The POP-Q also defines an ordinal staging sys-

necessary to further evaluate for rectocele or

tem for prolapse, which is based upon the maxi-

posterior enterocele.

mally protruding segment, and ranges from 0 (no

Genital sensation should be assessed as part of

prolapse) to 4 (vaginal eversion). All points must

the neurological evaluation by touch or pinprick.

be measured before assigning stage (Table 34.1).

The bulbocavernosus and anal reflexes can be

The physical exam should include many of

tested by tapping on the clitoris or gently stroking

the components of the general exam and should

the inside of the thigh and inspecting the anus for

include a thorough pelvic examination and

subsequent contraction. Anal sphincter tone

assessment of neurologic status. The pelvic

should be evaluated at the time of rectal exam.

exam is usually performed in dorsal lithotomy

The external components of the POP-Q (geni-

position with a full bladder, and may include a

tal hiatus, perineal body, and total vaginal

standing exam. A bivalved speculum or Sims’s

length) are measured. Also, notation should be

retractor is used during the exam to allow

made of vaginal volume particularly if vaginal

inspection of single compartments. Initial exam

repairs are considered to avoid narrowing the

should include an assessment of inguinal lymph

vaginal vault. Additional assessments can be

nodes, visual inspection of the external genita-

made using a lubricated Q-tip to quantify ure-

lia, assessment of the vaginal mucosa, and nota-

thral hypermobility (degrees at rest and at

tion of estrogen status. The urethral meatus

strain) or by the use of a ring forceps to support

should be inspected for evidence of prolapse or

the lateral vaginal fornices in evaluating for cys-

caruncle and the urethra palpated for presence

tocele (lateral versus central cystocele).

of diverticula or anterior vaginal wall cystic

Further imaging or diagnostic testing can be

structures. The urethra should also be assessed

useful to supplement physical exam findings in

for hypermobility and for the presence of con-

formulating the diagnosis. Often, urodynamic

comitant stress incontinence. The levator and

testing,MRI or CT,fluoroscopic studies,or cystos-

coccygeus muscles should be palpated for tone

copy will be needed to complete the evaluation.

and strength of kegel maneuvers evaluated.

Examination of the anterior and posterior vagi-

Outcome Measures

nal walls and cervix/vaginal apex should be per-

formed in a resting state. Each compartment

must be examined individually, using the specu-

Standardization in symptom assessment, physi-

lum to reduce the other compartments. The

cal examination,and outcome measures has been

compartments are then re-examined individu-

a challenge in the field of female pelvic recon-

ally in a straining state, either during cough or

struction. Despite much effort and attention,

valsalva maneuvers. Sometimes, a rectal exam is

there is no uniform system of preoperative or

470

Practical Urology: EssEntial PrinciPlEs and PracticE

postoperative evaluation in the literature.

In identifying objective measures of success,

Progress has been made in adopting the POP-Q

the pad weight test and the voiding diary have

grading system for prolapse, but there are many

often been incorporated as instruments in stud-

different validated bladder, bowel, and sexual

ies and trials. Both of these measures can be

function symptom questionnaires widely in use.

labor intensive and therefore are dependent

Because objective success is often vastly different

upon patient compliance. The 3 day voiding

than patient perception of success, more atten-

diary has been shown to have better patient

tion is now being focused on patient symptoms,

compliance with more accurate information

patient centered goals, and quality of life.

than the 5 or 7 day diary.31

Numerous bladder and bowel specific symp-

tom questionnaires exist, including those which

Imaging

aim to assess related quality of life perception.

Most of these questionnaires address voiding

symptoms, such as the Urogenital Distress

A supplement to history and physical exam, pel-

Inventory (UDI) or the Incontinence Impact

vic imaging by ultrasound, x-ray studies, or MRI

Questionnaire (IIQ); however, there are ques-

may provide additional anatomic information

tionnaires that are prolapse specific. The

in prolapse patients, particularly those who

Prolapse Quality of Life Questionnaire (P-QOL)

have had prior pelvic surgery or prior failed

is constructed to address the impact of prolapse

repairs.

on several quality of life domains. The Pelvic

The standing cystourethrogram can provide

Floor Distress Inventory (PFDI) and Pelvic Floor

dynamic information in changes in position of

Incontinence Questionnaire (PFIQ) incorporate

the bladder and urethra between rest and

both assessments of prolapse and voiding symp-

straining. It is a readily available modality

toms and resulting impact on quality of life.

which requires catheterization with retrograde

An important part of the initial patient evalu-

filling of the bladder with contrast material.

ation should be an assessment of patient expec-

Precise measurements of urethal angle and

tations and goals. Lowenstein et al. evaluated

degree/extent of bladder descent can be

patient goals at initial consultation and repeated

obtained on lateral views, along with voiding

an assessment of goals in the same group of

views32(Figs. 34.5–34.7).

patients at follow-up before surgical interven-

Defecography or culpocystodefecography are

tion. The authors found that the “most impor-

specialized imaging techniques requiring instil-

tant” goals changed after the initial visit in 56%

lation of contrast material into the rectum, the

of patients from“symptoms,”“information,” and

bladder, and the vagina. Fluoroscopic images are

“treatment” to “treatment” and “emotional” at

obtained at rest, at straining, and during defeca-

subsequent visits.29

tion/voiding. Interpretation requires a special-

Sexual function is often negatively impacted

ized radiologist. Physical examination is not

in patients with pelvic organ prolapse, either as

accurate in the detection of rectocele or entero-

a direct result of the anatomic changes and

cele, and defecography is used to enhance detec-

mechanical difficulties of intercourse or sec-

tion beyond exam.33 Obstructive defecation

ondarily by coexisting depression. Patients with

correlates well with presence of rectocele on

pelvic organ prolapse are more likely to feel

preoperative clinical examination, but not on

physically and sexually unattractive, more self-

postoperative exam, and is therefore limited for

conscious, and less confident than their normal

use in follow-up.34

counterparts.30 There are fewer validated sexual

MRI has been recently employed to evaluate

function questionnaires, the most commonly

the pelvic organs in cases of recurrent or com-

employed being the Female Sexual Function

plex prolapse. No standardized technique has

Index (FSFI) and the Pelvic Organ Prolapse/

been used in performing the study or in mea-

Urinary Incontinence Sexual Questionnaire

surements/assessment of prolapse; however,

(PISQ). The PISQ addresses bladder and bowel

MRI has gained wide acceptance thus far

function in addition to sexual function,whereas

(Fig. 34.8). Although the patient is supine and

the FSFI address sexual function alone, exam-

bladder filling is usually not standardized,

ining the domains of desire, arousal, orgasm,

images can be compared between static and

and pain.

dynamic states and provide exquisite detail of