Pop q (new)

this presentation explains the POP-Q system in addition to other tests used in patients with POP

1. !
TESTING!THE!WOMEN!WITH!POP!
(POP.Q!and!Other!tests)!
Osama!M!Warda!MD!
Professor'of'OBS/GYN''
Mansoura'University8Egypt'

2. Contents''
• POP8Q'system'
• Ultrasound'('2D,'3D)'
• Cystoscopy'
• MRI,'dynamic'MRI''
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3. IntroducKon''
Pelvic'Organ'Prolapse'Quan2fica2on'(POP5Q):'
First'published'In'1996,'an'arKcle'by'Bump'et'al*''
presents'a'standard'system'of'terminology''
approved'later'by'the'InternaKonal'ConKnence'
Society'(ICS),'the'American'Uro8gynecologic'
Society'(AUGS),'and'the'Society'of'Gynecologic'
Surgeons'(SGS)!for'the'descripKon'of'female'
pelvic'organ'prolapse'and'pelvic'floor'dysfuncKon.''
88888888888888888888888'
Bump!RC,!MaCasson!A,!Bø!K,!Brubaker!LP,!DeLancey!JO,!Klarskov!P!,!Shull!BL,!Smith!AR.!Am!
J!Obstet!Gynecol.!1996!Jul,175(1):10.7.,!Duke!University!Medical!Center,!Durham,!NC!27710,!
USA.!!
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4. IntroducKon''
• In'an'effort'to'create'an'encoding'tool'
useful'to'both'the'clinician'and'
researcher,'the'StandardizaKon'
SubcommiYee'of'the'ICS'created'the'
Pelvic'Organ'Prolapse'QuanKficaKon'
(POP8'Q)'system'in'2002'.'
88888888888888888888888888''
Abrams!et!al!(!2002)!
!!
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5. ObjecKves''of''POP8Q''
• QuanKficaKon'of'prolapse'
• Compare'outcome'of'surgical'repair'
• Inter8individual'reliability''
• Standards'in'wriYen'publicaKon'and'scienKfic'
presentaKons''
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6. How'POP8Q'system'works?'
• The'hymen'acts'as'the'fixed'point'of'reference'
throughout'the'POPQ'system.''
• There'are'six'defined'points'for'measurement'in'
the'POPQ'system'
'''''''''''''''''''''8'Anterior:'Aa,'Ba,'C,''
''''''''''''''''''''''8Posterior:'Ap,'Bp,'D''
• 'Three'others'landmarks:'GH,'TVL,'PB.'Each'is'
measured'in'cenKmeters'above'or'proximal'to'
the'hymen'(negaKve'number)'or'cenKmeters'
below'or'distal'to'the'hymen'(posiKve'number)'
with'the'plane'of'the'hymen'being'defined'as'
zero'(0).''
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7. How'POP8Q'system'works?'
• 'The'hymen'was'selected'as'the'reference'
point'rather'the'introitus'because'it'is'more'
precisely'idenKfied.''
• The'terminology'avoids'assigning'a'specific'
label,'such'as'cystocele'or'rectocele,'to'the'
prolapsing'part'of'the'vagina,'acknowledging'
that'the'actual'organ(s)'above'the'prolapse'
cannot'be'frequently'determined'by'a'physical'
examinaKon.''
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8. Points!and!landmarks!for!POP.Q!system!examina[on.!Aa,'point'A'anterior,'Ap,'point'A'
posterior,'Ba,!point'B'anterior;'Bp,'point'B'posterior;'C,!cervix'or'vaginal'cuff;'D,'posterior'
fornix'(if'cervix'is'present);'gh,'genital'hiatus;'pb,'perineal'body;'tvl,'total'vaginal'length.''
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9. Point'8'A'
• Anatomical'defined'(fixed)''
! Aa='midline'of'anterior,'3'cm'proximal'to'external'
urethral'meatus,'approximate*loca-on*of*urethro2
vesical*junc-on''
! 'Ap='middle'of'the'posterior'wall,'3cm'proximal'to'
the'hymen'
• 'Range'of'posiKon'='83'cm'to'+3cm''
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'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
'''''''''''''''''''''''''''''''''''''''''''''''''''''''
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10. Point'B'
• Points'Ba'and'Bp'are'defined'as'the*lowest*
points*of*the*prolapse*between*Aa*anteriorly*
or*Ap*posteriorly*and*the*vaginal*apex.'
• 'Anteriorly,'the'apex'is'point'C'(cervix),'and'
posteriorly'is'point'D'(pouch'of'Douglas).''
