Pelvic Organ Prolapse Quantification Point Research Articles

“Eyeball” POP-Q examination: shortcut or valid assessment tool?

The objective of this study was to compare the results of the Pelvic Organ Prolapse Quantification (POP-Q) examination by visual estimation to measurement. Women with pelvic organ prolapse underwent both "eyeball"/estimated and measured POP-Q examinations by two trained examiners in a randomized order. POP-Q points and stage were analyzed using the paired t test, chi-square, Pearson's correlation, and kappa statistics. Fifty subjects had a mean age of 60, mean BMI 27.8, and median parity of 2. The POP-Q stages by the measured technique were 18% (9/50) stage 1, 38% (19/50) stage 2, 44% (22/50) stage 3, and 0% (0/50) stage 4. The POP-Q stages based on estimation and measurement were highly associated (p < 0.05). Individual points did not differ significantly between the techniques and did not differ significantly between examiners (all p > 0.05). Among examiners who routinely perform POP-Q examinations, there is no significant difference between "eyeball"/estimated and measured POP-Q values and stage.

Vaginal Descent and Pelvic Floor Symptoms in Postmenopausal Women

To determine whether vaginal descent changes are associated with pelvic floor symptoms in postmenopausal women. This 4-year prospective study included 260 postmenopausal women with an intact uterus enrolled at one Women's Health Initiative (WHI) clinical trial site. All completed at least two annual pelvic organ prolapse quantification (POP-Q) examinations and symptom questionnaires (30 bladder, bowel, and prolapse symptom items, modified from the Pelvic Floor Distress Inventory). Symptoms were grouped, and group scores categorized into two or three evenly distributed levels. Year 4 data collection was incomplete because the overall WHI study halted. Generalized logistic linear models and generalized estimating equation methods were used to measure associations between vaginal descent and a symptom or symptom score, controlling for time, age, and body mass index (BMI). Mean age was 68+/-5 years, BMI 30+/-6 kg/m(2), and median parity 4. Ninety-five percent of women had POP-Q stages I-II prolapse. Increasing maximal vaginal descent was associated with "see/feel a bulge" and "sensation of protrusion or bulging," and with obstructive bladder, prolapse, and obstructive bowel scores. Increasing apical descent (POP-Q point C) was associated with "see/feel a bulge," increasing anterior descent (POP-Q point Ba) with bladder pain and obstructive bladder scores, and increasing posterior descent (POP-Q point Bp) with the bowel incontinence score. Although previous work showed that most pelvic floor symptoms correlated poorly with levels of early prolapse, longitudinal analysis suggests that vaginal descent progression over time is positively associated with various bladder, bowel, and prolapse symptoms in postmenopausal women with stages I-II prolapse. II.

Distribution of pelvic organ support measures in a population-based sample of middle-aged, community-dwelling African American and white women in southeastern Michigan

The purpose of this study was to report the distribution of pelvic support among a population-based sample of middle-aged community-dwelling women, as defined by pelvic organ prolapse quantification (POP-Q) and study factors that might influence POP-Q measurements. We conducted a secondary analysis of a population-based study of community-dwelling, African American and white women aged 35-64 years from southeastern Michigan. Three hundred ninety-four women consented to physical examination using the POP-Q. Statistical analysis included descriptive statistics and multivariable regression. Estimates were weighted to reflect probability and nonresponse characteristics of the sample to increase generalizability of the findings. The following values were the mean values for POP-Q points: Aa and Ba = -1.2 cm, C = -6.5 cm (intact uterus), C = -6.9 cm (hysterectomy), and Ap and Bp = -1.8 cm. The POP-Q stages were organized in the following manner: stage 0, 8.8%; stage I, 21.4%; stage II, 67.7%; stage III, 2.1%. Increasing vaginal parity was associated with increasing descent of the anterior, apical, and posterior vaginal wall (P < .001). In this population-based study of women from southeastern Michigan, 90% of the women had anterior and posterior vaginal wall support that was above or extended to the hymen. Increasing vaginal parity was associated with increasing descent of the anterior, posterior, and vaginal apex.

The Role of Apical Vaginal Support in the Appearance of Anterior and Posterior Vaginal Prolapse

To describe how simulated apical support affects the appearance of prolapse in the anterior and posterior vagina using a modification of the Pelvic Organ Prolapse Quantification (POP-Q) examination. Women with prolapse stage II or greater were examined using the POP-Q. To simulate apical support, the posterior blade of a standard Graves speculum was positioned over the posterior vagina to support the vaginal apex while remeasuring points Aa and Ba and over the anterior vagina to support the apex while remeasuring points Ap and Bp. Change in anterior and posterior POP-Q points and prolapse stage with apical support were calculated. One hundred ninety-seven women were enrolled with mean age of 62+/-14 years, median parity of 2 (range 0-8), and mean body mass index of 28+/-5 kg/m(2). By standard POP-Q, 36% had stage II prolapse, 54% had stage III, and 10% had stage IV prolapse. With simulated apical support, point Ba changed to stage 0 or I in 55% of cases and point Bp changed to stage 0 or I in 30% (P<.001 for each point). Mean change for point Ba with apical support was 3.5+/-2.6 cm and point Bp was 1.9+/-2.9 cm (P<.001). When the POP-Q examination is performed with simulated apical support, the critical role of level I vaginal support on the position of the anterior and posterior vagina, particularly the anterior vagina, becomes apparent. II.

