Pelvic organ prolapse in women: Diagnostic evaluation
- Tola B Fashokun, MD, FACOG
Tola B Fashokun, MD, FACOG
- Assistant Professor
- Johns Hopkins University School of Medicine
- Rebecca G Rogers, MD
Rebecca G Rogers, MD
- Professor of Obstetrics and Gynecology, Urogynecology and Professor of Surgery
- The University of New Mexico
Pelvic organ prolapse (POP), the herniation of the pelvic organs to or beyond the vaginal walls, in women is diagnosed using pelvic examination. 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'.)
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 . The Pelvic Organ Prolapse Quantitation system (POPQ), introduced in 1996, has become the standard classification system .
Diagnostic evaluation of women with POP is reviewed here. An overview of POP, general principles of the pelvic examination and additional aspects of evaluation of women with POP are discussed separately. (See "Pelvic organ prolapse in women: An overview of the epidemiology, risk factors, clinical manifestations, and management" and "The gynecologic history and pelvic examination".)
CLASSIFICATION OF PELVIC ORGAN PROLAPSE
POPQ system — The POPQ system is an objective, site-specific system for describing and staging POP in women . 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 1) [1,3].
The POPQ has proven interobserver and intraobserver reliability . Intraoperative POPQ measurements correlate well with preoperative findings, with slightly more prolapse under anesthesia when traction is placed on the POPQ points .
- Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
- Brubaker, L, Norton, P. Current Clinical Nomenclature for Description of Pelvic Organ Prolapse. Journal of Pelvic Surgery 1996; 2:257.
- Brubaker, L, Norton, P. Current clinical nomenclature for description of pelvic organ prolapse. J Pelvic Surg 1996; 2:257.
- 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.
- Vierhout ME, Stoutjesdijk J, Spruijt J. A comparison of preoperative and intraoperative evaluation of patients undergoing pelvic reconstructive surgery for pelvic organ prolapse using the Pelvic Organ Prolapse Quantification System. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:46.
- Muir TW, Stepp KJ, Barber MD. Adoption of the pelvic organ prolapse quantification system in peer-reviewed literature. Am J Obstet Gynecol 2003; 189:1632.
- Treszezamsky AD, Rascoff L, Shahryarinejad A, Vardy MD. Use of pelvic organ prolapse staging systems in published articles of selected specialized journals. Int Urogynecol J 2010; 21:359.
- Auwad W, Freeman RM, Swift S. Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS). Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:324.
- ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol 2007; 110:717.
- Elkadry EA, Kenton KS, FitzGerald MP, et al. Patient-selected goals: a new perspective on surgical outcome. Am J Obstet Gynecol 2003; 189:1551.
- Hullfish KL, Bovbjerg VE, Steers WD. Patient-centered goals for pelvic floor dysfunction surgery: long-term follow-up. Am J Obstet Gynecol 2004; 191:201.
- Mahajan ST, Elkadry EA, Kenton KS, et al. Patient-centered surgical outcomes: the impact of goal achievement and urge incontinence on patient satisfaction one year after surgery. Am J Obstet Gynecol 2006; 194:722.
- Barber MD, Lambers A, Visco AG, Bump RC. Effect of patient position on clinical evaluation of pelvic organ prolapse. Obstet Gynecol 2000; 96:18.
- Digesu GA, Athanasiou S, Cardozo L, et al. Validation of the pelvic organ prolapse quantification (POP-Q) system in left lateral position. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:979.
- Visco AG, Wei JT, McClure LA, et al. Effects of examination technique modifications on pelvic organ prolapse quantification (POP-Q) results. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:136.
- Shull BL. Clinical evaluation of women with pelvic support defects. Clin Obstet Gynecol 1993; 36:939.
- Kenton K, Shott S, Brubaker L. Vaginal topography does not correlate well with visceral position in women with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 1997; 8:336.
