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Current opinion on the classification and definition of genital tract

prolapse
Steven Swift

Purpose of review
There are few issues in obstetrics and gynecology that seem so
readily apparent but are in actuality replete with confusion than
the diagnosis of genital tract prolapse. This stems from the
difficulties in defining genital tract prolapse and from the long
history of turmoil regarding how to classify and describe it. In
the past 5±10 years our specialty has begun to make inroads
into these issues. Finally, there is an accepted classification
system and because of this we are beginning to recognize what
represents normal vaginal support versus genital tract prolapse.
Recent findings
In 1993 the confusion regarding the classification of genital tract
prolapse was documented by a very thorough review of the
literature; in response, the Pelvic Organ Prolapse Quantification
system was developed. Subsequent to this, several articles
have begun to define the epidemiology of genital tract prolapse
and this is providing a glimpse of what differentiates pathologic
genital tract prolapse from normal support.
Summary
We can now reliably classify and describe genital tract
relaxation and imply what is normal support versus pathological
genital tract prolapse. However, we still have not defined genital
tract prolapse, determined its prevalence or provided the
clinician with a simple and reliable means of testing for its
presence or absence.
Keywords
genital tract prolapse, classification systems
Curr Opin Obstet Gynecol 14:503±507.

#

2002 Lippincott Williams & Wilkins.

Department of Obstetrics and Gynecology, Medical University of South Carolina,
Charleston, South Carolina, USA
Correspondence to Steven Swift MD, Associate Professor, Department of Obstetrics
and Gynecology, Medical University of South Carolina, 96 Jonathon Lucas Street,
Suite 634, Charleston, SC 29425, USA
Tel: +1 843 792 6104; fax: +1 843 792 0533; e-mail: swifts@musc.edu
Current Opinion in Obstetrics and Gynecology 2002, 14:503±507
Abbreviation
POPQ

Pelvic Organ Prolapse Quantification

# 2002 Lippincott Williams & Wilkins
1040-872X

Introduction

The de®nition and classi®cation of pelvic organ support
defects has a history replete with confusion. Early
attempts at devising a system to codify genital tract
prolapse were often simplistic descriptions describing
prolapse as either complete or incomplete [1]. Over time,
authors attempted to re®ne previous systems by developing more complex and descriptive systems, which
introduced much of the confusion that followed. In 1993,
Brubaker and Norton [2] presented the results of a
review of over 100 articles and 15 textbooks and they
found no consensus regarding a standard system to
describe pelvic organ prolapse. Following the publication of this review, an international committee published
a document describing the Pelvic Organ Prolapse
Quanti®cation (POPQ) system [3].
Genital tract prolapse is a condition that affects the
quality of life and rarely has signi®cant morbidity or
mortality. Therefore, how do you de®ne prolapse?
Should this condition be de®ned in terms of symptoms
or physical ®ndings or both? Is `normal' support for an
18-year-old nulliparous patient the same or different
from `normal' support for a 45-year-old multigravida?
Currently, we do not have the answers to these
questions and we are still left without a clear-cut
de®nition for genital tract prolapse.
The recent development of quality of life tools, speci®c to
pelvic organ prolapse, provide us with a reliable inventory
of symptoms attributable to this condition and may help
us better de®ne this condition in terms of both physical
®ndings and symptomatology. At this point, however, we
are still very early on in the process of describing and
de®ning something that seems so intuitive but in reality is
a very complex subject ± genital tract prolapse.

