintained considerable popularity among gynecologists in their daily clinical practice.In 1996 Bump et al. published a new classifi cation: the POP-Q system that has been widely accepted and has become the de facto standard in clinical medicine and research.It has been adopted by major organizations including the International Continence Society (ICS), the Society of Gynecologic Surgeons, the American Urogynecologic Society, and the National Institute of Health (NIH) as an accepted method of describing pelvic support and comparing exams over time or before and after interventions. The POP-Q has been shown to have reproducibility in several centers when the exam is conducted in a standardized fashion. The clinical description of pelvic fl oor anatomy is determined during the physical examination of the external genitalia and vaginal canal. It is critical that the examiner sees and describes the maximum protrusion noted by the individual during her daily activities and during physical examination in gynecological position (better on 45° angle) at maximum effort or Valsalva maneuver. The system relies on specifi c measurements of six defi ned points in the midline of the vaginal wall: Aa, Ba, C, D, Ap, Bp, and three other landmarks: GH (genital hiatus), TVL (total vaginal length), and PB (perineal body). Each of the six points is measured in centimeters above or proximal to the hymen (negative number) or in centimeters below or distal to the hymen (positive number) with the plane of the hymen being defi ned as zero (0). The hymen was selected as the reference point rather the introitus because it is more precisely iden...