NON

Review
Received: May 31, 2007 Accepted: June 21, 2007
Address correspondence to: Dr. Gin-Den Chen, Department of Obstetrics and Gynecology,
Chung Shan Medical University Hospital, 110, Section 1, Chien-Kuo North Road,
Taichung, Taiwan
E-mail: gdchen@hotmail.com
Incont Pelvic Floor Dysfunct 2007; 1(4):121-124
Updated Definition of Female Pelvic Organ Prolapse
Gin-Den Chen, M.D., Soo-Cheen Ng, M.D.
Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung, Taiwan
ABSTRACT
Pe|v|c |oor oysunc|on may |nc|uoe pe|v|c oran pro|apse (POP)
ano |ncon|nence. The|r sympoms can be c|ass||eo |no m|cur||on,
oeeca|on, pro|apse, sex ano pa|n. Causes ano r|sk acors o POP
are ||ke|y o be mu||acor|a|, vary|n rom pa|en o pa|en, such as
prenancy, va|na| ch||ob|rh, |ncreas|n booy mass |noex, ae|n,
conen|a| pe|v|c |oor oeecs, ||esy|e (h|h-|mpac ac|v||es) ano
chron|c o|sease. Curren|y, here are hree rao|n sysems mos com-
mon|y useo wor|ow|oe. n h|s ar|c|e, we aoo a new c|ass||ca|on
sysem ha was proposeo by he nerna|ona| Uroyneco|oy Asso-
c|a|on |n 2006 o he summar|zeo ab|e or compar|son. Hopeu||y, h|s
work can upoae our reaoers o he new know|eoe ano he|p pr|mary
care prov|oer ano researchers o ac|||ae eec|ve commun|ca|on.
Key woros: pro|apse, aner|or va|na| wa||, poser|or va|na| wa||, va|-
na| cu, pe|v|c oran pro|apse
INTRODUCTION
Pe|v|c oran pro|apse (POP) |s an anaom|c suppor oeec o he
pe|v|c v|scera. may resu| rom a ser|es o |on-erm a||ure o he
suppor|n ano suspens|on mechan|sms o he uerus ano va|na| wa||.
The e|o|o|es o POP are a comb|na|on o oenerva|on |n he pe|v|c
|oor muscu|aure [1|, o|rec |njury o he pe|v|c |oor muscu|aure, or
oeecs |n he enoope|v|c asc|a ano suppor|n ||amens [2-5|. These
preex|s|n musc|e ano nerve oamae or asc|a breaks o he pe|v|c
|oor rom rauma or ch||ob|rh may be exacerbaeo by menopausa|
esroen oe|c|ency, ae|n, chron|c cons|pa|on, chron|c couh, heavy
|||n, or obes|y [6-8|. Pu oeher, hese k|nos o mechan|ca| rauma
may resu| |n pe|v|c |oor oysunc|on ano pro|apse consequen|y. We
cons|oer ha hese r|sks may conr|bue o he oeer|ora|on o he pre-
ex|s|n oeec o he pe|v|c |oor suppor|n mechan|sm. However,
when cons|oer|n he occurrence or he sever|y o POP, | |s an aoo-
on, summa|ve, or so-ca||eo carry-over eec o he above preo|spos-
|n acors.