- Walters, MD. Description and classification of lower urinary tract dysfunction and pelvic organ prolapse. In: Urogynecology and Reconstructive Pelvic Surgery, 3rd ed, Walters, MD, Karram MM (Eds), Mosby Elsevier, Philadelphia 2007. p.58.
- Parekh M, Swift S, Lemos N, et al. Multicenter inter-examiner agreement trial for the validation of simplified POPQ system. Int Urogynecol J 2011; 22:645.
- Manonai J, Mouritsen L, Palma P, et al. The inter-system association between the simplified pelvic organ prolapse quantification system (S-POP) and the standard pelvic organ prolapse quantification system (POPQ) in describing pelvic organ prolapse. Int Urogynecol J 2011; 22:347.
- Brubaker L, Barber MD, Nygaard I, et al. Quantification of vaginal support: are continuous summary scores better than POPQ stage? Am J Obstet Gynecol 2010; 203:512.e1.
- Lowder JL, Park AJ, Ellison R, et al. The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse. Obstet Gynecol 2008; 111:152.
- Whiteside JL, Barber MD, Paraiso MF, et al. Clinical evaluation of anterior vaginal wall support defects: interexaminer and intraexaminer reliability. Am J Obstet Gynecol 2004; 191:100.
- Walters, MD. Evaluation of urinary Incontinence and Pelvic Organ Prolapse. In: Urogynecology and Reconstructive Surgery, 3rd, Walters, MD, Karram, MM (Eds), Mosby Elsevier, Phildelphia 2007. p.69.
- www.icsoffice.org/ASPNET_membership/membership/documents/documents.aspx. (Accessed on January 16, 2012).
- Flynn, MK, Amundsen, CL. Diagnosis of pelvic organ prolapse. In: Multidisiplinary management of female pelvic floor disorders, Chapple, CR, Zimmerman, PE (Eds), Churchill Livingstone, Philadelphia 2006. p. 120.
- Gupta S, Sharma JB, Hari S, et al. Study of dynamic magnetic resonance imaging in diagnosis of pelvic organ prolapse. Arch Gynecol Obstet 2012; 286:953.
- Broekhuis SR, Fütterer JJ, Barentsz JO, et al. A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: the use of reference lines and anatomical landmarks. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:721.
- Ellerkmann RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001; 185:1332.
- Gutman RE, Ford DE, Quiroz LH, et al. Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms? Am J Obstet Gynecol 2008; 199:683.e1.
- Swift S, Woodman P, O'Boyle A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol 2005; 192:795.
- Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:122.
- Visco AG, Brubaker L, Nygaard I, et al. The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: the Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:607.
- American College of Obstetricians and Gynecologists. Urinary incontinence in women. Obstet Gynecol 2005; 105:1533.
- Kleeman S, Goldwasser S, Vassallo B, Karram M. Predicting postoperative voiding efficiency after operation for incontinence and prolapse. Am J Obstet Gynecol 2002; 187:49.
- Foster RT Sr, Borawski KM, South MM, et al. A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery. Am J Obstet Gynecol 2007; 197:627.e1.
- CLASSIFICATION OF PELVIC ORGAN PROLAPSE
- POPQ system
- Other classification systems
- MEDICAL HISTORY
- APPROACH TO THE EXAMINATION
- Examination components
- Patient positioning
- VISUAL INSPECTION
- SPECULUM AND BIMANUAL EXAMINATION
- Using the POPQ system
- - POPQ measurements
- - POPQ staging
- - Modifications of the POPQ system and reporting POPQ results
- Simplified POPQ
- Additional examination techniques
- - Simulated apical support
- - Inspection for paravaginal defects
- RECTOVAGINAL EXAMINATION
- NEUROMUSCULAR EXAMINATION
- Neurologic evaluation
- Pelvic floor muscle testing
- ANCILLARY STUDIES
- Evaluation of prolapse
- - Photography
- - Imaging
- Urinary tract evaluation
- - Urinary incontinence
- - Urinary retention
- Bowel function evaluation
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS