Mark D. Walters, M.D. Professor and Vice Chair of Gynecology

1. Evaluation of Pelvic Organ Prolapse Mark D. Walters, M.D. Professor and Vice Chair of Gynecology Department of Obstetrics and Gynecology Cleveland Clinic, USA

2. Disclosure of Financial Relationships • American Medical Systems and Boston Scientific: paid consultant and lecturer

3. Learning Objectives • At the conclusion of this lecture, participants should be able to: • Review epidemiology of pelvic organ prolapse • Summarize office evaluation and POPQ techniques and appraise evidence of their utility

4. Pelvic Organ Prolapse - Background • 16% of women in US have prolapse • Pannu et al. Radiographics 2000;20(6):1567-82 • Lifetime prevalence 30-50%, of which 2% are symptomatic • Samuelsson EC et al, AJOG 1999;180:299-305 • 7% lifetime risk of surgery for prolapse • Olsen et al., Obstet Gynecol 1997;89:501 • 29% of these patients require re-operation • Olsen et al., Obstet Gynecol 1997;89:501

5. Lifetime Risk of Single Operation for POP/UI 11.1% 12 10 7.5% 8 Percent 6 4.7% 4 2.8% 2 0.9% 0 30-39 40-49 50-59 60-69 70-79 Age Group Olsen et al., Obstet Gynecol 1997;89:501

6. Outcomes for Pelvic Organ Prolapse • Vaginal anatomy; bulge, pressure, mass • Visceral symptoms: Urinary and bowel symptoms • Sexual activity and expectations • Future surgical procedures or medicines to manage failures or complications

7. Vaginal Prolapse Exam • Vaginal apex • Enterocele • Anterior wall • Bladder neck • Posterior wall • Perineum

8. Uterine prolapse Anterior vaginal prolapse Vaginal vault prolapse

10. Pelvic Organ Prolapse Quantification System (POP-Q) • Adopted by ICS, AUGS and SGS • Objective, site-specific system • Documenting • Comparing • Communicating • Allows for: • Precise description of pelvic support without assigning severity value • Accurate observation of stability or progression of prolapse over time by same or different observers

11. The POP-Q System • Fixed reference point: hymen • Two points of measurement each • Anterior wall (Aa, Ba) • Posterior wall (Ap, Bp) • Apex (C, D) • Also measure genital hiatus (gh), perineal body (pb), and total vaginal length (tvl)

12. Anterior wall Cervix or cuff Genital hiatus Perineal body Total vaginal length Posterior wall Posterior fornix

13. POP-Q • Evaluate maximum prolapse • Valsalva • Traction • Confirmation by patient • Standing exam • Describe other variables

14. Perineal Body Genital Hiatus

15. Midline of anterior vaginal wall 3cm from external urethral meatus SLIDING POINT Most distal position of any part of anterior vaginal wall

16. Anterior points (Aa, Ba)

17. Location of posterior fornix Most distal edge of cervix or leading edge of vaginal cuff

18. SLIDING POINT Most distal position of any part of posterior vaginal wall Midline of posterior vaginal wall 3cm from hymen

20. POP-Q Staging • Stage 0 normal • Stage I • < -1 cm from (above) hymen • Stage II • +1 cm from hymen • Stage III-IV • >+1 cm to complete prolapse

21. Thank you for your attention!