Demographics of Prolapse

Incidence
Up to 40% of females with some degree of
prolapse

Samuelson et al, 1999; Slieker et al, 2004

Risk Factors: mulitparity, operative vaginal

delivery, obesity, aging, chronic increased
intraabdominal pressure, connective tissue
disorders
 Demographics of Prolapse
Incidence
US 1997: 225,000 surgical repairs/year
Cost: >$1 Billion/year
UK 2004: 25,000 surgical repairs
Cost £ 46 million
France 2004: 26,000 surgical repairs
Cost € 43-56 million

Recurrence: 29%-40% within 3 years with suture

only repairs
Boyles, SH, Weber, AM, Meyn, L. Procedures for pelvic organ prolapse in the United States, 1979-1997. Am J Obstet Gynecol 2003;
188:108.
Subak, LL, Waetjen, LE, van den, Eeden S, et al. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001;
98:646.
Luber et al. The demographics of pelvic floor disorders : currents observations and future projections. Amer J Obstet Gynecol 2001;
184(7):1496-1503.
1.                 Definitions of Prolapse
Pelvic organ prolapse: a hernia of one or more pelvic organs (uterus,
vaginal apex, bladder, rectum) and its associated vaginal segment from
its normal location.[1]
Anterior vaginal prolapse (cystocele): pathologic descent of anterior
vaginal wall and overlying bladder base. Enterocele: hernia in which
peritoneum is in contact with vaginal mucosa. The normal intervening
endopelvic fascia is absent, and small bowel fills the hernia sac.
Rectocele: defect of posterior vaginal wall support. May be
asymptomatic or associated with disorders of defecation.
Uterovaginal prolapse: Descent of uterus/apical vagina due to
attenuation of uterosacral/cardinal ligament support complex
Neeraj Kohli, MD, Donald Peter Goldstein, MD.An overview of the clinical manifestations, diagnosis, and
classification of pelvic organ prolapse.
 Definitions of Prolapse
      Two Systems of Classification          

Baden Walker (1968) and Beecham (1980)

Pelvic Organ Prolapse Quantification
1996

Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female

pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
 Definitions of Prolapse
Baden Walker (1968) and Beecham (1980)

Cystocele
First degree: The anterior vaginal wall, from the urethral
meatus to the anterior fornix,descends halfway to the hymen.
Second degree: The anterior vaginal wall and underlying
bladder extend to the hymen.
Third degree:The anterior vaginal wall and underlying urethra
and bladder are outside the hymen. This cystocele is often
part of the third degree uterine or posthysterectomy vaginal
vault prolapse.
Urogynecology and reconstructive pelvic surgery. Mark D. Walters, Mickey M. Karram.
2nd edition, 1999.
 
 Definitions of Prolapse
Baden Walker (1968) and Beecham (1980)

Uterine or Vaginal Vault Prolapse

First degree: The cervix or vaginal apex descends halfway to
the hymen.
Second degree: The cervix or vaginal apex extends to the
hymen or over the perineal body.
Third degree:The cervix and corpus uteri extend beyond the
hymen or the vaginal vault is everted and protrudes beyond
the hymen.

Urogynecology and reconstructive pelvic surgery. Mark D. Walters, Mickey M. Karram. 2 nd

edition, 1999.
 
 Definitions of Prolapse
Baden Walker (1968) and Beecham (1980)
Rectocele
First degree: The saccular protrusion of the rectovaginal wall
descends halfway to the hymen.
Second degree: The sacculation descends to the hymen.
Third degree:The sacculation protrudes or extends beyond the
hymen,
Enterocele
The presence an depth of the enterocele sac, relative to the
hymen, should be described anatomically, with the patient in
the supine and standing positions during Valsava maneuver.  

Urogynecology and reconstructive pelvic surgery. Mark D. Walters, Mickey M. Karram. 2 nd

edition, 1999.
 Definitions of Prolapse
POP Q Pluses
POP Q: objective, site-specific system for describing,
quantifying, and staging pelvic support in women
POP Q: provides standardized means for
documenting, comparing, and communicating clinical
findings with proven interobserver and intraobserver
reliability
POP Q: approved by the International Continence
Society, the American Urogynecologic Society, and
the Society of Gynecologic Surgeons for the
description of female pelvic organ prolapse
Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed International
Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse
classification system. Am J Obstet Gynecol 1996; 175:1467.
 POP Q
Normal

Bump R, et al. The standardiztion of terminology of female perlvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol. Vol 175, (1) pp10-17)
 POP Q
Vaginal Prolapse vs. Normal

Bump R, et al. The standardiztion of terminology of female perlvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol. Vol 175, (1) pp10-17)
 POP Q
Anterior Wall Prolapse

Bump R, et al. The standardiztion of terminology of female perlvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol. Vol 175, (1) pp10-17)
 POP Q
Posterior Wall Prolapse

Bump R, et al. The standardiztion of terminology of female perlvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol. Vol 175, (1) pp10-17)
 Definitions of Prolapse
POP Q Minuses

POP Q: too many variations to allow grouping

patients into comparable populations for study
purposes

POP Q: too complex for simple clinical

communication, such as describing a patient briefly
to a colleague
Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed International
Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse
classification system. Am J Obstet Gynecol 1996; 175:1467.
 
 Definitions of Prolapse
POP Q Minuses

Result: ordinal staging system created to make

comparative analyses and clinical communications
more practical

Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic
floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed International
Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse
classification system. Am J Obstet Gynecol 1996; 175:1467.
 
 Definitions of Prolapse
POP Q
Staging of pelvic organ prolapse by POP Q
measurements
Stage Description
0 No descensus of pelvic structures during straining

The leading surface of the prolapse does not descend bellow 1

I cm above the hymenal ring

II The leading edge of the prolapse extends from 1 cm above the

hymen to 1 cm through the hymenal ring

The prolapse extends more than 1 cm beyond the hymenal

III ring, but there is not complete vaginal eversion

IV The vagina is completely everted