Pelvic Organ Prolapse: Pathophysiology

Pelvic Organ Prolapse
Pelvic organ prolapse (POP) is a bulge or protrusion of pelvic organs and their associated
vaginal segments into or through the vagina
Pathophysiology
Pelvic organ prolapse results from attenuation of the supportive structures, whether
by actual tears or “breaks” or by neuromuscular dysfunction or both.
Definitions
The more common pelvic support disorders include rectoceles and cystoceles ,
enteroceles, and uterine prolapse, reflecting displacement of
the rectum, small bowel, bladder, and uterus, respectively, resulting from failure of the
endopelvic connective tissue, levator ani muscular support, or both.
Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical
support, which allows downward protrusion of the cervix and uterus toward the introitus.
Symptoms
Pelvic organ prolapse often is accompanied by symptoms of voiding dysfunction, including
urinary incontinence, obstructive voiding symptoms, urinary urgency and frequency, and, at
the extreme, urinary retention and upper renal compromise with resultant pain or anuria.
Other symptoms often associated with POP include pelvic pain, defecatory problems (e.
g., constipation, diarrhea, tenesmus, fecal incontinence), back and flank pain, overall
pelvic discomfort, and dyspareunia. Patients seeking care for prolapse may have one or several
of these symptoms involving the lower pelvic floor. Choice of treatment usually depends
on severity of the symptoms and the degree of prolapse consistent with the
patient's general health and level of activity.
Physical Examination
In evaluating patients with pelvic organ prolapse, it is particularly useful to divide
the pelvis into compartments, each of which may exhibit specific defects. The use of
a Graves speculum or Baden retractor can help to evaluate the apical compartment of the
vagina. The anterior and posterior compartments are best examined with the use of a univalve
or Sims' speculum. The speculum is placed posteriorly to retract the posterior wall downward
when examining the anterior compartment and placed anteriorly to retract the anterior wall
upward when examining the posterior compartment. A rectovaginal examination may be useful
in evaluating the posterior compartment to distinguish a posterior vaginal wall defect from
a dissecting apical enterocele or a combination of both.
If an anterior lateral detachment defect is suspected, an open ring forceps (or a Baden
retractor) may be placed in the vagina at a 45–degree angle posteriorly cephalad to hold the
lateral fornices adjacent to the pelvic sidewall.
During the evaluation of each compartment, the patient is encouraged to perform
Valsalva so the full extent of the prolapse can be ascertained. If the findings
determined with Valsalva are inconsistent with the patient's description of her
symptoms, it may be helpful to perform a standing straining examination with the
bladder empty
Pelvic Organ Prolapse Quantitation System

Many systems for staging prolapse have been described. Typically it is graded on a scale of 0 to
3 or 0 to 4, with the grade increasing with the severity of prolapse. Currently the
system approved by the International Continence Society is the Pelvic Organ
Prolapse Quantification system, or POP–Q. This standardized quantification
system facilitates communication between physicians in practice and research and
enables progression of these conditions to be followed accurately. In this system,
anatomic descriptions of specific sites in the vagina are used in place of traditional terms. The
system identifies nine
locations in the vagina and vulva in centimeters relative to the hymen, which are used to assign
a stage (from 0 to IV) of prolapse at its most advanced site. Although probably
more detailed than necessary for general practice, clinicians should be familiar with the POP–
Q system because most published studies use it to describe research results. Its two most
important advantages over previous grading systems are (i) it allows the use of a
standardized technique with quantitative measurements at straining relative to a constant
reference point (i.e., the hymen), and (ii) its ability to assess prolapse at multiple vaginal sites.
The classification uses six points along the vagina (two points on the anterior, middle,
and posterior compartments) measured in relation to the hymen. The anatomic
position
of the six defined points should be measured in centimeters proximal to the
hymen (negative number) or distal to the hymen (positive number), with the plane of
the hymen representing zero. Three other measurements in the POP–Q examination include
the genital hiatus, perineal body, and the total vaginal length.
The genital hiatus is measured from the middle of the external urethral meatus to
the posterior midline hymen. The perineal body is measured from the posterior margin
of the genital hiatus to the midanal opening. The total vaginal length is the greatest
depth of the vagina in centimeters when the vaginal apex is reduced to its full
normal position. All measurements except the total vaginal length are measured
during maximal straining.
The anterior vaginal wall measurements are termed Aa and Ba, with the Ba point
moving depending on the amount of anterior compartment prolapse. Point Aa represents
a point on the anterior vagina 3 cm proximal to the external urethral meatus,
which corresponds to the bladder neck. By definition, the range of position of this point is -3 to
+3. Point Ba represents the most distal or dependent point of any portion of the anterior vaginal
wall from point Aa to just anterior to the vaginal cuff or anterior lip of the cervix. This point can
vary depending on the nature of the patient's support defect. For example, point Ba is -3 in
the absence of any prolapse (it is never less than -3) to a positive value equal to the total
vaginal length in a patient with total eversion of the vagina.
The middle compartment consists of points C and D. Point C represents the

most dependant edge of the cervix or vaginal cuff after hysterectomy. Point D is
the location of the posterior fornix; it is omitted if the cervix is absent. This point
represents the level of the attachment of the uterosacral ligament to the posterior cervix. It
is intended to differentiate suspensory failure from cervical elongation.
The posterior compartment is measured similarly to the anterior compartment:
the corresponding terms are Ap and Bp. The nine measurements can be recorded as a
simple line of numbers (i.e., -3, -3, -8, -10, -3, -3, 11, 4, 3 for points Aa, Ba, C, D, Ap, Bp,
total vagina length, genital hiatus, and perineal body). The six vaginal sites have possible
ranges that depend on the total vaginal length (Table 24.1). After collection of the site–
specific measurements, stages are assigned according to the most dependent portion of the
prolapse (Table 24.2). The POP–Q examination often appears confusing on initial review;
however,
a measuring device (i.e., a marked ring forceps or marked cotton–tip applicator) can assist in
instructing those unfamiliar with this staging system. The POP–Q examination provides
a standardized measurement system to allow for more accurate assessments of
postoperative outcome and to ensure uniform, reliable, and site–specific descriptions of pelvic
organ prolapse. A videotape describing the system and showing its use in several patients
is available from the American Urogynecology Society.
In a clinical setting, at least three measurements should be obtained: the most advanced extent
of the prolapse in centimeters relative to the hymen that affects the anterior vagina, the
posterior vagina, and the cervix or vaginal apex.
As noted previously, whether the older staging systems or the POP–Q system is used, it
is important to document the most pertinent findings on examination. This will help
in documenting the baseline extent of prolapse and the results of treatment.

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Pelvic Organ Prolapse Quantitation System

The middle compartment consists of points C and D. Point C represents the

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