The document describes the Pelvic Organ Prolapse Quantification (POP-Q) system for evaluating and documenting pelvic organ prolapse. The POP-Q system uses specific anatomical points of reference to measure the degree of prolapse in centimeters in relationship to the hymen. It is the standard system used internationally for quantifying and comparing prolapse. The POP-Q allows for objective assessment of prolapse, comparison of surgical outcomes, and consistency in medical documentation and research.

1.
TESTING
THE
WOMEN
WITH
POP
(POP-­‐Q
and
Other
tests)
Osama
M
Warda
MD
Professor
of
OBS/GYN
Mansoura
University-­‐Egypt

2. Contents
• POP-­‐Q
system
• Ultrasound
(
2D,
3D)
• Cystoscopy
• MRI,
dynamic
MRI
2
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Warda

3. IntroducKon
Pelvic
Organ
Prolapse
Quan2fica2on
(POP-­‐Q):
First
published
In
1996,
an
arKcle
by
Bump
et
al*
presents
a
standard
system
of
terminology
approved
later
by
the
InternaKonal
ConKnence
Society
(ICS),
the
American
Uro-­‐gynecologic
Society
(AUGS),
and
the
Society
of
Gynecologic
Surgeons
(SGS)
for
the
descripKon
of
female
pelvic
organ
prolapse
and
pelvic
floor
dysfuncKon.
-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐
Bump
RC,
MaCasson
A,
Bø
K,
Brubaker
LP,
DeLancey
JO,
Klarskov
P
,
Shull
BL,
Smith
AR.
Am
J
Obstet
Gynecol.
1996
Jul,175(1):10-­‐7.,
Duke
University
Medical
Center,
Durham,
NC
27710,
USA.
3
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Warda

4. IntroducKon
• In
an
effort
to
create
an
encoding
tool
useful
to
both
the
clinician
and
researcher,
the
StandardizaKon
SubcommiYee
of
the
ICS
created
the
Pelvic
Organ
Prolapse
QuanKficaKon
(POP-­‐
Q)
system
in
2002
.
-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐
Abrams
et
al
(
2002)
4
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Warda

5. ObjecKves
of
POP-­‐Q
• QuanKficaKon
of
prolapse
• Compare
outcome
of
surgical
repair
• Inter-­‐individual
reliability
• Standards
in
wriYen
publicaKon
and
scienKfic
presentaKons
5
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Warda

6. How
POP-­‐Q
system
works?
• The
hymen
acts
as
the
fixed
point
of
reference
throughout
the
POPQ
system.
• There
are
six
defined
points
for
measurement
in
the
POPQ
system
-­‐
Anterior:
Aa,
Ba,
C,
-­‐Posterior:
Ap,
Bp,
D
•
Three
others
landmarks:
GH,
TVL,
PB.
Each
is
measured
in
cenKmeters
above
or
proximal
to
the
hymen
(negaKve
number)
or
cenKmeters
below
or
distal
to
the
hymen
(posiKve
number)
with
the
plane
of
the
hymen
being
defined
as
zero
(0).
6
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7. How
POP-­‐Q
system
works?
•
The
hymen
was
selected
as
the
reference
point
rather
the
introitus
because
it
is
more
precisely
idenKfied.
• The
terminology
avoids
assigning
a
specific
label,
such
as
cystocele
or
rectocele,
to
the
prolapsing
part
of
the
vagina,
acknowledging
that
the
actual
organ(s)
above
the
prolapse
cannot
be
frequently
determined
by
a
physical
examinaKon.
7
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8. Points
and
landmarks
for
POP-­‐Q
system
examina[on.
Aa,
point
A
anterior,
Ap,
point
A
posterior,
Ba,
point
B
anterior;
Bp,
point
B
posterior;
C,
cervix
or
vaginal
cuff;
D,
posterior
fornix
(if
cervix
is
present);
gh,
genital
hiatus;
pb,
perineal
body;
tvl,
total
vaginal
length.
8
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9. Point
-­‐
A
• Anatomical
defined
(fixed)
Ø Aa=
midline
of
anterior,
3
cm
proximal
to
external
urethral
meatus,
approximate
loca-on
of
urethro-­‐
vesical
junc-on
Ø
Ap=
middle
of
the
posterior
wall,
3cm
proximal
to
the
hymen
•
Range
of
posiKon
=
-­‐3
cm
to
+3cm
9
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Warda

