BARBER, MATTHEW D. MD; LAMBERS, ANOUK R. MD; VISCO, ANTHONY G. MD; BUMP, RICHARD C. MD
Division of Gynecologic Specialties, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
Address reprint requests to: Matthew D. Barber, MD, Duke University Medical Center, Box 3609, Durham, NC 27710; E-mail: firstname.lastname@example.org
Received September 20, 1999. Received in revised form January 18, 2000. Accepted February 10, 2000.
Objective: To compare the severity of pelvic organ prolapse between examinations performed in dorsal lithotomy position and examinations performed upright in a birthing chair using the Pelvic Organ Prolapse Quantification System (POPQ).
Methods: One hundred eighty-nine consecutive women were evaluated between April 1997 and September 1998. All women were examined in the dorsal lithotomy position and in a birthing chair at a 45° angle. Degree of pelvic organ prolapse was assessed using the POPQ.
Results: When examined upright, 133 patients (70%) had the same stage of prolapse, whereas 49 (26%) had a higher stage and seven (4%) had a lower stage. Of patients who were stage 0 or I when examined in lithotomy position, 23 (36%) were stage II or greater when examined upright. Similarly, of patients who were stage II in lithotomy, 17 (23%) were stage III or higher when examined upright. There was a statistically significant increase in the degree of prolapse at all the POPQ measurements (P < .05 for each point), except for measurement of total vaginal length. Forty-eight percent of patients had at least one measurement increase by 2 cm or more when examined upright. Logistic regression identified no patient characteristics that were independently associated with a significant increase in stage or POPQ values with change in examination position.
Conclusion: The degree of pelvic organ prolapse assessed with the patient in the lithotomy position correlates well with assessment performed upright; however, overall there is a higher degree of prolapse with upright examination.
Gynecologists have attempted to describe the location and extent of pelvic organ prolapse since before the turn of the century. Many systems for grading and describing disorders of pelvic floor support have been advocated in the medical literature and in gynecologic texts.1–3 Until recently, however, none has been accepted universally, standardized, or validated. Brubaker and Norton4 reviewed the English language literature from 1966 to 1990 to document the clinical classification or nomenclature for description of pelvic support defects. They concluded that no universally accepted method exists for performing the pelvic examination or for reporting the physical findings of patients with pelvic organ prolapse. To remedy this situation, an international multidisciplinary committee composed of members of the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons drafted a standardization document for the terminology of female pelvic organ prolapse and pelvic floor dysfunction.5 In it, they defined a system of pelvic organ prolapse quantification (POPQ) for systematically describing the vaginal topography or profile of patients with pelvic organ prolapse. This system has been shown to be clinically useful, have excellent interrater and intrarater reliability, and be relatively easy to learn.6–8
The International Continence Society's standardization document does not advocate any particular examination position for POPQ, but rather asks examiners to specify which position was used when reporting results. When examining a patient with pelvic organ prolapse it is critical that the examiner sees and describes the maximum protrusion noted by the woman during her daily activities.5 Because of this, several authors have advocated examining patients in the standing position because it offers the advantage of assessing pelvic organ support with greater stress than an examination in the dorsal lithotomy position.9,10 However, performing a detailed examination with the patient standing can be quite cumbersome for both patient and physician and it can be difficult to make precise measurements of the various sites of interest. Swift and Herring11 compared the POPQ measurements of 51 patients examined in both the supine and standing positions and found no significant differences between stage and any of the measured points. Because of the limitations of the standing examination, however, they were not able to complete two of the nine POPQ measurements, genital hiatus and perineal body.
One alternative to the standing examination that has been used by some physicians is examination in a birthing chair. This offers both the advantages of an upright examination and easy access to the vagina and perineum for making the site-specific measurements of the POPQ. Montella and Cater found poor correlation between stage of prolapse assigned in the supine position compared with that assigned in the sitting position using a birthing chair (Montella JM, Cater JR. Comparison of measurement obtained in supine and sitting position in the evaluation of pelvic organ prolapse [abstract]. 16th annual meeting of the American Urogynecologic Society, Seattle, Washington, 1995). Hall et al6 noted in their study of the intraobserver reliability of the POPQ system that there was a statistically significant but clinically unimportant increase in five of nine of the POPQ measurements when 25 patients were examined in both the dorsal lithotomy position and upright in a birthing chair.
