Pelvic Organ Prolapse Quantification Examination Research Articles

Laparoscopic uterosacral uterine suspension: A minimally invasive technique for treating pelvic organ prolapse

Study Objective To assess the surgical outcomes of laparoscopic uterosacral uterine suspension and describe the surgical technique. Design Retrospective chart review (Canadian Task Force classification II-3). Setting University tertiary medical center. Patients Twenty-three patients with symptomatic uterine prolapse and desire for uterine preservation who underwent surgical repair. Intervention Laparoscopic uterine uterosacral uterine suspension. Measurements Preoperative and postoperative evaluations were completed. The stage of pelvic organ prolapse was assessed using the ICS pelvic organ prolapse quantification (POP-Q) examination. Descriptive statistics and paired t testing were used for statistical analysis. Results Nineteen of 23 patients (82.6%) had preoperative prolapse stage 2 or greater. Nine patients (40.9%) had uterine prolapse beyond the hymen. After operation there were significant improvements in the stage of prolapse (2 vs 0, p < .01). The POP-Q scores for point C and D were significantly further away from the hymen after operation than compared with the preoperative values (−0.6 vs −7.8, and −5.0 vs −8.6; p < .01) respectively. There were no intraoperative complications. The estimated blood loss (mean ± SD) was 111.5 ± 139.4 mL. The hospital stay (mean ± SD) was 2.2 ± 1.7 days. None of the patients had symptomatic prolapse during the mean follow-up of 15.9 months. Conclusion Laparoscopic uterine suspension appears to be a safe and effective treatment option for uterine prolapse in patients who desire uterine preservation.

Outcomes with porcine graft placement in the anterior vaginal compartment in patients who undergo high vaginal uterosacral suspension and cystocele repair

The purpose of this study was to prospectively assess the cases of patients who had undergone a high uterosacral suspension and anterior repair with anterior compartment placement of porcine dermis graft. Thirty-six patients who underwent transvaginal high uterosacral suspension and cystocele repair with graft augmentation from June 2001 to July 2004 were identified from the University of Alabama at Birmingham Genitourinary Disorders database. Analysis included the pre- and postoperative Pelvic Organ Prolapse Quantification examinations and incontinence impact questionnaire-7/urogenital distress inventory-6. Mean Pelvic Organ Prolapse Quantification Ba improved from +3.3 +/- 2.2 cm to -0.6 +/- 1.7 cm (P < .01). Postoperative Ba was prolapse stage II or greater in 50% of subjects. Mean incontinence impact questionnaire-7 scores improved from 36.2 +/- 31.9 to 15.6 +/- 26.2 (P < .01), as did mean urogenital distress inventory-6 scores from 58.2 +/- 26.8 to 23.8 +/- 22.6 (P < .01). Significant improvements in Pelvic Organ Prolapse Quantification measures, urinary symptoms, and the impact of incontinence were seen after the operation. However, a significant proportion of patients had Pelvic Organ Prolapse Quantification stage II prolapse or greater, which made it unclear whether graft use confers a significant advantage.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

Vaginal Wall Descensus and Pelvic Floor Symptoms in Older Women

To understand the clinical significance of early pelvic organ prolapse in older women, we studied associations between vaginal descensus and pelvic floor symptoms. In this cross-sectional study, 270 women enrolled at one site of the Women's Health Initiative clinical trial completed a questionnaire modified from the Pelvic Floor Distress Inventory on pelvic floor symptoms and underwent a Pelvic Organ Prolapse Quantification (POP-Q) examination. We tested associations between symptoms (individual and grouped) with anterior, posterior, uterine, and maximum vaginal descensus. Mean age was 68 years. Ninety-six percent had POP-Q stages I or II. Only obstructive urinary symptoms and feeling a bulge were associated with vaginal descensus. Obstructive urinary symptom scores increased as anterior (P = .04), posterior (P < .01), and maximal (P = .01) vaginal descensus increased. Urinary incontinence or bowel symptoms were not associated with descensus of any vaginal compartment. ''See or feel a bulge,'' reported by 11 women (4%), was associated with descensus in all compartments (P < or = .04 for all) and with prolapse at or beyond the hymen (P < .001). This symptom was specific (100%), but not sensitive (16%) for prolapse, defined as descensus at or beyond the hymen. Vaginal support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge. However, symptoms are not useful in discriminating between women with and without milder vaginal wall descensus. Based on these results, we suggest that other etiologies for bothersome bladder or bowel complaints be considered before performing surgery for early pelvic organ prolapse.

