POP-Q made easy
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This was a lecture delivered during the 15th Postgraduate Course of the Jose R Reyes Memorial Medical Center- Department of Obstetrics and Gynecology on June 9, 2021. This is intended for Obstetrician-gynecologists in training and/or in practice.
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POP-Q made easy
- 1. POP-Q made easy Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS of Common Diseases
- 2. Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS Simplified Management Approach, Recognition and Treatment of Common OBGYN Diseases POP-Q made easy
- 3. Learning Objectives 1.How to score and stage pelvic organ prolapse using the POP- Quantification system (POP-Q) 2.How to diagnose anterior and posterior compartment prolapse 3.How to manage pelvic organ prolapse
- 4. Pelvic Organ Prolapse – Quantification System (POP-Q) 1. Identified (6) points on the anterior, posterior and apical vagina 2. Used the hymen as a point of reference
- 8. How to score Maximum protrusion • Any protrusion observed as tight on straining • Traction causes no further descent • Patient confirmation • Examine on standing, straining
- 9. How to score Point Definition Compartment Aa [A fixed point] 3 cm proximal to the external urethral meatus on the anterior vaginal wall Anterior Ba Maximum descent of the anterior wall
- 10. How to score : point Aa -3 +3
- 11. How to score Point Definition Compartment Aa 3 cm proximal to the external urethral meatus Anterior Ba Most distal or dependent position of the any part of the upper anterior vaginal wall* *from the anterior fornix/cuff to point Aa
- 12. How to score : point Ba -3 +(8) UPPER ANTERIOR vaginal wall UPPER ANTERIOR vaginal wall
- 14. How to score Point Definition Compartment Ap [A fixed point] 3 cm proximal to the hymen on the posterior vaginal wall Posterior Bp Most distal or dependent position of the any part of the upper posterior vaginal wall* *from the posterior fornix/cuff to point Ap
- 15. How to score : point Ap -3 +3
- 16. How to score : point Bp -3 +7 UPPER POSTERIOR vaginal wall UPPER POSTERIOR vaginal wall
- 18. How to score Point Definition Compartment C Cervix or vaginal cuff Midline or Apical D Posterior fornix* *omitted in vault prolapse
- 19. How to score : point C, D (-)
- 21. Other Landmarks Definition GH Genital hiatus from the middle of the external urethral meatus to the posterior midline hymen PB Perineal body from the posterior margin of the genital hiatus to the midanal opening TVL Total vaginal length greatest depth of the vagina when point C or D is reduced to its full normal position
- 22. How to measure : Genital hiatus, Perineal body
- 23. GH, PB, TVL = Absolute numbers At maximum protrusion With apex fully reduced
- 24. How to score How to stage Stage 0 NO prolapse Most distal point or the lowest point I > 1 cm above the hymen II 1 cm above or below the hymen III 1 cm below the hymen But not more than (TVL) -2 cms IV Descends to at least (TVL) – 2 cms below the hymen
- 25. How to stage Stage 0 NO PROLAPSE DEMONSTRATED Points Aa, Ap, Ba, and Bp are all at -3 cm; Either Point C or D is between – (TVL) cm and – (TVL -2) cm TVL = 7 -5 and - 7
- 28. How to stage Stage Definition THE MOST DISTAL PORTION OF THE PROLAPSE (or most descended point): I Is >1 cm above the level of the hymen II Is < 1 cm proximal to or distal to the plane of the hymen III Is >1 cm below the hymen but protrudes no further than 2 cm < total vaginal length in cms [TVL – 2] IV Protrudes to at least [TVL – 2]cm
- 29. How to stage Aa Ba C +2 +8 +8 GH PB TVL 6 2 9 Ap Bp D (+) +7 +7 STAGE IV (Ba, C)
- 30. How to stage Aa Ba C (-) +2 +5 GH PB TVL 4 2 8 Ap Bp D (-) +3 +3 STAGE III (C, D)
- 31. Learning Objectives 1. How to score and stage pelvic organ prolapse using the POP-Quantification system (POP-Q) 2.How to diagnose anterior and posterior compartment prolapse 3.How to manage pelvic organ prolapse
- 32. How to diagnose Anterior compartment Prolapse Image credit: Google Images
- 33. How to diagnose Anterior compartment Prolapse •Urinalysis •Post void residual determination Special circumstances: • Consider further urodynamic assessment if there is urinary incontinence • Assess urethral sphincter function in women with severe prolapse
