I mp roving Evidence-Based Practice

Improving Evidence-Based Practice:
Use of the POP-Q System for the
Assessment of Pelvic Organ
Prolapse
Katherine Marchese
P
elvic floor disorders, which
include pelvic organ prolapse, urinary and fecal
incontinence, and dysfunctional bowel and bladder
symptoms, comprise a confluent
series of medical conditions that
negatively impact the quality of
life for many women (Barber,
2005; Bo, 2006). Pelvic organ prolapse affects women of all ages
and is often under-reported,
under-diagnosed, and under-treated. Prevalence estimates are variable but range between 30% and
76% of the female population
(Barber, 2005; Bo, 2006; Hagen,
Stark, Maher, & Adams, 2006).
Many women do not seek early
medical care and postpone discussions with their health care
provider until the symptoms
become very troublesome and
have a deleterious effect on their
quality of life. It is expected that
pelvic organ prolapse will
i n c rease in frequency as the population ages (Bo, 2006; Trowbridge,
Rodriguez, & Fenner, 2005). It is
important that clinicians become
Katherine Marchese, MSN, CNP, CWOCN,
CURN, is a Nurse Practitioner, DuPage
Medical Group, Chicago, IL.
Note: The author reported no actual or
potential conflict of interest in relation to this
continuing nursing education article.
Note: Objectives and CNE Evaluation Form
appear on page 224.
216
The focus of improving health care outcomes today relies on utilizing
evidence-based practice. Pelvic organ prolapse affects women of all
ages and negatively impacts their quality of life. Evidence-based
tools for consistent assessment of prolapses have been developed,
validated, and used by many clinicians. Use of these tools needs to
become standard of practice for all clinicians who work in the
women’s health arena. The Brink scale and the POP-Q assessment
tool can assist clinicians, direct quality care, and provide evidencebased practice.
© 2009 Society of Urologic Nurses and Associates
Urologic Nursing, pp. 216-224.
Key Words: Pelvic organ prolapse, pelvic floor disorders, POP-Q
assessment tool, Brink scale.
Objectives
1. Define pelvic organ prolapse.
2. Explain the etiology and risk factors of pelvic organ prolapse.
3. List symptoms of pelvic organ prolapse.
4. Discuss two tools for assessing pelvic organ prolapse.
well-versed in the evaluation and
diagnosis of pelvic organ prolapse,
utilizing the upgraded assessment
tools, such as the POP-Q and the
Brink assessment scales. Conservative treatment options for this
condition can be managed by clinicians with proper re f e rral to
u rogynecologists or urologists for
s u rgical management as needed.
Each year, over 200,000 women
undergo inpatient surg e ry to
repair the prolapse at a cost of
over $1 billion for hospitalization
and physician fees alone (O’Dell
& Morse, 2008).
Definition
Pelvic organ prolapse is
defined as the weakness of the
muscles, ligaments, and connective tissues that normally support
the vaginal walls and pelvic
o rgans. This weakness results in
the descent of vaginal walls,
u t e rus, bladder, urethra, rectum,
or bowel into the vaginal vault
( H e r b ruck, 2008). Less frequently,
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
a complete utero-vaginal eversion may develop (Schaffer, Wai,
& Boreham, 2005; Swift, Tate, &
Nicholas, 2003).
Prior to the late 1990s, there
was no universally accepted system for grading, staging, describing, or recording the evaluation of
the pelvic floor support mechanisms, limiting the ability to
assess reliability, reproducibility,
and generalizability in clinical trials (Barber, 2005; Bump et
al.,1996). In 1996, the International Continence Society, the
American Urogynecologic Society,
and the Society of Gynecologic
S u rgeons developed and standardized the Pelvic Organ Prolapse – Quantification System
(POP-Q). This system, which describes specific anatomic sites to be
measured for evaluation and staging of a pelvic organ prolapse, has
become the most accepted evidenced-based tool for gynecologists
and urogynecologists (American
College of Obstetricians and
Gynecologists [ACOG] Committee
on Practice Bulletins – Gynecology,
2007; Barber, Lambers, Visco, &
Bump, 2000; Bump et al., 1996).