In'women'amer'hysterectomy,''
point'C'is'the'vaginal'cuff''
and'point'D'is'omiYed.''
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11. Urethro8vesical'juncKon'(Aa)'
Which'porKon'of'vaginal'wall'is'most'distal'(Ba)'
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12. C=cervix','cuff'
• Most'distal'edge'of'the'cervix'or;''
• Leading'edge'of'the'vaginal'cuff'
(hysterectomy'scar)'
c'
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13. D'='Douglas'
• Posterior'fornix'or'Pouch'of'Douglas''
• Represents'the'level'of'utero2sacral*ligament*
aYachment'to'the'posterior'cervix''
• (Diff.:'Suspensory'failure/cervix'elongaKon)''
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No'cervix'='no''‘D’'
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14. Three'measurements'
• Three*other*measurements*are*taken:''
8the'vaginal*length*(tvl)'at'rest,''
8 the'genital*hiatus*(gh)'from'the'middle'of'
the'urethral'meatus'to'the'posterior'
hymenal'ring,'and''
8 the'perineal*body*(pb)'from'the'posterior'
aspect'of'the'genital'hiatus'to'the'mid8
anal'opening.''
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15. gh='genital'hiatus'
• Middle'of'external'urethral'meatus'to'the'
posterior'hymen''
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16. pb=!perineal!body!
• Posterior'margin'of'genital'hiatus'to'mid8anal'
opening.''
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17. tvl='total'vaginal'length'
• Greatest'depth'of'the'vagina'in'cenKmeters.'
• 'C'and'D'in'normal'posiKon.''
• Measurement'without'straining''
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18. Stages!of!pelvic!organ!prolapse!
• Once'the'measurements'are'taken,'the'paKents'are'assigned'to'the'
corresponding'stage:'!
• Stage!0''='no'prolapse.'
• 'stage!I'='most'distal'porKon'of'prolapse'is''>'1cm'above'level'of'
hymen''
• Stage!II='the'most'distal'part'of'prolapse'is'<1cm'proximal'to'or'distal'
to'the'plane'of'hymen'
• Stage!III=the'most'distal'porKon'of'the'prolapse'protrudes'more'than'
1'cm'below'the'hymen'but'no'farther'than'2'cm'less'than'the'total'
vaginal'length'(for'example,'not'all'of'the'vagina'has'prolapsed).''
• Stage!IV=complete'vaginal''eversion'is'essenKal.'
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19. Stage'III'Bp'prolapse'19'
"'Hymenal'ring'
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20. 20'Osama''Warda'

21. Evalua[ng!the!POP.Q!system!
• Excellent!inter.observer!and!intra.
observer!reliability!has!been!shown!
[Hall'et'al.,'1996.]'
• It!has!been!used!for!longitudinal!follow.
up!in!!women!with!prolapse!!and!
extensively!for!outcome!repor[ng!a`er!
prolapse!repair!since!1996![Bland'et'al.,'
1999'and'Muir'et'al.,'2003.]''
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22. Evalua[ng!the!POP.Q!system'
• The!system!is!more!difficult!to!learn!than!the!
tradi[onal!staging,!and!overall!adop[on!by!
specialists!is!of!about!40%![Auwad'et'al.,'2004].'
• 'Pa[ent!posi[on!also!affects!reproducibility.!The!
measurements!are!taken!with!the!pa[ent!in!the!
dorsal!lithotomy!posi[on,!and!the!degree!of!prolapse!
is!assessed!with!pa[ent!straining.!Prolapse!may!be!
more!severe!with!the!table!raised!at!the!head!to!a!45.!
degree!angle![Barber'et'al.,'2000]'
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23. Evalua[ng!the!POP.Q!system'
• The!system!also!does'not'iden2fy'unilateral'or'
asymmetrical'defects.!In!2006,!this!system!was!only!
used!clinically!by!about!40%!of!members!of!ICS!and!
AUGS.!There!has!also!been!a!developing!of!a'POP5'Q'
simplified'system!based!on!POP.Q!with!similar!
ordinal!staging!but!with!only!four!points!measured!
instead!of!nine!(Aa,!Ba,!C,!D).!Evalua[on!of!the!
inter.observer!reproducibility!and!intersystem!
reliability!(in!comparison!with!the!standard!POP.Q!
system)!showed!good!correla[on''
[Steven'Swim,'Sarah'Morris'et'al'2006].''
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24. Addi[onal!tes[ng!for!!
women!with!POP'
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25. Addi[onal!tes[ng!for!!
women!with!POP!
