To pull or not to pull, that is the question…how should we define prolapse?

Abstract

Eleven per cent of women will at some stage in their lives undergo an operation for uterovaginal prolapse or incontinence [1, 2]. With an ageing population, and the desire for women to remain active and free from symptoms of prolapse, it is probable that the demand for urogynaecological surgery will increase. Over the last decade, debate has occurred about the best surgical treatment for uterovaginal prolapse, comparing alternative operations. In this debate, there is an assumption that data collected in one unit, concerning the degree of prolapse present in the women undergoing surgery, are comparable to the data acquired in another unit. What has perhaps not been discussed enough is the standardised examination of the support to the vagina, cervix, and uterus, and an agreement reached as to what constitutes symptomatic prolapse. Recent editorials have been written about how to best define pelvic organ prolapse based on symptoms, and identifying a Pelvic Organ Prolapse Quantification (POPQ) examination point beyond which subjects can be said to have symptomatic prolapse. Except for recommending the POPQ system, there has been very little mention about how to standardise the examination of the patient, and thus arrive at the POPQ values [3–5]. A good scientific test yields reproducible results under standardised conditions that can be repeated by different investigators. Without agreement as to a standardised method of examination, and documentation, the comparison of alternative surgical techniques for treatment cannot be compared between studies at different institutions. In addition, definitions of what is normal and abnormal should be based on scientific data rather than opinion. Since the stages of the POPQ system were based on committee opinion, we must accept the fact that these definitions of prolapse, based on the measurements made, are not evidence-based. As an example, the POPQ grading scheme labels as “grade 1 prolapse” women whose support is clearly within normal limits. There is a great variation in the practice of urogynaecological examination throughout the world, and within each separate country. Although it is generally accepted that prolapse is more symptomatic when the patient is standing, in many countries it has been conventional to examine patients in the left lateral position, using a Sims speculum with the patient “straining down”. This often leads to an underestimation of the true nature and degree of uterovaginal descent, especially as patients with pelvic muscle weakness may limit straining in an effort to maintain continence, both of urine and flatus, to avoid embarrassment. Examination with the patient standing and straining down, or in a gynaecological examination chair, has been shown to more accurately display the true extent of prolapse [6, 7]. In some centres it is normal practice to attempt to demonstrate maximal uterovaginal descent by applying traction to the cervix and vaginal walls, either under anaesthesia in theatre prior to surgery, or even in outpatients/ the office [8]. This practice deserves careful consideration. Two recent publications have looked at the results of POPQ examination pre-operatively and intra-operatively, with the use of traction [9, 10]. In both studies, applying traction to the cervix or vaginal apex intra-operatively resulted in much greater descent then could be documented during the pre-operative office POPQ examination. In one study all the cervices could be brought to within 1 cm of the P. Smith (*) Department of Urogynaecology, Southmead Hospital, Bristol BS10 5NB, UK e-mail: pasmithgyn@blueyonder.co.uk