Although used less frequently by
other specialty practices, it is a
valuable tool that all clinicians
should embrace.
In the past, generic terms
(such as cystocele, rectocele, and
e n t e rocele) were commonly used
to describe the prolapse without
any specific diagnostic information that identified the exact
anatomical structure behind the
vaginal wall weakness (ACOG
Committee on Practice Bulletins –
Gynecology, 2007; Bump et al.,
1996). The recent term i n o l o g y
changes have suggested limiting
the use of the terms rectocele, cystocele, and enterocele in order to
describe, more accurately, the specific anatomic site of the vaginal
wall weakness (Bump et al.,
1996). If, however, ancillary studies, such as cystoscopy, ultrasonography, contrast radiography,
CT, or MRI, are done and the particular organ of descent behind
the vaginal wall weakness is iden-
tified, the terms urethrocele, cystocele, rectocele, or entero c e l e
may be appropriately used (Bump
et al., 1996).
Prolapses are now best
defined in three anatomical term s
based on the segment of the vaginal wall that has prolapsed. These
a re identified as an anterior vaginal prolapse, posterior vaginal
prolapse, or apical/superior vaginal prolapse (Hagen et al., 2006).
The anterior prolapse, indicating
a prolapse in the anterior wall of
the vagina, could include an urethrocele, a cystocele, or an anterior enterocele. The posterior prolapse, indicating a prolapse in the
posterior wall of the prolapse,
could include a rectocele or a posterior enterocele. The apical/superior prolapse, indicating a prolapse in the apical vaginal wall,
could include the cervix, the
u t e rus, or the vaginal cuff.
Risk Factors/Etiology
The etiology of pelvic org a n
p rolapse may be related to multiple risk factors rather that a single cause (ACOG Committee on
Practice Bulletins – Gynecology,
2007; Schaffer et al., 2005).
Factors, congenital or acquired,
that result in a weakened support
mechanism predispose women
to pelvic organ pro l a p s e .
Pregnancy, difficult and prolonged labor, forceps delivery,
l a rge birth weight babies, and
i n c reased parity are often sited
( H e r b ruck, 2008; Swift, 2000).
Medical conditions, such as multiple sclerosis and muscular dystrophy, produce damaged or paralyzed muscles that cannot provide the normal supportive stru ct u res needed. Women with genetic collagen disorders, such as
Marfan’s and Ehlers-Danlos
S y n d rome, have demonstrated a
higher incidence of both urinary
incontinence and pelvic org a n
prolapse (Carley & Schaffer,
2000), suggesting that connective
tissues have a role in their development. Obesity, chronic constipation, and chronic cough relat-
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
ed to tobacco abuse, asthma, or
bronchitis result in significant
increase in intra-abdominal pre ssure, which has also been linked
to pelvic organ prolapse. Certain
occupations linked to heavy lifting may also predispose women
to prolapse. Ethnicity, age,
menopause, and familial history
of prolapse are additional factors
postulated to increase the risk for
pelvic organ prolapse. Pre v i o u s
pelvic surgeries, including hyst e rectomy and prior pro l a p s e
repair, are also risk factors (Swift,
2000).
Symptoms
Pelvic organ prolapse may be
asymptomatic or present with
such mild symptoms that no treatment is solicited or needed for
years (Sasso, 2006). Only 10% to
20% of women seek medical
assistance for this condition
(Barber, 2005; Bo, 2006). Development of bothersome symptoms
increases when the prolapse has
descended to the level of the
hymen, prompting health-seeking
behaviors (Barber, 2005; Bo, 2006;
Swift et al., 2003). Symptoms
commonly associated with prolapse are characterized into 4 primary areas: lower urinary tract
symptoms, bowel symptoms, sexual symptoms, and local symptoms (Bump et al., 1996;
Ellerkmann et al., 2001). Patients
may present with any or all of
these symptoms and in varying
degrees (Barber, 2005; Bo, 2006).