CLINICAL PRESENTATIONS OF POP
Women w|h POP can presen e|her |noepenoen|y or |n comb|-
na|on w|h oher sympoms such as uerova|na| bu||n or prorus|on,
see|n or ee||n a bu|e or proruo|n mass hrouh he va|na, pe|-
v|c pressure or heav|ness, or assoc|aeo ur|nary ano/or bowe| symp-
oms [9|. n he 2002 CS repor, sec|on 1.5 sympoms assoc|aeo
w|h POP, | saes ha women w|h a pro|apse may oescr|be symp-
oms |nc|uo|n ee||n o a |ump (someh|n com|n oown), |ower back
pa|n, heav|ness, ora|n sensa|on, or he neeo o o||a||y rep|ace
he pro|apse |n oroer o oeecae or m|curae [10|. However, excep
or he va|na| bu|e or prorus|on, none o he sympoms are spec||c
o pro|apse. Many women w|h POP are asympoma|c ano oo no neeo
reamen. Women w|h m||o ano mooerae pe|v|c re|axa|on oen com-
p|a|n o sress ur|nary |ncon|nence, whereas women w|h severe
uerova|na| pro|apse rare|y comp|a|n o |ncon|nence [11|. A |are
poser|or va|na| pro|apse can a|so cause mechan|ca| obsruc|on by
o|rec urehra| compress|on [12|. Some women w|h POP requen|y
comp|a|n o sympoms re|aeo o bowe| oysunc|on, |nc|uo|n a ee|-
|n o |ncomp|ee empy|n, sra|n|n, neeo o app|y o||a| pressure
o he va|na or per|neum o sar or comp|ee oeeca|on, urency,
ano |ncon|nence [9|. However, |n suo|es o he re|a|on beween bowe|
oysunc|on ano presence ano sever|y o pro|apse, researchers have
reporeo e|her a weak corre|a|on beween poser|or va|na| wa|| sup-
por ano spec||c anoreca| sympoms or no ||nk a a|| [13|. Sympoms
a|one oo no corre|ae w|h he oeree o pro|apse as oeerm|neo by
pe|v|c exam|na|on ano can no be useo o make a oe|n||ve o|anos|s.
Thereore, women w|h sympoms sues|ve o pro|apse neeo o un-
oero a comp|ee pe|v|c exam|na|on ano a horouh meo|ca| h|sory
mus be comp|eeo [9|.
CLASSIFICATION OF PELVIC ORGAN PROLAPSE
n he pas hree oecaoes, |n oroer o compare he resu|s o pe|-
v|c |nves|a|ons rearo|n uerova|na| pro|apse, many schemes or
eva|ua|n POP have been proposeo. n h|s ar|c|e, we have co||eceo
he hree mos common|y useo pe|v|c rao|n sysems or compar|son
o he o|vers||es amon hem. These hree rao|n sysems are sum-
mar|zeo |n F|. 1.
CURRENT POP GRADING SYSTEM EXCEPT POP-Q
Baoen ano Wa|ker houh ha erms useo or oescr|b|n va|na|
re|axa|on |n c||n|ca| recoros were oo enera| ano nonspec||c o a||ow
compar|son o he pa|en's preopera|ve ano posopera|ve saes [14|.
They reporeo a spec||c anaom|ca| |no|n beore ano aer recon-
sruc|ve surery. A s|x-o|| c|ass||ca|on sysem rom 0 (he bes
poss|b|e) o 4 (he wors poss|b|e) was proposeo o corre|ae he s|x
poen|a| |es|ons o va|na| re|axa|on: aner|or va|na| semen (1)
urehroce|e, (2) cysoce|e, super|or va|na| semen (3) pro|apse, (4)
eneroce|e, poser|or va|na| semen (5) recoce|e, (6) chron|c per|nea|
|acera|on. n h|s sysem, a norma| va|na w|h aoequae suppor o a||
s|x componens has a va|na| pro||e ha can be oescr|beo as 0-0 ---
0-0 ---0-0. When an urehroce|e proruoes ous|oe he hymen, a cyso-
ce|e oescenos o he hymen, ano componens o he super|or ano
poser|or semens are w|hou oeecs, he va|na| pro||e |s recoroeo
as 3-2---0-0---0-0. Each componen |s raoeo rom 0 o 4. The hymen
NOO
Review
r|n (remnans) |s useo as a reerence po|n (F|. 1). |s ca||eo he
ha|-way sysem.
Anoher w|oe|y useo rao|n sysem pub||sheo by Beecham |s
a|so curren|y |n use [15|. Beecham houh ha an urehroce|e canno
be cons|oereo as a s|n|e en|y. can be par o a pr|mary cysoce|e.