Genital tract prolapse classification systems

Currently, there is only one genital tract prolapse
classi®cation system that has attained international
acceptance and recognition: the POPQ, which was
developed by an international committee made up of
members from the International Continence Society, the
American Urogynecologic Society and the Society of
Gynecologic Surgeons. This system has been formally
recognized and adopted by these three societies [3]. The
POPQ is a very elegant and complex system that
requires measurement of nine points in the vagina and
on the perineum, which are then recorded in a 3 6 3
503

total vaginal length. C. A posterior. The leading edge of the prolapse is 5Tvl72 B anterior (Ba) C A posterior (Ap) B posterior (Bp) D Genital hiatus (gh) Perineal body (Pb) Total vaginal length (Tvl) Stage 1 Stage 2 Stage 3 Stage 4 Aa. but there is not complete vaginal eversion. The authors then sought to determine if this practice was reliable by comparing the results of exams using the POPQ with results of exams using the approximations. it was observed that many individuals were using the ordinal staging of the POPQ system by approximating the measures without taking actual centimeter measurements of the nine points described for the POPQ [6]. Ba. B posterior. Bp. Table 1.as well as inter-examiner reliability [4. Ap. The numbers are then translated into an ordinal staging system with values from 0 to 4. [5] who reported on the inter-examiner reliability of the POPQ and the Baden and Walker `half-way' vaginal pro®le. B posterior. Bp. genital hiatus. A anterior. done for simplicity ± it was dif®cult for clinicians to learn the nine individual points of the POPQ but the ordinal staging system was easy to employ. Bp. For full description of these points. which can be used to document small differences in patients within and between stages. Pb. The POPQ is a very sophisticated tool to describe the many subtle variations in genital tract support. total vaginal length. Ap. A anterior. C and D are greater than +1 but pt does not meet the criteria for stage 4 The vagina is completely everted. anterior lip of cervix (or cuff in hysterectomized patient). D. C and D are all less than 71 cm but patient does not have criteria for for stage 0 The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring. gh. Points Aa and Ap are at 73 cm and point D (or C in the hysterectomized patient)47(Tvl72) The leading edge of the prolapse does not descend below 1 cm above the hymenal ring. C and D are between 71 and +1 cm The prolapse extends more than 1 cm beyond the hymenal ring. Ba. posterior fornix. however it can be somewhat dif®cult to learn and use. anterior lip of cervix (or cuff in hysterectomized patient). Those points remaining above the hymen are designated as negative numbers and those points protruding beyond the hymen are designated as positive. Staging of pelvic organ prolapse Point Description Stage Description A anterior (Aa) A point on the anterior vaginal wall 3 cm above the hymenal ring Most dependent or distal point on the anterior vaginal wall segment between A anterior and point C or the cuff if patient has hada hysterectomy Anterior lip of the cervix or the cuff if the patient has had a hysterectomy A point on the posterior vaginal wall 3 cm above the hymenal ring Most dependent or distal point on the posterior vaginal wall segment between A posterior and point D or the cuff if patient has had a hysterectomy Posterior fornix (this space is left blank in the patient who has had a hysterectomy) Middle of external urethral meatus to posterior hymenal remnant Posterior hymen to middle of anal opening Hymenal ring to vaginal apex (only point measured at rest) Stage 0 No descensus of pelvic structures during straining. Ap. Tvl. They demonstrated that both systems had good inter-examiner reliability but noted that the `half-way' vaginal pro®le was easier to teach and use than the POPQ. 1). Any or all of points Aa. see Table 1.504 Urogynecology grid (Table 1 and Fig. B anterior. C. see Table 1. tvl. 0 being excellent support and 4 being complete uterine procidentia or vaginal vault eversion (Table 2). . perineal body. Sites measured in the quantitative pelvic organ prolapse examination Table 2. Move to a more simplified pelvic organ prolapse classification system Aa Ba C gh Pb Tvl Ap Bp D In a recent study. The 363 grid used to record the nine points of the Pelvic Organ Prolapse Quantification system This was also the ®rst system that was objectively studied and showed good intra.5]. This was mentioned in the study by Kobak et al. Ba. Bp. The POPQ grid numbers can also be used to draw a pro®le of the vagina. Any or all of points Aa. These numbers are measured in centimeters using the hymenal remnants as a reference point. Ba. D. B anterior. For full description of these points. Ap. A posterior. It was demonstrated that the approximations were consistent with the formal POPQ staging for the anterior and Figure 1. and suggested it was more applicable to the clinical setting. Points Aa. It was suggested that this was being Aa. posterior fornix. Ap.