ASSOCIATION BETWEEN VALSALVA AND COUGH LEAK POINT PRESSURES AND PELVIC ORGAN PROLAPSE QUANTIFICATION IN WOMEN WITH STRESS INCONTINENCE

Women with urodynamically documented stress urinary incontinence (SUI) and urethral hypermobility may have a higher pelvic organ prolapse quantification (POP-Q) stage according to anterior POP-Q measurements. In this study we determined if POP-Q system anterior components representing the urethrovesical junction (anterior wall point Aa/Ba) and/or POP-Q stage has a relationship with leak point pressure testing. Of the 1,511 women who underwent video fluoro-urodynamics during 1997 to 2003 at our institution 88 with only evidence of SUI with negative Valsalva leak point pressure and positive cough leak point pressure (CLPP) were selected. Average patient age was 58.6 years (range 32 to 89). Of the 88 women 82 had complete POP-Q examinations available, which revealed stages 0 to III in 21 (25.61%), 20 (24.39%), 40 (48.78%) and 1 (1.22%), respectively. The association between POP-Q stage/components and positive CLPP showed no significant difference in mean positive CLPP among POP-Q stages (p = 0.178) or components (p = 0.42 to 0.97). The test for linear trend was not significant (p = 0.636) for POP-Q stages/components (p = 0.40 to 0.93). No significant difference in volume at which positive CLPP occurred was observed among POP-Q stages (p = 0.283) or components (p = 0.13 to 0.75). The proportion of patients with leakage at 200 cc did not differ significantly among POP-Q stages (p = 0.119) or components (p = 0.15 to 0.60). Analysis of women with urodynamic evidence of SUI with negative Valsalva leak point pressure and positive CLPP did not show any significant association with components of the POP-Q system or with POP-Q stages. Findings support that POP-Q measurements should not be interpreted as indicators of urethral hypermobility when evaluating women with SUI.

Pelvic Organ Support Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects

The purpose of this study was to describe the distribution of pelvic organ support in a gynecologic clinic population to define the clinical disease state of pelvic organ prolapse and to analyze its epidemiologic condition. This was a multicenter observational study. Subjects who were seen at outpatient gynecology clinics who required an annual gynecologic examination underwent a pelvic organ prolapse quantification examination and completed a prolapse symptom questionnaire. Receiver operator characteristic curves were used to define pelvic organ prolapse with the use of symptoms and pelvic organ prolapse quantification examination measures. Standard age-adjusted univariate and multivariate logistic regression analysis were used to evaluate various relationships. The population consisted of 1004 women who were aged 18 to 83 years. The prevalence of pelvic organ prolapse quantification stages was 24% (stage 0), 38% (stage 1), 35% (stage 2), and 2% (stage 3). The definition of pelvic organ prolapse that was determined by the receiver operator characteristic curve was the leading edge of their vaginal wall that was -0.5 cm above the hymenal remnants. Multivariate analysis revealed age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus as risk factors for pelvic organ prolapse, as defined in this population. The results from this population suggest that there is a bell-shaped distribution of pelvic organ support in a gynecologic clinic population. Advancing age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus have the strongest correlations with prolapse.