Mos suppor|n oeecs o he aner|or va|na| semen shou|o be
cons|oereo as a cysourehroce|e. Us|n he |nr|ous as a reerence
po|n, he c|ass||eo he sever||es o va|na| suppor|n oeec rom
|rs o h|ro oeree |nc|uo|n: recoce|e, cysoce|e, uer|ne pro|apse,
eneroce|e ano pro|apse o he va|na| apex (F|. 1).
The above wo sysems oe|ne he suppor|n or suspens|on ana-
om|ca| oeecs as a s|e- spec||c. The pa|en |s eva|uaeo our|n
max|ma| sra|n|n by us|n a b|o||a| mehoo or |nser|n he specu-
|um or enacu|um |no he va|na. However, hese wo sysems were
no va||oaeo. Mos c||n|ca| prac||oners ee| rusraeo us|n hese non-
sanoaro|zeo |nva||oaeo sysems or commun|ca|on [10|. Thereore,
he Sanoaro|za|on Sub-comm|ee o he CS co||aboraeo w|h he
Amer|can Uroyneco|o|c Soc|ey (AUGS) ano Soc|ey o Gyneco|o|c
Sureons (SGS) o propose a va||oaeo quan|a|ve POP (POP-Q) sys-
em |n 1996 [16|. The new sysem |s easy o reproouce beween ano
w|h|n exam|ners [18,19|.
CURRENT POP GRADING SYSTEM IN USE
The POP-Q sysem shows ha he c||n|ca| oescr|p|on o pe|v|c
|oor anaomy shou|o be oeerm|neo our|n phys|ca| exam|na|on o
he exerna| en|a| ano va|na| cana|. n oroer o avo|o he m|sunoer-
sano|n o pr|or erms, wh|ch may |mp|y an unrea||s|c cera|ny as o
he srucures on he oher s|oe o he va|na| bu|e, he POP-Q sys-
em uses semens o he |ower reproouc|ve rac o rep|ace pr|or
erms o he above wo sysems such as cysoce|e, recoce|e,
eneroce|e, or urehrovas|ca| junc|on. The POP-Q sysem emphas|zes
ha cr|er|a or he eno po|n o he exam|na|on ano he u|| oeve|op-
men o he pro|apse shou|o be spec||eo. The cr|er|a or |no|ca|n a
max|mum pro|apse shou|o |nc|uoe one or a|| o he o||ow|n: (1) any
proruo|n o he va|na| wa|| has become |h our|n sra|n|n by he
pa|en, (2) rac|on on he pro|apse causes no urher oescen, (3) he
s|ze o he pro|apse ano he exen o he prorus|on seen by he exam-
|ner are as exens|ve as he mos severe prorus|on ha she has ever
w|nesseo, ano/or (4) a sano|n, sra|n|n exam|na|on con|rms ha
he u|| exen o he pro|apse was observeo |n oher pos||ons useo
[16|. The oeree o pe|v|c oran pro|apse can be assesseo aoequae|y
|n he oorsa| ||hoomy pos||on w|h he pa|en perorm|n max|ma|
Va|sa|va. |s no necessary o rou|ne|y repea he exam|na|on |n he
sano|n pos||on [17|. |ne measuremens o he oe|neo po|ns |n-
c|uo|n wo aner|or|y, wo poser|or|y, wo exerna||y, wo ap|ca||y, ano
he oa| va|na| |enh shou|o be recoroeo our|n pe|v|c exam|na|on.