The goal of this study was to evaluate the difference in the magnitude of pelvic organ prolapse as assessed by the POPQ system when patients are examined in the dorsal lithotomy position or upright in a birthing chair. A secondary goal was to identify factors that might predict a significant change in severity of prolapse with an upright examination.
Materials and Methods
One hundred eighty-nine consecutive patients who presented to the Pelvic Floor Dysfunction Clinic at the Duke University Medical Center between January 1997 and September 1998 were included in the study. Patients were examined at their initial visit in the dorsal lithotomy position, and a clinical assessment for pelvic organ prolapse was performed using the International Continence Society's POPQ system5 (Figure 1). Six sites of pelvic organ prolapse quantification are located with reference to the plane of the hymen and are measured in centimeters above or proximal to the hymen (negative number) or below or distal to the hymen (positive number) with the plane of the hymen defined as zero. The anterior and posterior points A (Aa, Ap) are located on the midline vaginal wall 3 cm proximal to the hymen (range ±3 cm). The anterior and posterior points B (Ba, Bp) represent the maximum extent of prolapse of the anterior and posterior vaginal wall (range −3 cm to total vaginal length [tvl]). Point C represents the position of the cervix or vaginal cuff, and point D, the posterior fornix. The genital hiatus (gh) is measured from the external urethral meatus to the posterior midline hymen, and the perineal body (pb) is measured from the posterior midline hymen to the midanal opening. At a second clinic visit, subjects were examined while sitting 45° upright in a birthing chair and a second clinical assessment for pelvic organ prolapse was performed using POPQ. Both examinations are part of the standard comprehensive evaluation of all patients who present to our Pelvic Floor Dysfunction Clinic.
Other than patient position, the supine and upright examinations were performed in the same fashion. All examinations were done or supervised by the senior author (RCB). Patients were asked to empty their bladder before both examinations. Before the upright examination, but not the supine examination, a catheter was placed to determine postvoid residual. During each examination, patients were asked to strain forcefully and measurements were made when the patient was performing maximum Valsalva maneuver. Before each examination in the birthing chair, the 45° position was determined using a level and a protractor. Instruments used for the determination of the nine quantitative POPQ measurements included a standard bivalve vaginal speculum; a ring forceps with measuring grooves engraved at 1, 2, 3, 4, 5, 7.5, and 10 cm; and a 15-cm clear plastic ruler. Before any manipulation, the first measurements obtained were the genital hiatus and perineal body measurements using the plastic ruler. If prolapse beyond the hymen was present, measurements of the external sites were obtained first. If no external prolapse was present, the bivalve speculum was inserted into the vagina and slowly withdrawn as the patient strained down. The points of maximal descent of the cervix or vaginal cuff (point C) and, in patients with a cervix, the posterior fornix (point D) were measured with the graduated ring forceps. The bivalve speculum was then separated in half and the anterior and posterior points A and B (points Aa, Ba, Ap, and Bp) were measured using the graduated ring forceps with the half speculum retracting the opposite vaginal wall. Total vaginal length was measured by digitally replacing the vaginal apex to its normal anatomic position and measuring the maximum depth with the ring forceps. All nine measurements, with the exception of total vaginal length, were taken with the patient performing maximum Valsalva.
After each examination, patients were assigned to one of five ordinal stages of prolapse (0–IV) in accordance with the POPQ system. Subjects were also subgrouped according to which portion of the lower genital tract was the most distal part of the prolapse during maximal strain, as previously described.5,6 All methods, definitions, and descriptions conformed to the standards recommended by the International Continence Society.
