3.1: 3.1：Physical Examination and the POP-Q

All women presenting with pelvic floor dysfunction should be thoroughly examined in the supine, left lateral and standing positions. Where a surgical intervention is planned, the responsible surgeon should determine exactly what may be required at operation – so that the appropriate consent can be obtained and the correct intervention planned.

General

The women’s mobility and general condition should be noted.

Neurological examination

The spinal segments S2,3.4 should be assessed by testing the tone, strength and sensation in the lower limbs. The anal sphincter tone should be tested.

Gynaecological Examination

It is impossible to perform an adequate urogynaecological examination without using a Sims speculum and in some circumstances two Sim’s speculae are required. The examination begins with the woman in the dorsal position. The vulva and vagina are inspected for any lesions, atrophy or excoriation. The woman is then asked to cough or valsalva while the clinician observes for any stress incontinence. She is then asked to turn onto her left side and the Sims speculum is used to inspect the anterior and posterior vaginal walls for prolapse. It is imperative that the middle compartment is also adequately assessed for any uterine or vaginal vault descent. This can be difficult, but if one uses two Sims speculae placed anteriorly and posteriorly, while the women strains down, it is relatively easy to assess this compartment. The prolapse should be graded using either the Baden- Walker or POP-Q systems (see below). If the women’s symptoms are not adequately explained by the findings at examination, it may be useful to perform an additional assessment with her standing. This is accomplished by asking her to stand with her legs apart while the examiner bends in front of the patient and gently palpates the anterior, middle and posterior compartments. She is then asked to cough again in the standing position.

Classification and grading of prolapse

Grading and classification of pelvic organ prolapse enables clinicians to communicate with each other and is also useful in a research setting. The most commonly used grading system is the BadenWalker halfway system which grades prolapse as follows:

Grade I: Descent halfway to the introitis

Grade 2: Descent down to the vaginal introitis

Grade 3: Descent beyond the introitis but not maximal

Grade 4: Maximal descent

This grading system is useful in day to day clinical practice but it has a number of shortcomings. It does not give a quantitative impression of the severity of the prolapse. It does not address the vaginal length, perineal body size or the length of the urogenital hiatus. The POP-Q (Pelvic Organ Prolapse Quantification System) was developed by the International Continence Society to address these issues and it supercedes the previous systems used to describe POP. The new objective assessment allows a clear and unambiguous description of prolapse, facilitating better objective assessment, management and surgical comparison. Precise staging made gynaecological oncology an objective progressive disciple, and it is hoped that introduction of POP – Q will allow similar advances in the management of prolapse. Terms used in the past such as for example small, medium or large, cystocoele or rectcoele, are no longer applicable. At first glance, the system appears complicated and difficult to master but once it is understood, it can be performed in less than 30 seconds while performing a routine gynaecological examination. It is based on measurements that are taken using the introitis as reference. Any measurement above this is negative and anything below this is positive. The measurements are taken using a marked Pap smear spatula. Six specific vaginal sites (points Aa, Ba, C, D, Bp and Ap) and the vaginal length (tvl) are assessed using centimeters of measurement from the introitus. The length of the genital hiatus (gh) and perineal body (pb) are measured.

The points are defined as follows, with the ranges as suggested in the following table.

All measurements are made to the nearest 0.5cm.

Table \(\PageIndex{3.1.1}\): POP - Q DEFINITION AND RANGES

Point	Measurement	Range
Aa	Anterior vaginal wall 3cm proximal to the hymen	-3 to +3
Ba	Leading – most point of anterior vaginal wall prolapse	-3 to +tvl
C	Most distal edge of cervix or vaginal cuff (if cervix is absent)	-/+ tvl
D	Most distal portion of the posterior fornix	-/+ tvl
Ap	Posterior vaginal wall 3cm proximal to the hymen	-3 to +3
Bp	Leading – most point of posterior vaginal wall prolapse	-3 to +tvl
gh	Perpendicular distance from mid – urethral meatus to posterior hymen	No limit
pb	Perpendicular distance from mid – anal opening to posterior hymen	No limit
tvl	Posterior fornix or vaginal cuff (if cervix is absent) to the hymen	No limit