Surgical outcome of abdominal sacrocolpopexy with synthetic mesh versus abdominal sacrocolpopexy with cadaveric fascia lata

Nineteen women who had an abdominal sacrocolpopexy (ASC) with synthetic mesh and 18 women who had an ASC with freeze-dried, irradiated cadaveric fascia lata returned for blinded pelvic organ prolapse quantification (POPQ) examinations. The mean relative vaginal descent (delta) from perfect total vaginal length in the mesh group was 1.1 (0.3) cm, and the delta in the fascia group was 2.8 (0.8) cm (p=0.02, Mann-Whitney U). The proportion of women with "optimal" surgical outcome in the mesh group was 89% and 61% in the fascia group (p=0.06, Fischer's exact test). This study suggests that cadaveric fascia lata may not be a good choice for ASC.

Evaluation of Aa Point and Cotton-Tipped Swab Test as Predictors of Urodynamic Stress Incontinence

To compare the predictive abilities of the Aa point of the pelvic organ prolapse quantification examination and the cotton-tipped swab test straining angle to diagnose urodynamic stress incontinence. A case-control study was conducted between June 1997 and February 2003. Cases were defined as patients with urodynamic stress incontinence (n = 352). Controls were patients who also underwent urodynamic testing but who did not have a diagnosis of urodynamic stress incontinence (n = 245). Independent variables were defined as Aa point, Aa point of 0 or greater, straining cotton-tipped swab angle, and straining cotton-tipped swab angle of 30 degrees or greater. Logistic regression estimated the odds ratio of stress incontinence in women based on Aa values and cotton-tipped swab straining angle measurements, controlling for other variables commonly associated with stress incontinence. The mean (+/- standard deviation) age of the cases was 55.9 +/- 13.4 and of controls was 55.3 +/- 14.8, (P = .6). The median parity of the cases was 2 (range 0-10) and of controls, 2 (range 0-9) (P = .7). The Aa point was not associated with a diagnosis of stress incontinence (odds ratio 1.01, 95% confidence interval (CI) 0.83-1.23). The adjusted odds ratios of having an Aa value of 0 or greater was 0.49 (95% CI 0.26-0.92), and of having a cotton-tipped swab angle of 30 degrees or greater was 3.1 (95% CI 1.09-5.07), in a model that adjusted for age, parity, race, and postmenopausal and hormonal replacement status. Aa point is not associated with a diagnosis of stress incontinence. However, a cotton-tipped swab angle of 30 degrees or greater is positively associated with stress incontinence.

Pelvic organ prolapse in older women: prevalence and risk factors.

We sought to estimate the prevalence of pelvic organ prolapse in older women using the Pelvic Organ Prolapse Quantification examination and to identify factors associated with prolapse. Women with a uterus enrolled at one site of the Women's Health Initiative Hormone Replacement Therapy randomized clinical trial were eligible for this ancillary cross-sectional study. Subjects underwent a Pelvic Organ Prolapse Quantification examination during a maximal Valsalva maneuver and in addition completed a questionnaire. Logistic regression was used to identify independent risk factors for each of 2 definitions of prolapse: 1) Pelvic Organ Prolapse Quantification stage II or greater and 2) the leading edge of prolapse measured at the hymen or below. In 270 participants, age (mean +/- SD) was 68.3 +/- 5.6 years, body mass index was 30.4 +/- 6.2 kg/m(2), and vaginal parity (median [range]) was 3 (0-12). The proportions of Pelvic Organ Prolapse Quantification stages (95% confidence intervals [CIs]) were stage 0, 2.3% (95% CI 0.8-4.8%); stage I, 33.0% (95% CI 27.4-39.0%); stage II, 62.9% (95% CI 56.8-68.7%); and stage III, 1.9% (95% CI 0.6-4.3%). In 25.2% (95% CI 20.1-30.8%), the leading edge of prolapse was at the hymen or below. Hormone therapy was not associated with prolapse (P =.9). On multivariable analysis, less education (odds ratio [OR] 2.16, 95% CI 1.10-4.24) and higher vaginal parity (OR 1.61, 95% CI 1.03-2.50) were associated with prolapse when defined as stage II or greater. For prolapse defined by the leading edge at or below the hymen, older age had a decreased risk (OR 0.50, 95% CI 0.27-0.92) and less education, and larger babies had an increased risk (OR 2.38, 95% CI 1.31-4.32 and OR 1.97, 95% CI 1.07-3.64, respectively). Some degree of prolapse is nearly ubiquitous in older women, which should be considered in the development of clinically relevant definitions of prolapse. Risk factors for prolapse differed depending on the definition of prolapse used.