- 34. How to diagnose Posterior compartment prolapse Image credit: Google Images
- 35. How to diagnose Posterior compartment prolapse Rectovaginal exam • Perineal descent • Enterocoele • Anal sphincter dysfunction Image credit: Google Images
- 36. How to manage CONSERVATIVELY I. Vaginal pessary 1. Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse. (Level III, Grade A)
- 37. How to manage CONSERVATIVELY I. Vaginal pessary 2. …pessary use should be considered before surgical intervention in women with symptomatic prolapse. (Level III, Grade A) 2019 recommendation - ACOG, NICE
- 38. How to manage
- 39. How to manage
- 40. How to manage II. Pelvic Floor Muscle Exercise Despite the lack of high quality evidence supporting pelvic floor muscle training for prevention and treatment, it poses no cost and risk to the patient. (Level II-3, Grade B)
- 41. How to manage II. Patient Education and Lifestyle Modifications Patients with POP should be counseled on the importance of various modifications that may prevent or improve their symptom of prolapse. (Level II-3, Grade B) 2019 NICE guidelines on Pelvic Organ Prolapse • losing weight, if the woman has a BMI > 30 kg/m2 • minimizing heavy lifting • preventing or treating constipation
- 42. How to manage DEFINITIVELY Reconstructive surgery Aims to restore anatomy and function of the pelvic floor Obliterative surgery Closes off the vagina
- 43. How to manage DEFINITIVELY Anterior Posterior Apical Reconstructive Colporrhaphy Augmented fascial repair Burch colposuspension Colporrhaphy Augmented fascial repair Perineorrhaphy Colpopexy Uterosacral ligament suspension Iliococcygeal ligament fixation Obliterative Colpocleisis Image credit: www.iuga.org Image credit: www.iuga.org
- 44. POP-Q made easy Simplified Management Approach, Recognition and Treatment of Common OBGYN Diseases Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS Learning Objectives: 1. How to score and stage pelvic organ prolapse (POP-Q system) 2. How to diagnose anterior and posterior compartment prolapse 3. How to manage pelvic organ prolapse
- 45. POP-Q made easy Simplified Management Approach, Recognition and Treatment of Common OBGYN Diseases Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS 10 June 2021 References: 1. Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL, Smith AR. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996 Jul;175(1):10-7. 2. Ostergaard’s Urogynecology and Pelvic Floor Dystfunction, 6th Ed. 2008. 3. Te Linde’s Atlas of Gynecologic Surgery. 2014. 4. Te Linde’s Operative Gynecology, 10th Ed. 2003. 5. Urogynecology and Reconstructive Pelvic Surgery, 4th Ed. 2015.
Editor's Notes
- Good afternoon. I am glad to be a part of the 15th post-graduate course the Jose R Reyes Memorial Medical Center Dept of OBGYN I have been asked to lecture on Pelvic organ prolapse.
- At the end of my lecture, you will be familiar with the Pelvic Organ Prolapse Quant Sys You will know how to use the POP Q to score and stage pelvic organ prolapse. I will talk specifically on the diagnosis and management of anterior and posterior compartment prolapse.
- By now, all gynecologists are aware of the POP-Q. Since its introduction in 1996 by the International Continence Society, it has been widely taught and used all over the world. The quantification system describes the site and degree of a prolapse through these key elements: There are 6 identified points on the anterior, posterior and apical vagina, and their descent is measured with reference to a definite anatomic landmark, the hymen
- The quantification system identifies and measures the descent 6 points on the vagina, including the cervix. It also describes other landmarks, namely: Genital hiatus, perineal body and total vaginal length.
- The scores for each point as well as the measurement of the landmarks are tabulated on a tic tac toe grid like so
- Measurements are recorded as negative numbers when proximal to the hymen and positive numbers when distal to the hymen. The unit of measurements is in centimeters.