Consensus and validation of the new system has been extensive. The clinical examination is performed and the measurements recorded on the “POPQ grid”. (Table 2)

Table \(\PageIndex{3.1.2}\): The POPQ Grid – Used to Record Examination Results

anterior wall Aa	anterior wall Ba	anterior wall C
genital hiatus gh	perineal body pb	total vaginal length tvl
posterior wall Ap	posterior wall Bp	posterior fornix D*

*Measurement D is not taken in the absence of a cervix

The measurement of prolapse is performed in accordance with certain measurement fundamentals. (Table 3)

Table \(\PageIndex{3.1.3}\): POPQ Measurement Fundamentals

All measurements are made to the nearest 0.5cm

All measurements are made relative to the hymen

Points proximal to the hymen are negative (inside the body)

Points distal to the hymen are positive (outside the body)

The hymen is assigned a value zero

gh, pb, and tvl measurements will always have a positive value

All measurements, except for tvl, are made while patient is bearing down

Both the patient’s position during the examination (lithotomy, birthing chair, or standing) and the state of her bladder and rectum (full or empty) should be noted

Staging of the grade of pelvic support is objectively done on a five – stage system. (Table 4)

Table \(\PageIndex{3.1.4}\): The five stages of Pelvic Organ Support

Stage 0:	No descent of any compartments
Stage 1:	Descent of the most prolapsed compartment between perfect support and – 1cm, or 1cm proximal to the hymen
Stage 2:	Descent of the most prolapsed compartment between -1cm and +1cm.
Stage 3:	Descent of the most prolapsed compartment between +1cm and (tvl -2cm)
Stage 4:	Descent of the most prolapsed compartment from (tvl -2cm) to complete prolapse

Explanation of individual points

Points Aa, Ab, Pa and Pb are the most difficult to understand. They represent the extent of prolapse, be it above the introitis ( ie negative) or below the introitis ( ie positive)

Point Aa

If an imaginary small man walked from the introitis up the anterior vaginal wall and made a mark once he had covered 3 cm this would be point Aa. The distance this point descends on the vertical plane can therefore be either -3, -2, -1 if it is above the introitis, 0 at the introitis and +1,+ 2 or +3 below the introitis. This point is therefore never more than 3 and represents the bottom 3cm of the vagina.

Point Ba

This point describes additional prolapse of the anterior vaginal wall that goes beyond the first 3 cm. It is the most distal part of the prolapse. It can therefore be greater than the +3 described for point Aa. For the milder prolapse, it often equates to that of Aa. Because it essentially defines more extensive prolapse, when there is no prolapse, by convention we make it the same as Aa.

Point Ap

Again our imaginary man makes the 3cm trip up the posterior wall where he marks off point Ap. The distance this point descends can again be therefore either -3, -2, -1 if it is above the introitis, 0 at the introitis and +1,+ 2 or +3 below the introitis.

Point Bp

Again, this point describes more extensive prolapse beyond the 3 cm mark of Ap similar to Ba. Again if there is no prolapse, by convention it is -3.

Point C

This describes the prolapse of the cervix or vaginal vault. If the cervix, for example, is 7cm above the

introitis, this point is then -7, if it is 4 cm below C is +4.

Point D

This describes the descent of the posterior fornix again similar to the cervix.

Total vaginal Length

This is the measurement of the length of the vaginal tube from top to bottom. It is usually measured with the marked spatula inserted to its maximum into the vagina.

Urogenital hiatus

The measuring spatula is placed anteroposteriorly along the introitis and measures from the urethral meatus to the midline of the posterior hymen.

Perineal body

Again the perineum is measured from the posterior hymen to the anus in the midline.