A r||o measur|n oev|ce such as ru|er may be useo or assess|n he
|enh o he prorus|on. A conven|en hree-by hree r|o |s sueseo
or recoro|n he n|ne po|ns (F|. 2). The oe|neo po|ns ha are meas-
ureo |n he POP-Q exam|na|on ano he sa|n sysem o he POP-Q
are summar|zeo |n Tab|e . ano F|ure . oea||y, he POP-q sysem |s
a anoem pro||e |n ha | w||| cona|n a ser|es o componen measure-
mens roupeo oeher |n comb|na|on, bu ||seo separae|y |n anoem,
w|hou be|n useo |no a o|s|nc|ve new express|on or raoe [16|.
SIMPLIFIED POP CLASSIFICATION SYSTEM IN THE FUTURE
n||a||y, he POP-Q sysem was cons|oereo o be eas||y |earneo
ano rap|o|y perormeo [8|. There are severa| expeceo poen|a| bene-
|s o he POP-Q sysem be|n useo wor|ow|oe. F|rs, h|s sysem a|-
|ows or he prec|se oescr|p|on o an |no|v|oua| women's pe|v|c sup-
por w|hou ass|n|n a sever|y va|ue. Secono, | a||ows accurae s|e-
spec||c observa|ons o he sab|||y or proress|on o pro|apse over
|me by he same or o|eren observers. Th|ro, | a||ows s|m||ar juo-
mens rearo|n he oucome o sur|ca| repa|r o pro|apse [16|.
However, a chasm ex|ss beween exper percep|ons ano a c||n|ca|
prac|ca| use. seems o be oo comp||caeo or pr|mary care prov|o-
ers o use h|s sysem |n oa||y prac|ce.
A new s|mp|||eo POP c|ass||ca|on sysem, | was |n||aeo |n he
annua| mee|n o UGA |n Me|bourne, was proposeo by UGA a he
eno o 2006 [20|. n he new sysem, on|y our va|na| semens are
Vaginal profile (Baden & Walker, 1972) Grading system (Beecham, 1980) Quantitative POP (ICS, AUGS, SGS; 1996) Simplified POP (IUGA 2006)

Grade 1
Midplane of vagina Stage I Stage I
1
st
degree
Grade 2
1 cm above hymen 1 cm above hymen
Hymenal ring
Introitus Stage II Stage II

Grade 3 1 cm through hymen 1 cm through hymen
2
nd
degree
Stage III Stage III

Grade 4 3
rd
degree Stage IV Stage IV
Simplified POP system proposed by the IUGA has yet to be validated.
ICS: International Continence Society; AUGS: American Urogynecologic Society; SGS: Society of Gynecologic Surgeons
Fig. 1. Comparison of the three most commonly used pelvic organ prolapse (POP) grading system and a new simplified POP classification system proposed by
Standardization & Terminology and Research & Development Committees of the International Urogynecology Association (IUGA) in 2006.
NOP
Review
Table 1. The Staging System of Quantitative Pelvic Organ Prolapse (POP-Q) System
Stage Descriptions
0 No prolapse is demonstrated during maximal straining
I The most distal portion (leading surface) of the prolapse is > 1 cm above the level of the hymen ( < - 1 cm)
II The most distal portion (leading edge)of the prolapse is 1 cm proximal to or extends 1 cm through the plane of hymen ( - 1 cm, but + 1 cm)
III The most distal portion of the prolapse is > 1 cm below hymen but no further than 2 cm less than the TVL (there is not complete vaginal eversion).
