Pelvic Organ Prolapse Diagnosis
Evaluation + Workup
Defining prolapse
- Anterior: bladder, urethra, or intestinal prolapse, most common type of prolapse
- Apical: intestinal, uterine, cervical, or vaginal cuff prolapse
- Posterior: rectum, intestine, or uterine prolapse
- Procidentia: total vaginal eversion
History
- Symptoms: palpable vaginal bulge noted by patient, pelvic pressure, discharge, need to splint (insert fingers and push) for urination/defecation, low back pain
- Urinary symptoms: frequency, urgency, nocturia, incontinence, incomplete emptying
- Poor correlation between symptoms and prolapse severity
- Risk factors: age, increased parity, obesity, prior hysterectomy, constipation
Imaging
- Ultrasound may be helpful to identify prior mesh usage/placement if unclear
- MR not necessary, but defecography may be helpful of symptoms unclear, helps to identify enterocele
POP-Q measurements, from Campbell's
POP-Q 3x3 table, from Campbell's
POP-Q
Methods
- Measures prolapse based on defined points on vaginal wall midline in relation to vaginal ring
- Negative refers to within introitus, positive refers to prolapse past introitus
- Take Aa, Ba, C, Ap, Bp, D all during maximal prolapse, take gh, pb, tvl at rest
- Recommended to perform both while recumbent and while standing (put one foot on short stool)
Understanding the measurements
- Aa: 3cm proximal to hymen on anterior vaginal wall, approximate location of urethrovesical junction, can only range -3 to +3
- Ba: most distal point of prolapse between vaginal apex and Aa, -3 if no prolapse, equals C if complete prolapse
- C: most distal edge of cervix or vaginal cuff (if prior hysterectomy)
- Ap: 3cm proximal to hymen (parallels Aa)
- Bp: most distal point of prolapse between vaginal apex and Ap, -3 if no prolapse, equals C if complete prolapse
- D: posterior fornix (if cervix present), approximate location of uterosacral ligament attachment, omitted if no cervix present
- gh: genital hiatus, measure urethral meatus to posterior hymenal ring, larger gh (smaller pb) decreases pessary and apical repair efficacy
- pb: perineal body, measure posterior genital hiatus to midanal opening
- tvl: total vaginal length, measure from posterior fornix to hymen
Staging
- Stage 0: no prolapse, Aa, Ba, Ap, Bp all equal -3, C and D are between tvl and tvl-2cm
- Stage 1: most distal prolapse is > -1
- Stage 2: most distal prolpase is between -1 and +1
- Stage 3: most distal prolapse is between +1 and tvl-2cm
- Stage 4: complete prolapse within 2cm of tvl
References
- AUA Core Curriculum
- Lemack, G. and M. Carmel. "Urinary Incontinence and Pelvic Prolpase: Epidemiology and Pathophysiology." Campbell-Walsh Urology 12 (2020).
- Lucioni, A. and K. Kobashi. "Evaluation and Management of Women with Urinary Incontinence and Pelvic Prolapse." Campbell-Walsh Urology 12 (2020).