Chapter 1 12 referred to as rectocele or enterocele, respectively) (Fig. 2B), and the apical compartment (uterine or cervical descent if the uterus or cervix is still in place, or, after hysterectomy, vaginal vault prolapse) (Fig. 2C). Fig. 2. Classification of pelvic organ prolapse based on the descending organ. Images: UZ Leuven and VVOG, drawings made by DreamTeam. Prolapse can be present in one compartment, but more often, multiple compartments are affected simultaneously. The presence of any such sign may correlate with relevant prolapse symptoms. The feeling of heaviness or a lump in the genital area is the most common symptom, but urinary complaints, constipation, obstructed defecation, fecal incontinence, and other symptoms may coincide. Symptoms are generally worse after long periods of standing or exercise and improve when gravity no longer interferes, such as when lying supine. Prolapse may also be more prominent during abdominal straining, such as during defecation or when lifting heavy weights.4 In order to standardize quantification of the degree of prolapse, the Pelvic Organ Prolapse Quantification system (POP-Q) has been developed.5 POP-Q is the most frequently used staging system in both clinical (76%) and research (88%) settings.6,7 During vaginal examination, maximum prolapse is provoked by asking the patient to cough or to perform a Valsalva maneuver, while each vaginal wall is individually exposed when needed using a speculum. The degree of prolapse of the anterior vaginal wall (point Aa and Ba), the posterior vaginal wall (point Ap and Bp) and the cervix or vault (point C and D) are measured in centimeters either above/proximal to the hymen (negative number) or beyond/distal to the hymen (positive number) (Fig. 3). The plane of the hymen is defined as zero. Furthermore, the perineal body (pb), the genital hiatus (gh) and the total vaginal length (tvl) are measured. Based on these measurements, a stage (0-4) is determined for each compartment whereas stage 4 is classified as complete eversion. Studies correlating clinical findings with bladder or bowel symptoms have generally shown poor associations. However, the correlation between the sensation of a vaginal lump or bulge and clinical findings is somewhat better.8 Several authors have shown that women who complain of a vaginal bulge are more likely to be found to suffer from prolapse on clinical examination.9 A B C
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