Pelvic organ prolapse is a common disease in middle-aged and elderly women, which seriously affects the quality of life of patients.
I. Risk factors for POP Risk factors for POP include genetic predisposition, number of births (vaginal delivery), menopause, advanced age, history of previous pelvic surgery, abnormal connective tissue development and factors that increase abdominal pressure (e.g., obesity, chronic constipation), etc. Preoperative evaluation of POP
1.Symptom assessment
(1) Prolapse-specific symptoms: Patients can see or feel tissue prolapse from the vaginal opening, and the degree of prolapse can vary with the amount of activity, body position and weight bearing.
(2) Non-specific symptoms: pelvic pressure, back pain, etc. Whether the symptoms can be relieved by surgical treatment is uncertain, and can be identified by using a uterine support.
(3) Urinary-related symptoms: anterior vaginal wall prolapse and uterine prolapse may be associated with difficulty in urination and inability to empty the bladder completely. In patients with urinary retention, complete bladder emptying is possible after the prolapse is returned. However, symptoms of urinary urgency, frequency or urge incontinence are not related to the degree of prolapse. Patients with prolapse may have a combination of stress urinary incontinence (SUI), which may gradually decrease or even disappear completely as the degree of prolapse increases.
(4) Bowel symptoms: Patients with posterior vaginal wall prolapse may have difficulty in defecation.
2.Physical examination
(1) Gynecological examination: whether there is atrophy of the vulva and vagina, and measurement of the size of the pubic fissure.
(2) Prolapse of pelvic organs: examination with a standard bilobed speculum and measurement as detailed in the POP-Q score.
(3) Evaluation of vaginal lateral wall support.
(4) Evaluation of pelvic floor muscle contraction: finger palpation was performed at 5 and 7 points located 5 cm inside the vaginal opening, and the patient was asked to contract the anal levator and vagina, while the other hand was placed on the patient’s abdomen, and the patient was told to avoid contracting the abdominal muscles. See Table 1.
Grading criteria.
0: No pelvic floor muscle contraction.
1: Unstable contraction of pelvic floor muscles.
2: Weak contraction of pelvic floor muscles.
3: Moderate pelvic floor muscle contraction with mild elevation.
4: Strong contraction of pelvic floor muscles with elevation, tension can be sustained.
5: Strong pelvic floor muscle squeezing pressure with elevation and clenching of the examiner’s fingers.
(5) Perineal body mobility: Place a finger in the vagina or rectum and gently pull the perineal body in the direction of the examiner; if the movement is >1 cm, it indicates excessive movement, and the thickness of the perineal body is also assessed.
(6) Anal and rectal examination: assess the integrity of the perineal body and the tone of the anal sphincter.
(7) Elicitation test for urinary incontinence: after the prolapse is reset, the patient is asked to hold his breath and exert himself or cough to determine whether there is urinary incontinence.
3.The assessment of the degree of prolapse was performed using the pelvic organ prolapse quantitative staging POP-Q staging system.
(1) Position: Mostly the bladder truncated position is used, with both feet placed on the stirrups and downward breath-holding exertion, and measurement is performed at the maximum degree of prolapse.
Ba anterior wall Bp posterior wall without prolapse, both point B and point A are -3 cm C most distal part of the apical portion of the vagina after cervical or hysterectomy D posterior vault (in patients without hysterectomy) gh distance between the midpoint of the external urethral opening and the midline hymenal margin of the posterior wall (cm) pb distance from the midline hymenal margin of the posterior wall to the midpoint of the anus (cm) TVL in the case of full repositioning of the prolapse to avoid Maximum depth of vagina measured under increased pressure or elongation (cm)
(2) POP-Q reference points: The degree of prolapse was determined by measuring 6 measurement points (Aa, Ba, C, D, Bp and Ap) and 3 meridians of the genital fissure and total vaginal length of the perineal body in patients with pelvic organ prolapse.
(3) Measurement method: The single-lobe speculum is pulled on the posterior vaginal wall, a ruler or a long sterile swab with a fixed mark is placed 3 cm from the urethral orifice, and while pulling the speculum toward the posterior wall, the patient is asked to perform a Valsalva maneuver or hold the breath downward with force to measure the degree of descent of point A and at the same time point Ba. The single lobe speculum is pulled on the anterior wall of the vagina and Ap and Bp are measured in the same way, along with the length of the vagina and points C and/or D. Finally, the genital fissure and the length of the perineal body are measured.