Classification of Pelvic Organ Prolapse

A standardized description and classification of pelvic organ prolapse is critical for accurate planning of treatment, improving physician communication, and advancing research. Two systems are currently accepted, the Baden-Walker Halfway system and the Pelvic Organ Prolapse Quantification (POP-Q) system. The Baden-Walker system has good interobserver validity and is simpler and more commonly understood.4 In this classification system,

Figure 3-1.2. Prolapse evaluation with speculum.

prolapse of each vaginal compartment (cystocele, entero-cele, rectocele, uterus, and vaginal vault) is isolated and the most dependent position during maximum straining is recorded. Each compartment is recorded in accordance to its relationship with the hymen and the mid-vaginal plane (Figure 3-1.4).

The POP-Q system is the currently established International Continence Society standard for description of female pelvic organ prolapse.5 In this system, six points are used to make site-specific measurements during maximal straining (Figure 3-1.5). This replaces previously used descriptive terms such as cystocele, rectocele, and entero-cele. The location of the points is recorded in centimeters above (negative numbers) or below (positive numbers) the hymen. The points are defined as follows:

Anterior vagina

Point Aa: anterior midline vaginal wall 3 cm proximal to the external urethral meatus (range, -3 to +3cm).

Point Ba: the most dependent position of the anterior vagina up to and including the anterior vaginal fornix or vaginal cuff. Posterior vagina

Point Ap: posterior midline vaginal wall 3 cm proximal to the hymen (range, -3 to +3 cm).

Point Bp: the most dependent position of any part of the posterior vagina up to and including the posterior vaginal fornix or the vaginal cuff. Apical vagina

Point C: most dependent edge of the cervix or vaginal cuff after total hysterectomy.

Point D: apex of the posterior fornix in a woman who has a cervix or the level of attachment of the uterosacral ligaments to the posterior cervix. It is useful to differentiate between loss of apical vaginal and uterine support and cervical hypertrophy. This point is not used in a woman who has had a hysterectomy.

Figure 3-1.3. a, Anterior vaginal compartment evaluation. b, Posterior vaginal compartment evaluation.

Figure 3-1.4. Cystocele BadenWalker vaginal profile. (Reprinted with the permission of The Cleveland Clinic Figure 3-1.5. POP-Q Scoring System. (Reprinted with the permission of The Cleveland Clinic Foundation.) Foundation.)

Figure 3-1.4. Cystocele BadenWalker vaginal profile. (Reprinted with the permission of The Cleveland Clinic Figure 3-1.5. POP-Q Scoring System. (Reprinted with the permission of The Cleveland Clinic Foundation.) Foundation.)

Additional measurements include the genital hiatus (GH), measured from the urethral meatus to the posterior hymen in the midline, the perineal body (PB), measured from the midline posterior hymen to the midanus, and the total vaginal length (TVL), recorded as the maximum vaginal length from the hymen. Measurements are organized as a 3 x 3 grid and/or a vaginal profile diagram.

The overall POP-Q stage is determined according to the most dependent portion of the prolapse, ranging from stage 0 (no prolapse) to stage IV (complete eversion).

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