10. Point
B
• Points
Ba
and
Bp
are
defined
as
the
lowest
points
of
the
prolapse
between
Aa
anteriorly
or
Ap
posteriorly
and
the
vaginal
apex.
•
Anteriorly,
the
apex
is
point
C
(cervix),
and
posteriorly
is
point
D
(pouch
of
Douglas).
In
women
amer
hysterectomy,
point
C
is
the
vaginal
cuff
and
point
D
is
omiYed.
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11. Urethro-­‐vesical
juncKon
(Aa)
Which
porKon
of
vaginal
wall
is
most
distal
(Ba)
11
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12. C=cervix
,
cuff
• Most
distal
edge
of
the
cervix
or;
• Leading
edge
of
the
vaginal
cuff
(hysterectomy
scar)
c
12
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13. D
=
Douglas
• Posterior
fornix
or
Pouch
of
Douglas
• Represents
the
level
of
utero-­‐sacral
ligament
aYachment
to
the
posterior
cervix
• (Diff.:
Suspensory
failure/cervix
elongaKon)
No
cervix
=
no
‘D’
13
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14. Three
measurements
• Three
other
measurements
are
taken:
-­‐the
vaginal
length
(tvl)
at
rest,
-­‐ the
genital
hiatus
(gh)
from
the
middle
of
the
urethral
meatus
to
the
posterior
hymenal
ring,
and
-­‐ the
perineal
body
(pb)
from
the
posterior
aspect
of
the
genital
hiatus
to
the
mid-­‐
anal
opening.
14
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15. gh=
genital
hiatus
• Middle
of
external
urethral
meatus
to
the
posterior
hymen
15
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16. pb=
perineal
body
• Posterior
margin
of
genital
hiatus
to
mid-­‐anal
opening.
16
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17. tvl=
total
vaginal
length
• Greatest
depth
of
the
vagina
in
cenKmeters.
•
C
and
D
in
normal
posiKon.
• Measurement
without
straining
17
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Warda

18. Stages
of
pelvic
organ
prolapse
• Once
the
measurements
are
taken,
the
paKents
are
assigned
to
the
corresponding
stage:
• Stage
0
=
no
prolapse.
•
stage
I
=
most
distal
porKon
of
prolapse
is
>
1cm
above
level
of
hymen
• Stage
II=
the
most
distal
part
of
prolapse
is
<1cm
proximal
to
or
distal
to
the
plane
of
hymen
• Stage
III=the
most
distal
porKon
of
the
prolapse
protrudes
more
than
1
cm
below
the
hymen
but
no
farther
than
2
cm
less
than
the
total
vaginal
length
(for
example,
not
all
of
the
vagina
has
prolapsed).
• Stage
IV=complete
vaginal
eversion
is
essenKal.
18
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Warda

19. Stage
III
Bp
prolapse
19
ß
Hymenal
ring
Osama
Warda

20. 20
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Warda

21. Evalua[ng
the
POP-­‐Q
system
• Excellent
inter-­‐observer
and
intra-­‐
observer
reliability
has
been
shown
[Hall
et
al.,
1996.]
• It
has
been
used
for
longitudinal
follow-­‐
up
in
women
with
prolapse
and
extensively
for
outcome
repor[ng
a`er
prolapse
repair
since
1996
[Bland
et
al.,
1999
and
Muir
et
al.,
2003.]
21
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22. Evalua[ng
the
POP-­‐Q
system
• The
system
is
more
difficult
to
learn
than
the
tradi[onal
staging,
and
overall
adop[on
by
specialists
is
of
about
40%
[Auwad
et
al.,
2004].
•
Pa[ent
posi[on
also
affects
reproducibility.
The
measurements
are
taken
with
the
pa[ent
in
the
dorsal
lithotomy
posi[on,
and
the
degree
of
prolapse
is
assessed
with
pa[ent
straining.
Prolapse
may
be
more
severe
with
the
table
raised
at
the
head
to
a
45-­‐
degree
angle
[Barber
et
al.,
2000]
22
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Warda

23. Evalua[ng
the
POP-­‐Q
system
• The
system
also
does
not
iden2fy
unilateral
or
asymmetrical
defects.
In
2006,
this
system
was
only
used
clinically
by
about
40%
of
members
of
ICS
and
AUGS.
There
has
also
been
a
developing
of
a
POP-­‐
Q
simplified
system
based
on
POP-­‐Q
with
similar
ordinal
staging
but
with
only
four
points
measured
instead
of
nine
(Aa,
Ba,
C,
D).
Evalua[on
of
the
inter-­‐observer
reproducibility
and
intersystem
reliability
(in
comparison
with
the
standard
POP-­‐Q
system)
showed
good
correla[on
[Steven
Swim,
Sarah
Morris
et
al
2006].
23
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Warda