Correlation of Q-Tip Values and Point Aa in Stress-Incontinent Women

To estimate the relationship between pelvic organ prolapse quantification (POP-Q) point Aa and straining Q-tip angle. We compared preoperative straining Q-tip angles and Aa measurements from 655 women with predominant stress incontinence and urethral hypermobility (defined as a resting or straining angle of greater than 30 masculine) using Pearson correlations and linear regression. Point Aa is 3 cm deep to the urethral meatus in the midline of the anterior vagina and corresponds to the urethrovesical crease. The median for point Aa was -1 cm (range -3 to +3 cm) and for straining Q-tip was 60 masculine (30-130 masculine). Twenty-nine percent of participants had an Aa at least 2 cm deep to the hymen, whereas in 69%, Aa was at or below -1 cm. The straining Q-tip angle was significantly different between these respective groups: 51.5 masculine and 64 masculine (P<.001). Linear regression analysis indicates that point Aa and straining Q-tip were moderately correlated (r=0.35, P<.001). As straining point Aa increased by 1 cm, Q-tip angle increased 4.6 masculine (P<.001). Age and prior anterior vaginal or incontinence surgery had no significant effect on the correlation (P=.08 and P=.64, respectively). Nearly a third of stress-incontinent women with urethral mobility by Q-tip test visually appeared to have a well-supported urethrovesical junction with POP-Q point Aa values of -2 cm or less. The position of the urethrovesical crease (point Aa) on POP-Q and straining angle on Q-tip test do not appear to reflect the same anatomic support and cannot be used to predict one another. No Aa value can rule out urethral hypermobility.

The natural history of posterior vaginal wall support after abdominal sacrocolpopexy with and without posterior colporrhaphy

The objective of the study was to determine the degree of posterior vaginal wall support after abdominal sacrocolpopexy (ASC) with and without a posterior colporrhaphy as a function of time. Retrospective review was performed on women who underwent ASC between 1997 and 2004. Pelvic organ prolapse quantification (POP-Q) points Ap and Bp and stage of posterior compartment were collected at initial visit and at 1, 4, 10, 22, and 34 months after ASC. Significant improvement of POP-Q point Ap and Bp and stage of posterior compartment was initially seen after ASC with or without posterior colporrhaphy. With concomitant posterior colporrhaphy, the improvement in Ap persisted 34 months after surgery. Mean Bp and stage of the posterior compartment returned to preoperative values after 10 months, regardless of whether a concurrent posterior colporrhaphy had been performed. Fifty-one of 191 women (29%) had subsequent stage 2 posterior wall prolapse, 4 (2%) of whom underwent subsequent posterior colporrhaphy. For ASC with concomitant posterior colporrhaphy, POP-Q point Ap significantly improved and persisted at 34 months after surgery. Ten months after surgery, descent of POP-Q point Bp returned to preoperative levels and was the same regardless of whether a site-specific posterior colporrhaphy was performed at the time of an abdominal sacrocolpopexy.

Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse

The purpose of this study was to determine the relationship between the most prolapsed portion of the anterior and posterior vaginal walls and the apex. After obtaining institutional review board approval, demographic data and pelvic organ prolapse quantification findings from consecutive new patients who were seen at our urogynecologic practice between January 2004 and February 2005 were reviewed. Three hundred twenty-five women were included in this cohort. The support of the vaginal apex (pelvic organ prolapse quantification point C) correlated strongly with the most prolapsed portion of the anterior vaginal wall, Ba (Spearman's rho = 0.835; P < .001) and correlated moderately with the most prolapsed portion of the posterior vaginal wall, Bp (Spearman's rho = 0.556; P < .001). A strong linear relationship was found between C and Ba, which is best modeled by the following regression equation: C = Ba(1.4) - 4.4 (r = .869). Anterior vaginal wall prolapse is associated strongly with apical prolapse. Anterior vaginal wall defects that are surgically repaired usually require a concomitant repair of the apex.

A Randomized Controlled Trial Comparing Fascia Lata and Synthetic Mesh for Sacral Colpopexy

To compare the objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh. Patients undergoing a sacral colpopexy were randomized to receive either fascia lata or polypropylene mesh in a double-blinded fashion. Data were collected at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The main outcome measures were pelvic organ prolapse quantification (POP-Q) system stage and individual POP-Q points over time. Objective anatomic failure was defined as POP-Q stage 2 or more at any point during the follow-up period. Proportions of patients with objective anatomic failure at 1 year in each group were compared using the chi(2) test. Mean POP-Q points and stage at 1 year were compared by using the independent samples t test. One hundred patients were randomized to receive either fascia (n = 46) or mesh (n = 54). Of the 89 patients returning for 1-year follow-up, 91% (41/45) of the mesh group and 68% (30/44) of the fascia group were classified as objectively cured (P = .007). We found significant differences between the mesh and fascia groups with respect to the 1-year postoperative comparisons of points Aa, C, and POP-Q stage. There were no differences between the 2 groups with respect to points TVL (total vaginal length), GH (genital hiatus), PB (perineal body), Ap or Bp (2 points along the posterior vaginal wall). Polypropylene mesh was superior to fascia lata in terms of POP-Q points, POP-Q stage, and objective anatomic failure rates. I.

Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse?

To determine if women with anterior support stages 0 or I by pelvic organ prolapse quantification (POP-Q) system require Q-tip testing to assess urethral mobility. A prospective study of 134 women presenting for urogynecologic evaluation were examined and assigned stages of anterior wall support according to the POP-Q system. A Q-tip test was performed and urethral hypermobility was defined as a straining angle > or =30 degrees. The Spearman correlation coefficient was used to assess degree of correlation between POP-Q point Aa position and Q-tip values. The correlation coefficient between point Aa position and Q-tip angle was r = 0.787 (P < 0.001). Urethral hypermobility was noted in 91% of stage I and 100% of stage II-IV patients. The positive predictive value of Q-tip angle > or =30 degrees in stage I-IV prolapse was 99%. The POP-Q system is highly predictive of straining urethral angle in all stages of prolapse.

Paper 33: Vaginal Descensus and Pelvic Floor Symptoms in Older Women

OBJECTIVE: To better understand the clinical significance of early pelvic organ prolapse, we studied the association between vaginal descensus and pelvic floor symptoms in older community-dwelling women not seeking care for pelvic floor disorders. METHODS: This cross-sectional study included women with an intact uterus enrolled at 1 site of the WHI Hormone Therapy clinical trial. Subjects underwent a Pelvic Organ Prolapse Quantification (POP-Q) exam and completed a questionnaire of 30 bladder, bowel and prolapse symptom items, modified from the Pelvic Floor Distress Inventory (PFDI). Symptoms were grouped and simple additive scores were calculated (presence of symptom = 1, absence = 0). We tested associations between individual symptoms, as well as symptom group scores and anterior, posterior, apical and maximal vaginal descensus (measured in centimeters in relation to the hymen) and also compared rates of symptoms and symptom group scores using a dichotomous definition of prolapse (defined as the most distal POP-Q point at or beyond the hymen). Statistical tests included Chi-square or Fisher exact, Cochrane-Armitage test for trend and Wilcoxon rank sum. RESULTS: Two hundred seventy women were enrolled with mean age 68 years (range 57–84). On exam, 96% had POP-Q stages I or II. Of bladder symptoms, only certain obstructive symptoms (difficulty emptying, incomplete emptying, weak stream, intermittent stream, pushing on abdomen to urinate and changing positions to urinate) were associated with increasing descensus in at least 1 vaginal compartment (P<0.05 for all); all 3 vaginal compartments were associated with obstructive symptoms. Obstructive urinary symptom group scores increased as anterior, posterior and maximal vaginal descensus increased (P<0.05 for all). Weak stream and position change to urinate were more common in women with prolapse at or beyond the hymen (both P=0.01), but the majority of women reporting these symptoms did not have prolapse using this definition. Bowel symptoms were not associated with increasing descensus of any vaginal compartment. “See or feel a bulge,” endorsed by 11 women (4%), was associated with descensus in all compartments (P<0.05) and was also strongly associated with the dichotomous definition of prolapse (P<0.0001). This symptom alone was highly specific (100%), but not sensitive (16%) for the presence of prolapse at or beyond the hymen. The obstructive urinary and prolapse group symptom scores were not associated with prolapse by this definition. CONCLUSION: “Milder” support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge, but in general, these symptoms are not helpful in discriminating between women with and without prolapse. For the most part, symptoms and symptom group scores were not helpful in identifying a cut-point in vaginal descensus that might indicate normal or abnormal support in these women with largely POP-Q Stage I and II prolapse.

The natural history of pelvic organ support in pregnancy.

Little is known about the anatomic and physiologic changes in the pelvic floor that occur during pregnancy. The purpose of this study was to prospectively document pelvic organ support throughout pregnancy using the standardized system of the International Continence Society, also known as the Pelvic Organ Prolapse Quantification (POPQ) Staging System. Pelvic organ support evaluations were performed in nulliparous pregnant women presenting for routine obstetric care during each trimester. POPQ stage assignments and POPQ component measurements were compared for first-, second- and third-trimester examinations. Overall POPQ stage was significantly higher in the third trimester than in the first (P=0.001). Individual POPQ points which showed significant differences between the first and third trimesters include Aa, PB, Ap, Ba, Bp, TVL and GH. These findings probably represent normal physiologic changes of the pelvic floor during pregnancy, but suggest that significant changes may be objectively demonstrated prior to delivery.