• The'iniKal'evaluaKon'of'urinary'inconKnence'in'women'
includes'history*tacking,*physical*examina-on,*urinalysis,*
and*measurement*of*post2void*residual*urine*[Abrams'et'al.,'
2005.a]''
• The'basic'evaluaKon'may'be'saKsfactory'for'the'proceeding'
with'treatment,'including'surgery,'for'paKents'with'
straigh?orward*stress*incon-nence*associated*with*
urethral*hypermobility*with*normal*post2void*residual*
volume'['Fantl'et'al'1996]'
• 'However,'the'InternaKonal'ScienKfic'CommiYee'of'the'Third'
InternaKonal'ConsultaKon'on'Urinary'InconKnence'advised'that,'for*
women*who*desire*interven-onal*treatment,*urodynamic*tes-ng*is*
highly*recommended*[Abrams'et'al.,'2005.b]''
• ''
25'
URINARY!!
INCONTINENCE!
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26. Addi[onal!tes[ng!for!!
women!with!POP'
• The'role'of'rouKne'cystoscopy'in'the'evaluaKon'of'
inconKnence'is'controversial.''
• Cystoscopy'has'also'been'reported'to'aid'in'the'
preoperaKve'and'intraoperaKve'differenKaKon'of'the'
type'of'organ'prolapse'in'paKents'with'high8grade'
prolapse'or'mulKple'prolapsing'organs'.''
• It'is'done'simply'by'idenKfying'the'light*transmi@ed*
through*the*bladder*wall.**
• IntraoperaKve'cystoscopy'is'also'necessary'to'assess'for'
bladder'or'urethral'perforaKon'or'ureteric'obstrucKon'
during'various'pelvic'procedures'[Vasavada!et!al.,!1999]'
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CYSTOSCOPY!
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27. Addi[onal!tes[ng!for!!
women!with!POP'
• Ultrasound'imaging'of'the'bladder'and'urethra'
can'be'done'by'the'trans2abdominal,*trans2
perineal,*trans2labial,*trans2vaginal,*or*trans2
rectal*route.**
• The'advantage'of'ultrasound'is'the'ability'to'do'
real8Kme'scanning'without'radiaKon'exposure,'
but'the'major'disadvantages'are'the*variability*
introduced*by*the*examiner*with*small*changes*in*
the*transducer*posi-on*and*the*availability*of*
only*a*limited*number*of*pictures*aBer*the*
examina-on.**
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ULTRASOUND!
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28. Addi[onal!tes[ng!for!!
women!with!POP'
• Two2dimensional*trans2labial*scanning*is'now'a'
standard'technique'and'has'been'reported'to'assess:'
''''18'the'posiKon'and'mobility'of'the'bladder'neck'and''''
proximal'urethra,''
''''2'8stress'inconKnence,''
''''3'8bladder'wall'thickness'(with'TVS'as'well),''
''''4'8levator'ani'acKvity'(with'perineal'scanning),'and'
''''5'8'prolapse'quanKficaKon.''
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(Dietz!HP!,!2004)'
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ULTRASOUND!
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29. Addi[onal!tes[ng!for!!
women!with!POP'
• '32D*ultrasound*has'been'used'to'image'the:''
'''''''''''''18'urethra,''
'''''''''''''28'levator'ani'complex,''
''''''''''''''38paravaginal'supports,'''''
''''''''''''''48prolapse,''
''''''''''''''58syntheKc'implant'materials'
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(!Dietz!HP.!2004)''
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ULTRASOUND!
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30. Addi[onal!tes[ng!for!!
women!with!POP'
• Ultrasound'is'not'recommended'in'
the'primary'evaluaKon'of'women'
with'inconKnence'and'prolapse'and'
is'an'opKonal'test'for'complex'
problems.'''
!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(!Tubaro!et!al.,2005)''
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ULTRASOUND!
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31. Addi[onal!tes[ng!for!!
women!with!POP'
• MRI'may'be'helpful'in'paKents'with'complex'
organ'prolapse'to'supplement'the'physical'
examinaKon.!(Tubaro!et!al.,!2005)''
• Dynamic!MRI!of'the'pelvic'floor'is'an'excellent'
tool'for'assessing'funcKonal'disorders'of'the'
pelvic'floor,'including'organ'prolapse'and'
inconKnence.'It'is'also'useful'in'assessing'the'
results*of*surgery*for'pelvic'organ'prolapse,'even'
when'the'paKent'has'no'clinical'symptoms.''
'''''''''''''''''''''''''''''''''''''(Novellas'et'al.'2009)'
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MRI!
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32. '
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Thanks''
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