24. Addi[onal
tes[ng
for
women
with
POP
24
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25. Addi[onal
tes[ng
for
women
with
POP
• The
iniKal
evaluaKon
of
urinary
inconKnence
in
women
includes
history
tacking,
physical
examina-on,
urinalysis,
and
measurement
of
post-­‐void
residual
urine
[Abrams
et
al.,
2005.a]
• The
basic
evaluaKon
may
be
saKsfactory
for
the
proceeding
with
treatment,
including
surgery,
for
paKents
with
straigh?orward
stress
incon-nence
associated
with
urethral
hypermobility
with
normal
post-­‐void
residual
volume
[
Fantl
et
al
1996]
•
However,
the
InternaKonal
ScienKfic
CommiYee
of
the
Third
InternaKonal
ConsultaKon
on
Urinary
InconKnence
advised
that,
for
women
who
desire
interven-onal
treatment,
urodynamic
tes-ng
is
highly
recommended
[Abrams
et
al.,
2005.b]
•
25
URINARY
INCONTINENCE
Osama
Warda

26. Addi[onal
tes[ng
for
women
with
POP
• The
role
of
rouKne
cystoscopy
in
the
evaluaKon
of
inconKnence
is
controversial.
• Cystoscopy
has
also
been
reported
to
aid
in
the
preoperaKve
and
intraoperaKve
differenKaKon
of
the
type
of
organ
prolapse
in
paKents
with
high-­‐grade
prolapse
or
mulKple
prolapsing
organs
.
• It
is
done
simply
by
idenKfying
the
light
transmi@ed
through
the
bladder
wall.
• IntraoperaKve
cystoscopy
is
also
necessary
to
assess
for
bladder
or
urethral
perforaKon
or
ureteric
obstrucKon
during
various
pelvic
procedures
[Vasavada
et
al.,
1999]
26
CYSTOSCOPY
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Warda

27. Addi[onal
tes[ng
for
women
with
POP
• Ultrasound
imaging
of
the
bladder
and
urethra
can
be
done
by
the
trans-­‐abdominal,
trans-­‐
perineal,
trans-­‐labial,
trans-­‐vaginal,
or
trans-­‐
rectal
route.
• The
advantage
of
ultrasound
is
the
ability
to
do
real-­‐Kme
scanning
without
radiaKon
exposure,
but
the
major
disadvantages
are
the
variability
introduced
by
the
examiner
with
small
changes
in
the
transducer
posi-on
and
the
availability
of
only
a
limited
number
of
pictures
aBer
the
examina-on.
27
ULTRASOUND
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Warda

28. Addi[onal
tes[ng
for
women
with
POP
• Two-­‐dimensional
trans-­‐labial
scanning
is
now
a
standard
technique
and
has
been
reported
to
assess:
1-­‐
the
posiKon
and
mobility
of
the
bladder
neck
and
proximal
urethra,
2
-­‐stress
inconKnence,
3
-­‐bladder
wall
thickness
(with
TVS
as
well),
4
-­‐levator
ani
acKvity
(with
perineal
scanning),
and
5
-­‐
prolapse
quanKficaKon.
(Dietz
HP
,
2004)
28
ULTRASOUND
Osama
Warda

29. Addi[onal
tes[ng
for
women
with
POP
•
3-­‐D
ultrasound
has
been
used
to
image
the:
1-­‐
urethra,
2-­‐
levator
ani
complex,
3-­‐paravaginal
supports,
4-­‐prolapse,
5-­‐syntheKc
implant
materials
(
Dietz
HP.
2004)
29
ULTRASOUND
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Warda

30. Addi[onal
tes[ng
for
women
with
POP
• Ultrasound
is
not
recommended
in
the
primary
evaluaKon
of
women
with
inconKnence
and
prolapse
and
is
an
opKonal
test
for
complex
problems.
(
Tubaro
et
al.,2005)
30
ULTRASOUND
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Warda

31. Addi[onal
tes[ng
for
women
with
POP
• MRI
may
be
helpful
in
paKents
with
complex
organ
prolapse
to
supplement
the
physical
examinaKon.
(Tubaro
et
al.,
2005)
• Dynamic
MRI
of
the
pelvic
floor
is
an
excellent
tool
for
assessing
funcKonal
disorders
of
the
pelvic
floor,
including
organ
prolapse
and
inconKnence.
It
is
also
useful
in
assessing
the
results
of
surgery
for
pelvic
organ
prolapse,
even
when
the
paKent
has
no
clinical
symptoms.
(Novellas
et
al.
2009)
31
MRI
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Warda

32.
Thanks
32
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