This is due. (Additional data were presented in conjunction with the abstract on inter-examiner reliability of a new simpli®ed pelvic organ prolapse quanti®cation system at the 26th Annual Meeting of the International Urogynecologic Association in Melbourne in 2001. Finally. Most clinicians can recognize severe degrees of genital tract prolapse and can recognize excellent vaginal support when they see it. however.]. similar to the POPQ. The authors recommended measuring only four points. This remains speculation. the anterior and posterior vaginal walls. In an earlier study [9]. These data. Other investigators are currently performing similar studies to determine if the results are consistent. while some assumptions can be made regarding the distribution of genital tract support in the female population. If studies become available to demonstrate that a modi®ed/ simpli®ed system is more readily acceptable and easier to learn and retain. did not seek to determine which of these patients had symptoms attributable to genital tract prolapse and which were asymptomatic. Therefore. the POPQ should be retained as the scienti®c standard when reporting in the literature. They cannot. The simpli®ed classi®cation system was subsequently studied in 49 patients and it demonstrated good interexaminer reliability [8]. then the use of such a system would be recommended for use in clinical settings. It also appears that around 3±6% of patients will have signi®cant prolapse beyond the introitus. the literature provides us with limited information. Regardless of the results of studies employing a simpli®ed system. genital tract prolapse still has not been de®ned.Genital tract prolapse Swift 505 posterior vaginal wall segments but not for the apex and cervix. Current opinion on genital tract prolapse classification systems There are investigators who have concerns regarding the widespread use of the POPQ system because of a perceived dif®culty in learning and using the tool. with 5±6% demonstrating prolapse beyond the introitus. while describing a large number of patients. It must have good inter-system reliability with the POPQ so that patients examined and staged with either system would correlate. Stemming from similar concerns. Instead. instead of trying to approximate the various points of the POPQ. [12 . The definition of genital tract prolapse There is no current de®nition of pathologic genital tract prolapse that is clinically valid. however. Only one of the four studies which employed the POPQ examined a broad age range [9]. The committee did not feel that any new system should replace the POPQ. it should act as a simpli®ed version that would give the average practitioner a tool that could be employed to take advantage of the current use of the POPQ. it must be easy to learn and use in clinical practice. The vaginal apex and cervix are identi®ed and their descent staged.) It has still not been determined if this simpli®ed pelvic organ prolapse classi®cation system is easy to learn and use. For this we need to . Therefore. at least in regard to the cervix and vaginal apex. and the vaginal apex. Therefore. posterior or apical vaginal walls. they recommended identifying a point half way between the hymenal remnants and the cervix or cuff of the anterior vaginal wall and then measuring where that point descends. The system must have good inter.] and Samuelsson et al. however. Therefore. 2). the distribution of the stages of genital tact support in the population demonstrated a bell-shaped curve. The committee that developed this simpli®ed system felt that any alternative to the POPQ system must ful®ll certain criteria before its use could be recommended. to the absence of a good description of the distribution of genital tract support in the general female population.12 . at this time it is recommended that the POPQ should remain the standard for use. There are only a few studies that have attempted to describe and document the distribution of genital tract support in female populations [9±11. This is somewhat consistent with the studies by Versi et al.and intraexaminer reliability. Two of these studies looked at a very narrow age range (perimenopausal women) and only two described genital tact support using the POPQ. as it remains the most detailed and speci®c system for describing genital tract prolapse. a group of investigators from the International Urogynecologic Association developed a simpli®ed pelvic organ prolapse classi®cation system that retained the ordinal staging system of the POPQ (except for the deletion of stage 0) [7]. the cervix. and to date no one has studied the ease or dif®culty associated with learning the POPQ. [10]. who noted that a very large percentage of their patients had some relaxation of the anterior. in part. de®ne at what point a patient goes from normal support to pathologic genital tract prolapse. A similar technique is employed for the posterior vaginal wall. The same authors also reported that in 35 patients the simpli®ed system demonstrated good inter-system reliability with the POPQ. from these results it appears that there is some relaxation of the vaginal walls in a large number of patients and that the relaxation increases with the patient's age. Also. It is suggested that clinicians should not use the POPQ unless they are prepared to take the measures as formally described for the POPQ. with the majority of patients having stage 1 or 2 support and only 3% demonstrating stage 3 prolapse (when the leading edge of the prolapse is greater then 1 cm beyond the introitus) (Fig.