( > +1 cm, but < + [ TVL-2] cm)
IV Complete eversion of the vagina ( + [TVL -2] cm )
TVL Total vaginal length; Negative number: centimeters above or proximal to the hymen; Positive number: centimeters below or distal to the hymen
Fig. 2. The convenient scheme using a three-by three grid is better for recording the nine points [10]. (Modified from Am J Obstet Gynecol 1996; 175: 10-17. Fig. 1
and 2)
A point on the anterior vaginal wall, 3 cm proximal The most dependent point of the upper anterior Most distal edge of cervix or the leading edge
to the external urethral meatus vaginal wall; from vaginal fornix to Point Aa of vaginal cuff
Aa Ba C
A point at posterior vaginal wall, 3 cm proximal to The most dependent point of the upper posterior A point represent the location of the posterior fornix
the hymen vaginal wall; from vaginal fornix to point Ap
Ap Bp D
Middle of the external urethral meatus to the Posterior margin of the genital hiatus to the midanal The greatest depth of the vagina
posterior midline hymen opening
gh pb tvl
reerreo o be eva|uaeo: he aner|or va|na| wa||, he apex or pose-
r|or orn|x, he cerv|x (| presen), ano poser|or va|na| wa||. The sa-
|n sysem or each semen |s s|m||ar o ha o POP-Q o 1996 bu no
measur|n oev|ces w||| be requ|reo or quan|a|ve|y measur|n he
pro|apse semens. The s|mp|||eo POP-Q po|ns or each semen |n
conras o ha o he sanoaro POP-Q sysem are as o||ow: (1) The
aner|or va|na| semen |s saeo us|n po|n Ba, (2) The poser|or
va|na| semen |s saeo us|n po|n Bp, (3) The cerv|x |s saeo
us|n po|n C, ano (4) The apex/poser|or orn|x |s saeo by us|n
po|n C |n he non-hyserecom|zeo pa|en ano po|n D |n he hyserec-
om|zeo pa|en.
Th|s new sysem has been va||oaeo by an |ner-sysem assoc|a-
|on ano an |ner-exam|ner areemen |n a sma|| sca|e suoy by Sw| e
a| |n 2006. For he |ner-exam|ner re||ab|||y o he POP-Q exam|na|on,
he kappa sa|s|cs or he |ner-exam|ner re||ab|||y o he s|mp|||eo
POP-Q c|ass||ca|on sysem were 0.86 or he overa|| sae, 0.89 ano
0.86 or he aner|or ano poser|or va|na| wa||s, respec|ve|y, 0.82 or
he apex/cu, ano 0.72 or he cerv|x. A|| oemonsrae a s|n||can
areemen amon he |ner-exam|ners. For he |ner-sysem assoc|a-
|on beween he s|mp|||eo POP-Q ano sanoaro POP-Q, he Kenoa||'s
au-b va|ue or overa|| sae was 0.90, 0.83, 0.87 or he aner|or ano
poser|or va|na| wa||s respec|ve|y, ano 0.78 or he cu/apex, ano 0.
98 or he cerv|x. There |s ooo |ner-exam|ner areemen o he s|m-
p|||eo POP-Q c|ass||ca|on sysem ano | a|so appears o have ooo
|ner-sysem assoc|a|on w|h he sanoaro POP-Q [21|.
Beore h|s new sysem |s recommenoeo, a |are sca|e suoy neeos
o be conouceo o be va||oaeo by an |ner-sysem assoc|a|on ano an
|ner-exam|ner areemen. n oroer o e w|oespreao accepance ano
use by prac|c|n c||n|c|ans, | shou|o unoero urher es|n o oeer-
m|ne |s ease o use, corre|a|on w|h sanoaro POP-Q. Pearo|n
erm|no|oy, he s|mp|||eo POP-Q useo boh he oescr|p|ve erm|no|-
oy o aner|or, poser|or ano ap|ca| semens as we|| as he anaom|c
erm|no|oy |nc|uo|n cysoce|e, recoce|e, eneroce|e, ano cerv|x.
`lk`irpflk
POP |s a|so ca||eo uerova|na| pro|apse or uroen|a| pro|apse.
Severa| curren rao|n sysems are s||| |n use. Th|s means ha a
wor|ow|oe consensus has no ye been reacheo or accepeo or oa||y
prac|ca| use. The |oea| rao|n sysem seems no on|y o prov|oe
quan|a|ve oaa or compar|son bu a|so neeos o prov|oe sympo-
ma|c |norma|on or corre|a|on.
D
Ap
gh
C
Bp
pb
Ba
Aa
t
v
l
NOQ
Review
obcbobk`bp
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