- During the examination, it is critical that the examiner sees and describes the maximum protrusion that the patient experiences during her daily activities. How do know that the maximum prolapse is already demonstrated? Well, you can observe that the protrusion of the vaginal wall has become TIGHT during straining such as in this picture on the left Or, application of traction ON the prolapse causes no further descent. You must be gentle when you do this, you can use an allis, babcook or your fingers. You can also ask the patient to confirm that the size of the prolapse and the extent of the protrusion is indeed what she experiences at home. I find a mirror helpful so the patient visualize the protrusion and give feedback. In times when the prolapse can not be observed during the pelvic exam, you can ask the patient to stand and strain.
- Okay, I will now go by compartment and discuss the POP-Q points to be scored There are 2 points to be scored in the anterior compartment, point A and B. The small letter a designates they are in the anterior vagina Point Aa is located in the midline of the anterior vaginal wall 3 cm proximal to the external urethral meatus This corresponding to the approximate location of the "urethrovesical crease," However this landmark of variable prominence and is usually obliterated in many patients with prolapse. By definition, the range of position of point Aa relative to the hymen is -3 to +3 cm. Point Ba represents the most distal position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa. By definition, point Ba is at -3 cm in the absence of prolapse
- Point Ba represents the most distal position of any part of the upper anterior vaginal wall – this means from anterior vaginal fornix or vaginal cuff to point Aanterior.
- For point Ba, you looking which part of the upper anterior vaginal wall descends the lowest. Consider the area from the anterior fornix to point Aanterior and score the most dependent part So in the case of no prolapse, the part that is most dependent is correspond to Aa So point Ba is scored as -3 because the point is 3 cms above the hymen Now the part of the upper vagina that will be scored will change with progressive prolapse Consider the case of maximum prolapse, the part that descends the lowest is closer to the anterior fornix And it will be given a (+) value because it lies lower than the hymen
- Similarly, the posterior compartment is also described using the corresponding Point A and B. The small letter p indicates that these points are in the posterior vagina Point Bposterior represents the most distal position of any part of the upper posterior vaginal wall And Point Ap is the point located in the midline of the posterior vaginal wall 3 cm from to the hymen. from the vaginal cuff or posterior vaginal fornix to point Ap. By definition, point Bp is at-3 cm in the absence of prolapse and would have a positive value equal to the position of the cuff in a woman with total posthysterectomy vaginal eversion.
- For Apost, we are looking at the point 3 cms from the hymen..
- Again for B posterior, we are looking at the upper post wall which is this area from the posterior fornix to Ap Point Bp is a point in the most distal or dependent portion of the area, which in a case of no prolapse will correspond to point Ap And given a score of -3 In the case of maximum prolapse, the point that is most distal or dependent or lies the lowest from the hymen is at the posterior fornix In this example, Bp is scored with a positive value since it lies below the hymen
- Lets look this case here. Points Aposterior and Bposterior clearly lie below the hymen and will be given (+) scores Point Bposterior is identified close to the fornix here In the example, point Aposterior seem to lie within the vagina and will be given a (-) score While the part of the upper posterior vaginal wall that is the most dependent is here at the fornix and so this will be designated as Bposterior. It will be scored with a positive value because it lies below the cervix
- For the midline or apical compartment, the points to be scored are C and D Where C represents either the most dependent)edge of the cervix or the leading edge of the vaginal cuff after total hysterectomy Point D corresponds to the location of the posterior fornix (or pouch of Douglas) in a woman who still has a cervix And so it is cannot be identified or scored in patient with a vault prolapse
- D is included as a point of measurement to differentiate suspensory failure of the uterosacral-cardinal ligament complex from cervical elongation. When the location of point C is significantly more positive than the location of point D, it is indicative of cervical elongation, which may be symmetric or eccentric.