]. Limited data.506 Urogynecology Figure 2. In addition. regardless of her degree of support. by Pelvic Organ Prolapse Quantification stage Data represent a population of 497 women presenting to an outpatient gynecology clinic requiring an annual pap smear. This observation was con®rmed in a study which again used a short nonvalidated questionnaire. Note how the age curves shift to the right with advancing age. but at present the POPQ should be the accepted means of reporting . however. As a part of the study. Current opinion on the definition of genital tract prolapse The de®nition of genital tract prolapse is still unresolved. It is apparent. These tools are providing a means of objectively identifying and quantifying symptoms that are produced by genital tract prolapse. however. There are investigators who have concerns regarding its appeal to a widespread audience. the investigators used a de®nition of pelvic organ prolapse that was based on symptoms obtained from a short nonvalidated questionnaire [17 . Therefore. As a starting point. a good de®nition of genital tract prolapse may be `any symptomatic genital tract support defects where the leading edge of the prolapse is beyond the hymenal remnants'. but so far these concerns have not been documented. These symptom scores have also been correlated to the stages of support as measured by the POPQ and increasing values have been demonstrated with worsening stages of genital tract prolapse [16]. Quality of life tools to assess genital tract prolapse In the last few years there has been considerable research on the development of quality of life tools or questionnaires condition-speci®c for genital tract prolapse [13±15]. The distribution of genital tract support. any woman with symptoms of genital tract prolapse in which the leading edge of the prolapse is above the hymenal remnants may be de®ned as having pelvic organ prolapse once all other possible causes of her complaints have been ruled out. Therefore. Conclusion The POPQ is the only pelvic organ prolapse classi®cation system to have universal acceptance. It was noted that the number of positive responses increased rapidly once the leading edge of the pelvic organs was greater than 1 cm past the hymenal membrane or between POPQ stage 2 and 3 prolapse. This should exclude the asymptomatic patient. Percent 70 of patients 60 overall 18–39 50 40–59 40 60+ 30 20 10 0 Stage 0 determine which patients have symptoms and at what stage or level of support these become prevalent. are available on responses to these questionnaires in patients with good and intermediate levels of support to determine if there is a stage of genital tract support at which the majority of patients begin to experience symptoms. There are current studies afoot to determine if these concerns are justi®ed. we may have to adjust our de®nition of normal versus abnormal depending on many factors. The great- Stage 1 Stage 2 Stage 3 est jump in the incidence of reported symptoms occurred between stage 2 and 3 prolapse. there is still no cutoff to de®ne at what point a patient goes from normal genital tract support to pathologic prolapse. that there is a lot more subtle genital tract relaxation in the female population then was previously suspected. all participants answered nine questions regarding common symptoms of pelvic organ prolapse. In a recent case control study on the aetiology of genital tract prolapse. and alert the clinician to the possibility of alternative aetiologies for the patient's symptoms if she has genital tract support such that nothing is protruding beyond the hymenal remnants. Nineteen percent of participants with stage 2 prolapse reported symptoms of a vaginal bulge and this increased to 78% in those with stage 3 prolapse. and demonstrated a statistically signi®cant increase in prolapse symptoms with increasing POPQ stage [18].