The nine POPQ measurements and the stage of prolapse obtained from examination in the supine position were compared with those from the examination in the upright sitting position by using paired Wilcoxon signed-rank test and the nonparametric correlation coefficient, Spearman rho. A clinically important change in a POPQ value was defined a priori as an increase of 2 cm or more. Logistic regression analysis was done to identify patient characteristics that were independently associated with a clinically important increase in POPQ value with a change in examination position. A second logistic regression analysis was done to identify patient characteristics that were independently associated with an increase in stage of pelvic organ prolapse with change in examination position. All values of continuous variables are expressed as the mean ± standard deviation (range). Ordinal variables, such as stage of prolapse, are expressed as median (range). Statistical analysis was performed using SAS 6.12 (SAS Institute Inc., Cary, NC).
The mean age of the study subjects was 61 ± 13.5 years (range 30–85 years), the median parity was two (range 0–14), and the mean weight 74 ± 16 kg (range 43–160 kg). One hundred eighty-three women (94%) were white, and 167 (87%) were either premenopausal or using estrogen replacement therapy. One hundred thirty women (67%) had a previous hysterectomy, and 89 (44%) had previous urogynecologic or pelvic reconstructive surgery.
Table 1 shows the relationship between stage of pelvic organ prolapse in the supine position compared with reexamination in the upright sitting position. When examined in the upright position, 133 patients (70%) had the same stage of prolapse, whereas 49 (26%) had a higher stage of prolapse and seven (4%) had a lower stage of prolapse. Of the patients who were stage 0 or I when examined supine, 23 (36%) were stage II or greater when examined sitting upright. Similarly, of patients who were stage II when supine, 17 (23%) were stage III when examined upright. Nine patients (23%) who were stage III on supine examination were stage IV when examined upright.
The mean values for the nine POPQ measurements for each examination position are shown in Table 2. There was a statistically significant increase in the magnitude of prolapse at all eight POPQ sites but not in the measurement of total vaginal length. The median change for each site ranged from a low of 0.25 cm at site Ap to a high of 1.0 cm at the genital hiatus and point C. Over 15% of measurements at sites Ba and Bp and over 20% of measurements at sites C and the genital hiatus increased 2 cm or more when patients were examined upright. In all, 91 patients (48%) had at least one POPQ measurement increase by 2 cm or greater when examined in the upright position.
Logistic regression analysis was used to identify variables that might be independently associated with an increase in at least one POPQ measurement by 2 cm or more when a patient was examined upright. A second regression analysis was used to identify variables that might be independently associated with an increase in prolapse stage when a patient was examined upright. Variables considered included age, race, parity, weight, height, estrogen status, history of hysterectomy, history of urogynecologic or pelvic reconstructive surgery, the genital hiatus measurement in lithotomy position, and stage of prolapse in lithotomy position. None of those variables was significantly associated with either outcome variable.
In this study we compared quantification of pelvic organ prolapse in the most common examination position, dorsal lithotomy, with examination upright in a birthing chair, a position designed to maximize the magnitude of prolapse while allowing the access to the vagina and perineum necessary for precise measurements. Overall, the average values for each measurement increased when patients were examined upright, but only by a relatively small amount. There was moderate to good correlation between the POPQ measurements made in each position. Importantly, however, there was a subset of patients whose prolapse increased substantially when examined in the birthing chair. Over one quarter of patients in our study had a higher stage of prolapse and almost half of our subjects had at least one POPQ measurement increase by 2 cm or more when examined upright. Our findings are consistent with those of two smaller studies that evaluated quantification of pelvic organ prolapse in both dorsal lithotomy position and sitting upright.6 Both studies found a greater stage of prolapse when patients were in the upright sitting position.