- Of all the compartments, the points on the apex may be the easiest to score since you only need to identify definite anatomic parts namely the cervix and the insertion of the uterosacral ligament which is at the posterior fornix In a patient without a uterus, point C refers to the hysterectomy scar or the cuff
- The other landmarks that must be measured are the following: The length of the genital hiatus and perineal body at maximum prolapse And the depth of the vagina when the apex is reduced to its normal position
- The genital hiatus is measured from the mid urethral opening to the level of posterior midline vagina, while the perineal body is assessed from posterior margin of the genital hiatus to the midanal opening The total vaginal length is taken from the hymen to the posterior fornix As these measurements are lengths, they ARE NOT DESIGNATED AS + or – But rather reported as absolute values
- While GH and PB are assessed at maximum protrusion the total vaginal length is taken from the hymen to the posterior fornix with the apex reduced As these measurements are lengths, they ARE NOT DESIGNATED AS + or – But rather reported as absolute values
- Now that we have discussed how to score, lets us move on to staging the prolapse. To stage the severity of the prolapse as 1, 2, 3 or 4, look at your scoring grid and take the most distal of the 6 points Which has the most positive value And then you can consider if this point lie way 1 cm above the hymen – and therefore is a stage 1 Around the area of the hymen – stage II Or far below and is
- When there is no prolapse demonstrated Points A and B anterior as well as A and B posterior will all lie 3 cms above the hymen.. And therefore have a -3 score Points C and D will lie at the very depth (or top) of the vaginal canal (or within 2 cms of it) and have a negative value So that if the total vaginal length is 7, the scores of C and D will be between -5 and -7
- In a stage I prolapse, the most dependent point lie within the vaginal canal, more than 1 cm above the hymen. This is a mild, oftentimes, asymptomatic prolapse In a stage II prolapse, the most dependent point is at the introitus – specifically it lies in between 1 cm above the hymen and 1 cm below it.
- Significant prolapse is reported when the protrusion falls way below the hymen, the most dependent point is descend to a level more than 1 cm below the hymen. In a total prolapse, the entire length of the vagina is out. So that the measurement of the protrusion will approximate at least total vaginal length in centimeters MINUS 2. This is a Stage IV. In a stage III prolapse, the most distal point does not fall lower than the level of TVL – 2.
- Remember that a st II prolapse will descend 1 cm above to 1 cm below the hymen. If the prolapse is observed higher than 1 cm above the hymen, it is a stage I A stage IV prolapse will protrude to the level of the TVL –2 at least Higher than that, but more 1 cm beyond the plane of the hymen is a stage III
- Lets look at examples- the identifiable points here are Aanterior +2, Banterior +8 The Cervix is at the same level as Ba +8 And Bposterior is pegged at the same level as the posterior fornix +7 The points most dependent are Ba and C Total vaginal length -2 is 7 (9-2) Since these points fall beyond 7 cms, this is a stage IV prolapse
- I hope that I have adequately covered the POP Q For the remainder of the time allotted, I will discuss diagnosis and management of the anterior and posterior compartment prolapse
- Oftentimes, in a predominantly apical prolapse, the extent of the anterior compartment prolapse may be overlooked It is ideal to isolate the anterior vagina during the examination by using a vaginal retractor or Sims speculum to depress the posterior vagina. You should also reduce the apex (meaning the cervix or the vaginal cuff) to its original position. Instruct you patient to cough or stain, and move your retractor slowly, outward, to allow the anterior vagina to descend. Take note of the position of Aanterior and B anterior After a careful history and physical examination, few diagnostic tests are needed to evaluate patients with anterior vaginal prolapse. A urinalysis should be performed to evaluate for urinary tract infection if the patient complains of any lower urinary tract dysfunction. Hydronephrosis occurs in a small proportion of women with severe prolapse; however, even if identified, it usually does not change management in women for whom surgical repair is planned. Therefore, routine imaging of the kidneys and ureters is not necessary If urinary incontinence is present, further diagnostic testing is indicated to determine the cause of the incontinence. Urodynamic (simple or complex), endoscopic, or radiologic assessments of filling and voiding function are generally indicated only when symptoms of incontinence or voiding dysfunction are present. Even if no urologic symptoms are noted, voiding function should be assessed to evaluate for completeness of bladder emptying. This procedure usually involves a timed, measured void, followed by urethral catheterization or bladder ultrasound to measure postvoid residual urine volume. In women with severe prolapse, it is important to check urethral function after the prolapse is repositioned. Women with severe prolapse may be paradoxically continent because of urethral kinking; when the prolapse is reduced, urethral dysfunction may be unmasked with occurrence of incontinence (occult stress incontinence). A pessary, vaginal retractor, or vaginal packing can be used to reduce the prolapse before office bladder filling or electronic urodynamic testing. If urinary leaking occurs with coughing or Valsalva maneuvers after reduction of the prolapse, the urethral sphincter may be incompetent, even if the patient is normally continent. This is reported to occur in 17% to 69% of women with stage III or IV prolapse. In this situation, the surgeon should choose an anti-incontinence procedure in conjunction with anterior vaginal prolapse repair. If stress incontinence is not present even after reduction of the prolapse, an anti-incontinence procedure probably is not indicated, although this is a subject of ongoing research.
