91372018 Pelvic organ prolapse in women: Diagnostic evaluation - UpToDate 3 Wolters Kluwer Pelvic organ prolapse in women: Diagnostic evaluation Authors: Tola B Fashokun, MD, FACOG, Rebecca G Rogers, MD Section Editor: Linda Brubaker, MD, FACOG Deputy Editor: Kristen Eckler, MD, FACOG All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Aug 2018. | This topic last updated: Jun 21, 2017 INTRODUCTION — Pelvic organ prolapse (POP), the herniation of the pelvic organs to or beyond the vaginal walls, occurs in up to 50 percent of parous women and causes a variety of pelvic, urinary, bowel, and sexual symptoms [1]. The exact stage of POP is diagnosed on pelvic exam. A medical history is also important to elicit associated symptoms, since treatment of urinary or fecal symptoms is typically coordinated with treatment for POP. Asymptomatic POP may not require treatment. ‘The diagnostic evaluation of women with POP is reviewed here. ‘An overview of the female pelvic exam, POP. and treatment options are discussed separately and include: © (See "The gynecologic history and pelvic examination".) © (See "Pelvic organ prolapse in women: E} management’,) jemiology. risk factors, clinical manifestations, and * (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure") CLASSIFICATION OF PELVIC ORGAN PROLAPSE — Historically, the severity of prolapse was graded using a variety of imprecise classification systems that were not easily reproduced or communicated in a standard way among clinicians [2]. The Pelvic Organ Prolapse Quantitation system (POPQ), introduced in 1996, has become the standard classification system [3]. POPQ system ‘The POPQ system is an objective, site-specific system for describing and staging POP in women [2]. The POPQ system involves quantitative measurements of various points representing anterior, apical, and posterior vaginal prolapse to create a "topographic" map of the vagina, These anatomic points can then be used to determine the stage of the prolapse (figure 1 and figure 2 and table 4) [2,3] The POPQ system is the POP classification system of choice of the International Continence Society (ICS), the ‘American Urogynecologic Society (UGS), and the Society of Gynecologic Surgeons (SGS) [3]. The American College of Obstetricians and Gynecologists has also recommended its use [4]. It has proven interobserver and intraobserver reliability [5] and is the system used most commonly in the medical literature [6,7]. Intraoperative POPQ measurements correlate well with preoperative findings, with slightly more prolapse under anesthesia when traction is placed on the POPQ points [8] tps: www uplodate.com/contens/pelvic-organ-prolapse-in-women-siagnostic-evaluaoniprin(?source=hislory widget 12091372018 Pelvic organ prolapse in women: Diagnostic evaluation - UpToDate similarly to the standard POPQ exam, with a half speculum placed in the vagina to visualize the vaginal walls and cervix. (See ‘Simplified POPQ! below.) In this topic, classification of POP will be described using the original POPQ. (See ‘Using the POPQ system! below.) Baden-Walker system — While not recommended by leading societies, the Baden-Walker Halfway Scoring ‘System is another commonly used POP staging system. The degree, or grade, of each prolapsed structure is, described individually (eg, grade 1 anterior vaginal wall prolapse or grade 3 uterine prolapse). The grade/degree is defined as the extent of prolapse for each structure noted on examination while the patient is straining Because there are no clear demarcations among the cut-off stages, the Baden-Walker system lacks the precision and reproducibility of the POPQ system: The system has five degrees/grades [10]. For the urethra, posterior descent is graded, for other anatomic sites, the lowest part is graded: © 0—Normal position for each respective site © 1 —Descent halfway to the hymen 2—Descent to the hymen ‘* 3—Descent halfway past the hymen © 4—Maximum possible descent for each site Modifications of this system also exist. ‘The Baden-Walker system lacks the precision and reproducibility of the POPQ system. MEDICAL HISTORY — The medical history includes symptoms specific to prolapse, as well as urinary, defecatory, and sexual problems, which are often associated with POP. A detailed discussion of symptoms associated with POP can be found separately. (See "Pel inical manifestations, and management", section on ‘Cli 1 manifestations'.) There are no robust screening questionnaires for mild pelvic organ prolapse. Some epidemiologic studies have used a single question to screen for prolapse from a validated pelvic floor distress questionnaire [11], which likely captures only those patients with severe prolapse. By asking the question "Do you experience bulging or something falling out you can see or feel in the vaginal area’, the National Health and Nutrition Examination ‘Survey reported a 3 percent prevalence rate of advanced prolapse in the study population of nearly 2500 women [12]. Women with a positive response to this question should undergo a pelvic examination. ‘Symptom assessment is important, since treatment is generally not indicated for asymptomatic POP. In addition, assessment of POP symptoms and their impact on a patient's quality of life helps patients and clinicians set treatment goals [13-15]. Treatment of urinary or defecatory conditions is typically coordinated with POP treatment. (See “Pelvic organ prolapse in women: Choosing a primary surgical procedure”, section on ‘Women tps: www uplodate.com/contens/pelvic-organ-prolapse-in-women-siagnostic-evaluaoniprin(?source=hislory widget 22091372018 Pelvic organ prolapse in women: Diagnostic evaluation - UpToDate In addition, the medical history should include a review of medical comorbidities that could impact whether the patient is a candidate for surgical treatment. (See "Overview of the principles of medical consultation and perioperative medicine") DIAGNOSIS — POP is diagnosed with a pelvic examination using the pelvic organ prolapse quantification system. A medical history is also important to elicit prolapse-associated symptoms, since treatment is generally indicated only for symptomatic prolapse. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure”, section on Women with symptomatic prolapse’.) APPROACH TO THE EXAMINATION Examination components — Physical examination of women with POP includes the following components: © Visual inspection ‘© Speculum examination ‘© Bimanual pelvic examination ‘* Rectovaginal examination ‘* Neuromuscular examination Each component of the examination is discussed in the sections below. Equipment — instruments that are useful in assessment of pelvic prolapse include a Sims retractor (single blade speculum) or a bivalve speculum that can be easily taken apart so that the anterior and posterior blades can be used separately to observe individual compartments of the vagina (anterior, posterior, apical). ‘To make the measurements for the POPQ system, a ruler or a large cotton swab or sponge forceps marked in 1 ‘om increments is used [2.6]. Patient positioning — The examination is performed in each position with the woman relaxed and then straining (to demonstrate the maximum degree of prolapse) [16]. The extent of prolapse visualized on examination should confirm the patient's description of bulging symptoms. If the severity of prolapse visualized does not correlate with the patient's description, a hand-held mirror may be beneficial to confirm that what the provider is seeing is the full extent of the prolapse. The patient is examined initially in the dorsal lithotomy position. A prospective series of 218 women reported that performing the pelvic examination in the left lateral position (a common position used to assess pelvic support in the United Kingdom) yielded results that correlated highly with findings in the lithotomy position [17] ‘The examination is then repeated with the patient standing [16.18]. This is the position that will best approximate the extent of prolapse that the patient experiences daily. In the standing position, the patient places one foot on a well-supported footstool. The examining gown is lifted slightly to expose the genital area during the examination [19]. Documentation — A full description of the examination is recorded, including [2} tps: www uplodate.com/contens/pelvic-organ-prolapse-in-women-siagnostic-evaluaoniprin(?source=hislory widget 320