Swift and Herring11 directly compared POPQ measurements in the standing position with measurements in the dorsal lithotomy position. They found a high degree of correlation between the values obtained in the two positions and no significant differences in stage of prolapse. They postulated that they did not find an effect of patient position on prolapse quantification because the standing position does not provide the same degree of pelvic tilt that is provided by the sitting position. They likened sitting in a birthing chair to McRoberts maneuver, in which maximum hip flexion straightens out and opens up the pelvis. Certainly, the birthing chair is designed to open the pelvic outlet and maximize the effect of pushing in order to facilitate vaginal birth. In contrast, we found a significantly larger mean genital hiatus measurement in the upright sitting position than in dorsal lithotomy position. This finding is consistent with the concept that sitting upright in a birthing chair opens the pelvic outlet thereby allowing the pelvic organs to protrude to a greater extent than examination in the lithotomy position in some patients. Although a standing examination is advocated by many as a means of demonstrating the maximal extent of pelvic organ prolapse, an examination in a birthing chair might be superior because of the mechanics of the pelvis and pelvic floor. Regardless of examination position, we should remember that the patient is an important resource in the clinical evaluation of pelvic organ prolapse and she should be asked whether the examination is demonstrating the maximum extent of prolapse that she has noted.
One confounding factor that could have influenced the results of this study was the difference in urine volume in the bladder at the time of each examination. Bladder catheterization was done routinely before the upright examination, to determine the postvoid residual urine volume, but not before the supine examination. In the proportion of patients who had voiding dysfunction that resulted in an elevated postvoid residual urine volume, an accentuation of anterior vaginal prolapse might have occurred during the supine examination. Had we catheterized patients before both examinations, we might have seen a larger increase in anterior vaginal prolapse with upright examination than was observed in this study.
It is standard at our clinic for a new patient referred for pelvic floor dysfunction to have a comprehensive pelvic floor evaluation, which includes two examinations, one supine and one upright in a birthing chair. Clinical decisions are not made until both examinations have occurred. Consequently, we cannot reliably determine the proportion of patients whose clinical treatment was changed because of the upright examination. Future studies that evaluate the effect of patient position on the clinical evaluation of pelvic organ prolapse should attempt to accurately determine the effect of examination position on clinical decision making.
The POPQ system has proved to be reliable and reproducible in several studies. It has been advocated by both national and international professional societies interested in the study of pelvic floor dysfunction. Consequently, it has the potential of improving scientific and clinical communications about pelvic organ prolapse. Several variables, including examination position, can affect POPQ values and the stage of pelvic organ prolapse. Various examination positions have been advocated, and each has its relative advantages and disadvantages. The severity of pelvic organ prolapse that can be demonstrated when an examination is performed upright in a birthing chair is greater in many patients than can be demonstrated in lithotomy position even with maximum straining. However, birthing chairs are not universally available, and a standardized examination position has not been and should not be specified. This highlights the importance of clearly specifying patient position when describing pelvic organ prolapse and of performing studies such as this one that elucidate the relationship that differences in examination technique have on the clinical evaluation of pelvic floor dysfunction.
1. Baden WB, Walker TA. Surgical repair of vaginal defects. Philadelphia: JB Lippincott 1992:13–7.
2. Beecham CT. Classification of vaginal relaxation. Am J Obstet Gynecol 1980;136:957–8.
3. Porges RF. A practical system of diagnosis and classification pelvic relaxation. Surg Gynecol Obstet 1963;117:769–73.
4. Brubaker L, Norton P. Current clinical nomenclature for description of pelvic organ prolapse. J Pelvic Surg 1996;2:257–9.
5. Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.
6. Hall AF, Theofrastous JP, Cundiff GW, Harris RL, Hamilton LF, Swift SE, et al. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol 1996;175:1467–71.
7. Kobak WH, Rosenberger K, Walters MD. Interobserver variation in the assessment of pelvic organ prolapse. Int Urogynecol J 1996;7:121–4.
8. Steele A, Mallipeddi P, Welgoss J, Soled S, Kohli N, Karram M. Teaching the Pelvic Organ Prolapse Quantitation system. Am J Obstet Gynecol 1998;179:1458–64.
9. Grody MHT. Posterior compartment defects. In: Rock J, Thompson T, eds. Telinde's operative gynecology. 8th ed. Philadelphia: Lippincott-Raven Press 1997:1044–56.
10. Walters MD, Karram MM. Enterocele. American Urogynecologic Society quarterly report. Chicago: American Urogynecologic Society, 1992;10.
11. Swift SE, Herring M. Comparison of pelvic organ prolapse in the dorsal lithotomy compared with the standing position. Obstet Gynecol 1998;91:961–4.