Careful evaluation and discussion are needed to identify
whether these symptoms are
related to the prolapse condition
or may be related to some other
condition, such as pelvic or vaginal mass, hernias, interstitial cystitis, urinary tract infection, overactive bladder, irritable bowel
syndrome, primary rectal disorder, or sexual disorder unre l a t e d
to the prolapse (Barber, 2005;
Weber et al., 2001). Severity of
presenting symptoms is not necessarily related to the pro g ression
of the pro l a p s e .
217
U r i n a ry symptoms are related
to the effect of the prolapse on the
ability of the bladder to fill,
empty, and maintain continence.
Common symptoms include hesitancy, urgency, frequency, decreased force of stream, and
incomplete emptying (Barber,
2005). Patients may need to develop compensatory adaptive mechanisms to empty the bladder,
which could include manipulation of the prolapse or assuming
multiple positions on the toilet to
facilitate complete voiding.
Patients with pelvic org a n
prolapse may also present with
bowel symptoms that include
incontinence of flatus and feces,
straining to defecate, incomplete
emptying, increased urgency,
and/or fecal blockage (Barber,
2005; Bo, 2006). Compensatory
mechanisms for fecal evacuation
may also be needed if the prolapse has placed increased pre ss u re on the rectum. These patients
may detail extensive procedures,
including splinting and position
changes, to facilitate bowel emptying.
Further symptoms experienced by patients with pelvic
o rgan prolapse may include local
“bulge” symptoms described as a
sensation of fullness, pro t ru s i o n
in the vagina, or increased vaginal pressure (Barber, 2005). The
bulge may be visible either internally in the vagina or externally
past the hymen remnant. It may
i n t e rf e re with sexual activity and
activities of daily living, and/or
result in a decreased quality of
life (Barber, 2005; Bo, 2006).
Sexual dysfunction may be related to the presence of the pro l a p s e
in the vagina, causing dyspare unia, decreased sensation, and
lubrication with subsequent
avoidance of sexual encounters
(Barber, 2005). Symptoms noted
in other studies include low back
pain, generalized pelvic pain, or
blood-stained or purulent disc h a rge. Blood stains or purulent
d i s c h a rge noted on the underwear or protection pads may be
related to the erosion sore s
218
caused by the prolapse rubbing
against skin, underwear, or protection pads (Barber, 2005; Bo,
2006; Swift et al., 2003).
Assessment and Diagnosis
The assessment of pelvic
organ prolapse begins with a
detailed history and follows with
a five-component physical examination (Bump et al., 1996;
Schaffer et al., 2005). The physical
examination begins with an evaluation of the external genitalia (1),
followed by the internal examination of the vaginal tissue (2) and
the digital rectal-vaginal examination (3). Assessment of the muscle
strength (4) and the evaluation of
the prolapse (5) are done during
the internal vaginal assessment.
H i s t o ry
Assessment of a female presenting with a prolapse begins
with obtaining a complete medical history. This history should
include age, weight, body mass
index, number of pregnancies,
b i rth weight of children, complications during delivery, and any
familial history of pro l a p s e
(ACOG Committee on Practice
Bulletins – Gynecology, 2007).
Personal medical history should
also include any medical condition, tobacco use, chronic constipation, or other conditions that
may result in a chronic cough. In
addition, the pertinent surg i c a l
h i s t o ry should include any pelvic or re t roperitoneal surgeries,
especially a hysterectomy and
any prior prolapse re p a i r.
Specific symptoms to be
evaluated include pelvic pain,
back pain, dyspareunia, abnormal bleeding, vaginal discharg e ,
u r i n a ry symptoms, and defecatory symptoms (Ellerkmann et al.,
2001; Kahn et al., 2005; Schaffer
et al., 2005). Assessment of each
symptom should be described
separately and should include
onset, duration, severity, pre c i p itating or associated factors, alleviating factors, and any prior
t reatments. This in-depth assess-
ment of each symptom is necessary to identify any possible differential diagnosis that may alter
the treatment plan.
