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Pelvic organ prolapse (POP) is a bulge or protrusion of pelvic organs and their associated vaginal segments into or through the vagina
Pelvic organ prolapse results from attenuation of the supportive structures, whether by actual tears or “breaks” or by neuromuscular dysfunction or both.
The more common pelvic support disorders include rectoceles and cystoceles , enteroceles, and uterine prolapse, reflecting displacement of the rectum, small bowel, bladder, and uterus, respectively, resulting from failure of the endopelvic connective tissue, levator ani muscular support, or both. Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus.
Pelvic organ prolapse often is accompanied by symptoms of voiding dysfunction, including urinary incontinence, obstructive voiding symptoms, urinary urgency and frequency, and, at the extreme, urinary retention and upper renal compromise with resultant pain or anuria. Other symptoms often associated with POP include pelvic pain, defecatory problems (e. g., constipation, diarrhea, tenesmus, fecal incontinence), back and flank pain, overall pelvic discomfort, and dyspareunia. Patients seeking care for prolapse may have one or several of these symptoms involving the lower pelvic floor. Choice of treatment usually depends on severity of the symptoms and the degree of prolapse consistent with the patient's general health and level of activity.
In evaluating patients with pelvic organ prolapse, it is particularly useful to divide the pelvis into compartments, each of which may exhibit specific defects. The use of a Graves speculum or Baden retractor can help to evaluate the apical compartment of the vagina. The anterior and posterior compartments are best examined with the use of a univalve or Sims' speculum. The speculum is placed posteriorly to retract the posterior wall downward when examining the anterior compartment and placed anteriorly to retract the anterior wall upward when examining the posterior compartment. A rectovaginal examination may be useful in evaluating the posterior compartment to distinguish a posterior vaginal wall defect from a dissecting apical enterocele or a combination of both. If an anterior lateral detachment defect is suspected, an open ring forceps (or a Baden retractor) may be placed in the vagina at a 45–degree angle posteriorly cephalad to hold the lateral fornices adjacent to the pelvic sidewall. During the evaluation of each compartment, the patient is encouraged to perform Valsalva so the full extent of the prolapse can be ascertained. If the findings determined with Valsalva are inconsistent with the patient's description of her
anatomic descriptions of specific sites in the vagina are used in place of traditional terms. Typically it is graded on a scale of 0 to 3 or 0 to 4..e. and (ii) its ability to assess prolapse at multiple vaginal sites. which are used to assign a stage (from 0 to IV) of prolapse at its most advanced site. or POP–Q. with the grade increasing with the severity of prolapse. Its two most important advantages over previous grading systems are (i) it allows the use of a standardized technique with quantitative measurements at straining relative to a constant reference point (i. . This standardized quantification system facilitates communication between physicians in practice and research and enables progression of these conditions to be followed accurately. The system identifies nine locations in the vagina and vulva in centimeters relative to the hymen. Currently the system approved by the International Continence Society is the Pelvic Organ Prolapse Quantification system. In this system. it may be helpful to perform a standing straining examination with the bladder empty Pelvic Organ Prolapse Quantitation System Many systems for staging prolapse have been described. Although probably more detailed than necessary for general practice.symptoms. the hymen). clinicians should be familiar with the POP– Q system because most published studies use it to describe research results.
-10. middle. D. stages are assigned according to the most dependent portion of the prolapse (Table 24. This point represents the level of the attachment of the uterosacral ligament to the posterior cervix. point Ba is -3 in the absence of any prolapse (it is never less than -3) to a positive value equal to the total vaginal length in a patient with total eversion of the vagina.1). however. 11. which corresponds to the bladder neck. it is omitted if the cervix is absent. 3 for points Aa. Point Ba represents the most distal or dependent point of any portion of the anterior vaginal wall from point Aa to just anterior to the vaginal cuff or anterior lip of the cervix. Bp. with the Ba point moving depending on the amount of anterior compartment prolapse. -3. The anterior vaginal wall measurements are termed Aa and Ba. . By definition. Three other measurements in the POP–Q examination include the genital hiatus. total vagina length. After collection of the site– specific measurements.e. -8. genital hiatus. and perineal body). The genital hiatus is measured from the middle of the external urethral meatus to the posterior midline hymen. Point D is the location of the posterior fornix. perineal body. This point can vary depending on the nature of the patient's support defect. It is intended to differentiate suspensory failure from cervical elongation. Ba. Ap. The middle compartment consists of points C and D. -3. The total vaginal length is the greatest depth of the vagina in centimeters when the vaginal apex is reduced to its full normal position. The POP–Q examination often appears confusing on initial review. The posterior compartment is measured similarly to the anterior compartment: the corresponding terms are Ap and Bp. All measurements except the total vaginal length are measured during maximal straining. 4. the range of position of this point is -3 to +3. For example. Point Aa represents a point on the anterior vagina 3 cm proximal to the external urethral meatus.. -3.The classification uses six points along the vagina (two points on the anterior. with the plane of the hymen representing zero. The anatomic position of the six defined points should be measured in centimeters proximal to the hymen (negative number) or distal to the hymen (positive number). The nine measurements can be recorded as a simple line of numbers (i. The perineal body is measured from the posterior margin of the genital hiatus to the midanal opening. C.2). and the total vaginal length. and posterior compartments) measured in relation to the hymen. The six vaginal sites have possible ranges that depend on the total vaginal length (Table 24. Point C represents the most dependant edge of the cervix or vaginal cuff after hysterectomy. -3.
A videotape describing the system and showing its use in several patients is available from the American Urogynecology Society. .e. The POP–Q examination provides a standardized measurement system to allow for more accurate assessments of postoperative outcome and to ensure uniform. at least three measurements should be obtained: the most advanced extent of the prolapse in centimeters relative to the hymen that affects the anterior vagina. the posterior vagina. This will help in documenting the baseline extent of prolapse and the results of treatment. and the cervix or vaginal apex. reliable. As noted previously. it is important to document the most pertinent findings on examination. whether the older staging systems or the POP–Q system is used.. In a clinical setting.a measuring device (i. a marked ring forceps or marked cotton–tip applicator) can assist in instructing those unfamiliar with this staging system. and site–specific descriptions of pelvic organ prolapse.
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