Pelvic organ support in pregnancy and postpartum

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

Influence of spontaneous and instrumental vaginal delivery on objective measures of pelvic organ support: assessment with the pelvic organ prolapse quantification (POPQ) technique and functional cine magnetic resonance imaging

Objective: To determine the influence of spontaneous and instrumented vaginal delivery on objective measures of pelvic organ support. Study design: Prospective study at a university hospital with two study groups: vaginal spontaneous delivery ( n=26) and vacuum extraction ( n=49). Control group consisted of healthy nulliparous volunteers ( n=20). Participants underwent pelvic organ support evaluation by use of the pelvic organ prolapse quantification (POPQ) examination and postpartum functional cine magnetic resonance imaging (MRI). Results: Significant differences for individual POPQ component measurements were noted for points Aa and Ba, TVL, and GH (spontaneous delivery versus control) and in addition for Ap, Bp, and D (vacuum extraction versus control). Significant differences for MRI measurements were observed for the position of bladder base, bladder neck, posterior fornix of the vagina, anorectal junction, hiatus perimeter and depth of rectocele. Conclusions: Considerable changes in pelvic organ support after vaginal delivery can be demonstrated by a reproducible and reliable clinical classification system (POPQ) and by functional cine magnetic resonance imaging.

Evaluation of a clinical skills orientation program for residents

Objective Our purpose was to implement and evaluate an orientation program for residents, focusing on outpatient clinical skills. Study design Eleven of 12 residents participated in a clinical skills orientation program immediately preceding the academic year. The skill stations included evaluation of abnormal uterine bleeding, intrauterine device insertion, basic infertility evaluation, endometrial and vulvar biopsies, pelvic organ prolapse quantification examination, hysterosalpingography and office hysteroscopy, ultrasound scanning, labor and delivery triage, and clinic administrative responsibilities. Before test, after test, and anonymous resident evaluations were used to evaluate the program. Results First-year residents demonstrated a statistically significant increase in posttest scores compared to pretest scores (42.5% vs 71.3%, P = .003). Only first-year resident posttest scores for the labor and delivery triage and basic infertility evaluation stations demonstrated statistically significant increases over pretest scores (14.3% vs 46.4%, P = .009; and 41.7% vs 83.3%, P = .049, respectively). Sixty-four percent of the residents rated the program as “very helpful.” Most residents felt that the program was well organized and that the facilities were conducive to learning; all of the participants recommended an annual clinical orientation program. Conclusion A clinical skills orientation program was well received and strongly desired by residents. First-year residents appeared to benefit the most from this orientation.

Pelvic organ support in nulliparous pregnant and nonpregnant women: A case control study

Objective: Our purpose was to compare pelvic organ support in nulliparous pregnant and nonpregnant women at a single institution. Study Design: This was a case-control study. Pregnant patients and nonpregnant control subjects were matched according to age and race. Subjects underwent pelvic organ support evaluation by use of the pelvic organ prolapse quantification (POPQ) examination as part of routine prenatal or gynecologic care.The Pearson χ2 statistic was used for statistical analysis, with a P value of 5% set for significance. Results: A total of 21 pregnant and 21 nonpregnant nulliparous women between the ages of 18 and 29 years were included. All patients in the nonpregnant group had a POPQ stage of 0 or 1, whereas 47.6% of the pregnant subjects had POPQ stage 2 (P <.001). Individual components of the POPQ examination were compared. Significant differences were noted for points Aa and Ba, Ap and Bp, and PB and TVL. Conclusions: In nulliparous women, pregnancy is associated with increased POPQ stage compared with nonpregnant control subjects. (Am J Obstet Gynecol 2002;187:99-102.)