Physical Examination
The physical examination
begins with inspection and palpation of the external genitalia,
assessing for any discoloration,
inflammation, irritation, discharge, rash, or lesions. The vaginal epithelium should also be
assessed for vaginal atrophy,
abrasions, erosions, and inflammation. The bimanual examination is done to assess for any
abnormalities in the vaginal wall,
abdomen, or rectum. Specifics of
these examinations may be found
in other sources and will not be
covered in this article; they are a
necessary component in the evaluation of a pelvic organ pro l a p s e
and can be instrumental in establishing the diff e rential diagnosis,
which is composed (Weber et al.,
2001).
Brink scale. The Brink scale
assesses the strength of the pelvic
floor composed of the levator ani
muscles, coccygeal muscles, and
the related fascia, using a transvaginal or transrectal approach.
The transvaginal approach is
most common, with the examiner’s finger inserted 4 to 6 cm into
the vagina, while asking the
patient to squeeze the pelvic floor
muscles without using the accessory muscles (FitzGerald et al.,
2007). Three components of each
pelvic floor muscle contraction
(levator ani muscles and coccygeal
muscles) are assessed: a) the muscle force, b) the vertical displacement of the examiners fingers during the contraction, and c) the
duration of the contraction
(FitzGerald et al., 2007). A 4-point
ordinal scale is used by the examiner to assess each of the 3 components (see Table 1). The scores of
the three components are added
and provide an overall score ranging from 3 to 12, with higher
scores reflecting increasing muscle strength contractions (Sasso,
2006).
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
Table 1.
Brink Assessment Scale
Muscle Strength Rating
Ve rtical Displacement Rating
Duration Rating
1 – No response
1 – No response
1 – None
2 – Weak squeeze
2 – Finger base moves anteri o rl y
2 – Less than 1 second
3 – Moderate squeeze
3 – Whole length of fingers moves anteri o rl y
3 – Lasts 1 to 3 seconds
4 – Strong squeeze
4 – Whole finger moves anteri o rl y, gripped and pulled up
4 – Lasts more than 3 seconds
Note: Vertical displacement means how and where the examiner’s finger is gripped during the contraction and the degree to
which it is pulled deeper into the vagina and pulled upwa r d s.
During each contraction, the
examiner rates the ability of the
patient to contract the pelvic
floor muscles and the ability of
the patient to tighten the muscles
around the base of the examiner’s
finger or the whole finger. The
duration of the contraction is
assessed as well. When the examiner learns this technique, it may
take more than one contraction to
assess adequately. The patient is
i n s t ructed to completely re l a x
the pelvic muscles before beginning the next contraction. It is
v e ry important to explain to the
patient exactly which muscles to
contract and how to contract
those specific muscles.
POP-Q assessment tool.
S t a n d a rdized terminology identifying the degree, grade, and
anatomical points of prolapse
were needed to advance the science underlying the etiology,
assessment, and prolapse treatment efficacy (Bump et al., 1996;
Weber et al., 2001). Use of the
POP-Q system (see Figure 1)
requires assessment of the prolapse at maximum protrusion
(Bump et al., 1996; Trowbridge et
al., 2005). After voiding, the
patient is usually placed in the
dorsal lithotomy position and
asked to perform a Valsalva
maneuver, exerting maximum
strain to simulate maximal pro t rusion (Barber et al., 2000). If necessary, assisting the patient into a
standing position may be beneficial to achieve maximal strain
(Bump et al., 1996; Trowbridge et
al., 2005).
Table 2.
POP-Q Grid for
Recording Values
Aa
Ba
C
Gh
Pb
Tvl
Ap
Bp
D
Note: Please refer to Figure 1. The
numerical values placed in each of
these squares are obtained by using
the pre-marked swab and recording
the distance of that particular point
from the hymen. Gh and Pb are also
measured with the pre-marked swab
but identify the distance between diffe rent points as indicated in Figure 1.
