POP: Introduction - What's Dropping?
- Pelvic Organ Prolapse (POP): Descent of one or more pelvic organs (bladder, uterus, bowel) into or beyond the vaginal canal.
- Key Terminology by Compartment:
- Anterior Wall: Cystocele (bladder), Urethrocele (urethra).
- Apical Compartment: Uterine prolapse, Vaginal vault prolapse (post-hysterectomy).
- Posterior Wall: Rectocele (rectum), Enterocele (small bowel).
- Symptoms can include vaginal bulge, pelvic pressure, and urinary, bowel, or sexual dysfunction.
⭐ The anterior vaginal wall, leading to cystocele, is the most frequently affected compartment in POP.
POP-Q System - Measuring the Sag
The Pelvic Organ Prolapse Quantification (POP-Q) system is a standardized, objective method to describe and stage POP. Measurements are in centimeters (cm) relative to the hymen (0cm).
- Proximal to hymen: negative values (-cm)
- Distal to hymen: positive values (+cm)
- Measurements taken at maximal Valsalva.
Nine Reference Points: (Hymen = 0cm)
- Aa: Anterior wall, 3cm from hymen (normally -3cm).
- Ba: Most distal anterior vaginal point.
- C: Cervix / vaginal Cuff.
- D: Posterior fornix (if cervix present).
- Ap: Posterior wall, 3cm from hymen (normally -3cm).
- Bp: Most distal posterior vaginal point.
- GH: Genital Hiatus (urethra to posterior hymen midline).
- PB: Perineal Body (posterior hymen midline to anal opening).
- TVL: Total Vaginal Length (greatest depth of vagina when C or D is reduced). 📌 Remember the 6 key vaginal points (Aa, Ba, C, D, Ap, Bp) and 3 external/length points (GH, PB, TVL).
POP-Q Staging (0-IV): Based on the most distal extent of prolapse.
- Stage 0: No prolapse. Aa, Ba, Ap, Bp are all -3cm. C or D is between -TVL and -(TVL-2)cm.
- Stage I: Most distal prolapse is >-1cm but ≤+1cm from hymen.
- Stage II: Most distal prolapse is >+1cm but < (TVL-2)cm.
⭐ The most common site for prolapse is the anterior vaginal wall (cystocele).
- Stage III: Most distal prolapse is ≥(TVL-2)cm but < TVL.
- Stage IV: Complete eversion. Most distal prolapse is ≥(TVL-2)cm (often ≈TVL).
Staging Flowchart:
Other POP Classifications - Grading Games
| Feature | Baden-Walker System | POP-Q System (Contrast) |
|---|---|---|
| Description | Simpler system. Grades 0 (normal) to 4 (procidentia) based on descent relative to hymen. | Gold standard; objective 9-point measures. |
| B-W Stages | 0: Normal; 1: Halfway to hymen; 2: To hymen; 3: Halfway past hymen; 4: Complete prolapse. | Uses Stages 0-IV (cm based). |
| Pros | Quick, easy bedside assessment. | Reproducible, research standard. |
| Cons | Subjective, less reproducible. | More complex, time-consuming. |
High‑Yield Points - ⚡ Biggest Takeaways
- POP-Q is the standardized system for POP classification.
- Hymen is the zero reference point.
- Anterior points: Aa (anterior wall at -3cm), Ba (most distal anterior).
- Posterior points: Ap (posterior wall at -3cm), Bp (most distal posterior).
- Apical points: C (cervix/vaginal cuff), D (posterior fornix).
- Measurements: Genital hiatus (gh), perineal body (pb), total vaginal length (tvl).
- Staging (0-IV) based on maximal prolapse extent relative to hymen.
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