Rosenberger K. Tibblin G. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Inter Urogynecol J 2001. organ prolapse. Kammerer-Doak D. et al. An interesting look at the distribution of pelvic organ support in perimenopausal women. Inter-examiner reliabilty of a new pelvic organ prolapse quantification (POPQ) system [Abstract]. 12 (Suppl 3):S99. Correlation of symptoms with location and severity of pelvic organ prolapse. 17 Swift S. Int Urogynecol J 2001. Pieper C.. Interesting look into the causes of pelvic organ prolapse with well defined cases and controls. 12 (Suppl 1):S2. Int Urogynecol J 2001. Theofrastous JP. Am J Obstet Gynecol 1996. 18 Otto L. 11 (Suppl 1):S25. Dias J. 8 Swift SE. 10 Samuelsson EU. Svardsudd KF. Clark A. there are no good de®nitions in the literature. Short form to assess sexual function in women with urinary incontinence and/or pelvic organ prolapse: the PISQ II [Abstract]. 16 Ellerkmann RM. Urankar R. of special interest . 7 Swift SE. Correlation of symptoms of pelvic organ prolapse to clinical stage [Abstract]. Freeman R. Urogenital prolapse and atrophy at . et al. Most investigators are employing de®nitions that are somewhat random. This de®nition should include both physical ®ndings and patient's symptoms. Earle BB. Int Urogynecol J 2001. 175:10±17. 12 (Suppl 3):S45. and American Urogynecologic Society pelvic organ prolapse classification system. Pelvic organ prolapse: is ICS-grading without POP-Q measurement reliable? [Abstract]. 10 (Suppl 1):S25. Psychometric analysis of two new comprehensive condition-specific quality of life instruments for women with pelvic floor disorders [Abstract]. 12:107±110. Walters MD. Petri E. 4 Hall AF. Bump R. Int Urogynecol J 2001. This is one area that needs to be investigated. References and recommended reading 12 Versi E. Papers of particular interest. 11 (Suppl 1):S26. Coates K. Morris S. Bent AE. Interobserver and intraobserver reliability of the proposed International Continence Society. Qualls C. 3 Bump RC.Genital tract prolapse Swift 507 research on genital tract prolapse. Am J Obstet Gynecol 1999. Int Urogynecol J 1996. Int Urogynecol J 2000. menopause: a prevalence study. Mouritsen L. 12:176±192. P-QOL: a validated questionnaire to assess the symptoms and quality of life of women with urogenital prolapse [Abstract]. and the Society of Gynecologic Surgeons in perimenopausal women. Int Urogynecol J 2001. Use of the pelvic organ prolapse staging system of the International Continence Society. Harvey M. 183:277±285. 11 Bland DR. 5 Kobak WH. Int Urogynecol J 2000. Vitolins MZ. Int Urogynecol J 1999. 9 Swift SE. 12 (Suppl 1):S2. Mattiasson A. Cundiff GW. 14 Rogers R. Burke G. et al. Case±control study of the etiology of severe pelvic . The standardization of terminology of female pelvic floor dysfunction. Current clinical nomenclature for description of pelvic organ prolapse. Cardozo L. have been highlighted as: . Interobserver variation in the assessment of pelvic organ prolapse. Am J Obstet Gynecol 2000. 2 Brubaker L. 2:257±259. Am J Obstet Gynecol 1996. published within the annual period of review. Cardozo L. American Urogynecologic Society. Bo K. of outstanding interest 1 Kelly HA. et al. Society of Gynecologic Surgeons. Proposal for a world-wide user-friendly classification system for pelvic organ prolapse classification [Abstract]. 180:299±305. 181:1324±1328. .. Norton P. New York: Appleton & Co. Kuchibhatla M. Digesu GA. Int Urogynecol J 2001. 7:121±124. 12 (Suppl 3):S46. Victor FTA. We need to know what is normal genital tract support and at what point the individual moves from normal support to pathologic prolapse. et al. Regarding the de®nition of genital tract prolapse. 15 Khullar V. 13 Barber M. 175:1467±1471. The distribution of pelvic organ support in a population of women presenting for routine gynecologic healthcare. 1898. Am J Obstet Gynecol 1999. Operative gynecology. 6 Prien-Larsen J. et al. Pound T. J Pelvic Surg 1996. Cundiff GC.