- A few diagnostic tests are needed in patients with anterior vaginal prolapse. A urinalysis should be performed to evaluate for infection if the patient complains of any lower urinary tract dysfunction, which most women with prolapse do. Their ability to completely empty the bladder even if there are no urinary symptoms reported. *This procedure usually involves a timed, measured void, followed by urethral catheterization or bladder ultrasound to measure postvoid residual urine volume. *You may consider further urodynamic assessment if urinary incontinence is present. *In women with severe prolapse, it is important to check urethral function after the prolapse is repositioned. They may be paradoxically continent bec of the urethra kinking, and when the prolapse is reduced, occult stress urinary incontinence is unmasked. Leakage observed with coughing or Valsalva maneuvers may indicate that the urethral sphincter is incompetent. This is occurs in up to 70% of women with stage III or IV prolapse. Continence surgery maybe warranted and can be done with prolapse repair.
- For posterior compartment prolapse, evaluation of the vaginal wall is likewise performed with a vaginal retractor such as the posterior blade of a bivalve speculum or Sim's speculum. The retractor elevates the anterior wall and reduces any uterine or cuff prolapse. Ballooning of the vaginal wall is observed with a cough or Valsalva and point A and B posterior are scored.
- A rectovaginal examination should be done to evaluate the descent of the perineal body AND check if loops of small bowel or sigmoid colon is palpable within the rectovaginal space. This confirms an enterocele. An assessment of the anal sphincter should be undertaken, noting noting anal tone, squeeze, and symmetry. Women with prolapse often describe bulging of the vagina and pressure (particularly if the prolapse extends beyond the hymen), which worsens by the end of the day and improves when she is lying down. Sexual function is multifaceted in women. Sexual dysfunction may occur in the setting of prolapse through discomfort, loss of sensation, alteration in body image, or incontinence. Women with a perineal body defect, which leads to a widened genital hiatus, may describe loss of sensation for her and her partner during intercourse. If stool is trapped in the rectocele, intercourse may lead to fecal incontinence or instill the fear of fecal incontinence, leading to the avoidance of se
- How can pelvic organ prolapse be managed? Our patients have surgical and nonsurgical options. Vaginal pessries can be fitted in most women… This is a recommendation form the POGS CPG on Urogynecology
- Not only is it an option for all, pessary use… The recent guidelines from the American College of Obstetricians and Gynecologists And the National Institute for Health and Care Excellence have maintained this recommendation
- Here are examples of support pessaries that can be for uterine and vaginal prolapse
- Here are space occupying pessaries particularly useful in patient with large vault prolapse and posterior compartment prolapse
- Pelvic floor muscle exercise may be offered to all patients who are asymptomatic or mildly symptomatic and are interested in preventing the progression of the condition and who decline other treatments as it poses no risk to the patient
- We should counsel on the modifying certain risks factors to improve the symptom of prolapse ..
- The definitive treatment for pelvic organ prolapse is surgery. The main goal is to relieve the patient of the symptom of prolapse. Reconstructive procedures will achieve this through restoration of the pelvic floor support While obliterative surgery simply close off the vagina
- Generally, for both anterior and posterior compartment prolapse, colporrhapy can be done. In some select cases, the repair can be augmented with a mesh. Partial or total colpocleisis involves suturing the distal or entire length of the anterior vaginal wall to the posterior, effectively close off the canal.
- How to score and stage pelvic organ prolapse using the POP-Quantification system (POP-Q) How to diagnose anterior and posterior compartment prolapse How to manage pelvic organ prolapse
- How to score and stage pelvic organ prolapse using the POP-Quantification system (POP-Q) How to diagnose anterior and posterior compartment prolapse How to manage pelvic organ prolapse