376 Obstetrics and Gynecology Board Review •••
❍ When describing the stage of pelvic organ prolapse, what is actually being described?
The leading edge of prolapse in relation to the hymenal ring.
❍ What is the benefit of describing prolapse using the POPQ system versus only describing the stage of
prolapse or using the Baden Walker Halfway score?
The POPQ system is a validated reproducible tool that quantifies measurements and is generally utilized for research
purposes. It also outlines the degree of prolapse in anterior, apical and posterior compartments of the vagina.
❍ What four compartments does the POPQ system measure?
Anterior, apical, posterior and cul-de-sac support areas.
❍ What are the measurements of the POPQ system?
All measurements are in reference to the hymen level. Measurements above the hymen are recorded as negative
numbers, while measurements beyond the hymen are designated at positive values.
Measurements are of the following:
- Point Aa: Midline anterior wall, 3 cm proximal to urethral meatus.
- Point Ba: Most proximal part of anterior vaginal wall, anterior fornix.
- Point Ap: Midline of posterior vaginal wall.
- Point Bp: Furthest and the most dependent in the posterior vaginal wall.
- Point C: Anterior cervix, most dependent in anterior wall.
- Point D: Deepest point in the posterior fornix (uterosacral ligament level).
- TVL: Total vaginal length is the distance from hymen the point D (without prolapse).
- Genital hiatus (gh): distance from mid-urethra to posterior hymen.
- Perineal body (pb): distance from posterior hymen to mid anus.
❍ What are the risk factors for pelvic organ prolapse?
Caucasian race, older age, obesity, vaginal delivery, family history, smoking, and hysterectomy.
❍ What structures are most important in prevention of posthysterectomy enterocele formation?
Uterosacral-cardinal ligament complex and rectovaginal fascia.
❍ The contents of an enterocele may include omentum but always include what structure?
Small intestine.
❍ What is the classification of the leading edge of prolapse at the introitus or hymen for the Baden Walker and
POP-Q System?
Grade 2 or Stage II.
❍ Although ulcers of the vagina associated with complete prolapse are rarely malignant, they should be
biopsied. What is the most common cause?
Stasis and abrasion with garments. Vaginal atrophy found in post menopausal women also likely plays a role.
❍ What are conservative therapies for POP?
Pessaries and Kegel exercises.