Anatomic Landmarks
Assessment of a prolapse
begins with the identification of
the hymen. This becomes the
fixed point of reference, and the
six defined anatomical points in
the vagina are given a value in
centimeters based on their position relative to the hymen, either
above or below. There are two
points on the anterior portion of
the vaginal wall, two points on
the posterior wall, and two points
on the apical/superior wall.
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
Symbols used to identify these six
points include lower case letter
“a” (representing the anterior
vaginal wall) and lower case “p”
(representing the posterior vaginal
wall). Capital letters “A” and “B”
reflect the proximal (A) and distal
points (B) on the anterior and posterior vaginal walls. Capital “C”
represents the cervix or posterior
vaginal cuff. Capital “D” represents the posterior fornix (see
Figure 2). Figure 3 shows the pre marked swab used for measuring
displacement.
Ordinal Stages of Pelvic Organ
Prolapse
Following the assessment of
the POP-Q and completing the
POP-Q grid (see Table 2), an ord inal stage is assigned. The prolapse is graded from 0 to IV based
on the extent of maximal pro t rusion. The stage of pro l a p s e
should be entered into the
p ro g ress notes along with the
POP-Q grid. The most common
stages are I and II (Sasso, 2006;
Swift, 2000). Refer to Table 3 for
staging specifics.
C o n s e rvative Management
Treatment options for conservative management of prolapse
are dictated by results of the GU
examination, assessment of the
prolapse stage, and patient preferences (Herbruck, 2008). These
conservative options include
lifestyle modifications, use of a
pessary, pelvic muscle therapy,
219
Figure 1.
P rocedure for Performing a POP-Q Examination
Equipment
8” OB/GYNE swab, previously measured in 1 cm markings
for 12 cms.
Gloves
Speculum
Water-soluble lubricant
Procedure
Wash hands.
Explain procedure to patient. Have patient empty her bladder prior to the examination.
Assist patient into dorsal lithotomy position.
Don gloves.
Examine ex t e rnal genitalia for any abnormalities.
Identify the hymen. Begin the measurements.
Gh can be documented at rest and with strain.
At rest (no straining), measure the distance from the
ex t e rnal mid-urethra to the midline hymen using the
pre-marked swab. Record the value.
Have patient perfo rm a Valsalva for maximum strain.
Again, measure the distance from the ex t e rnal midurethra to the midline hymen using the pre-marked
swab, noting any change in the distance. Record the
value.
Point D
This point is only measured if the patient still has a
cervix. While the speculum is still in position,
advance the swab stick past the cervix into the
posterior fornix (pouch of Douglas). Record this
value.
Remove the speculum and separate the blades.
Discard the upper portion of the blade.
Anterior Aspect of Vaginal Wall
Aa
Slide the single blade of the speculum into the vagina retracting the posterior portion of the vaginal wall.
Identify the urethrovesical crease on the anterior portion of the vagina, if present. Slide the pre-marked
swab 3 cm in from the external urethral meatus
(should approximate the urethrovesical crease).
Gently hold the swab in that position and ask the
patient to slowly bear down to again achieve maximal
straining. O b s e rve the distance that the swab stick
moved back out of the vagina. Measure the distance
from that point to the urethral meatus and record.
Range of -3 (no prolapse) to +3 (maximal prolapse).
Ba
With the speculum remaining in that position, visually identify the most dependent portion of the anterior wall. Place the pre-marked swab at that point, and
again, have the patient bear down to achieve maximal straining. Measure the distance from that point
to the urethral meatus. Record that value.
Pb can be measured at rest and with strain.
At rest (no straining), measure the distance from the
midline hymen to the mid-anal orifice using the prem a rked swab. Record the value.
Have the patient perform a Valsalva maneuver for
maximum strain. Measure the distance from the midline hymen to the midline anal orifice, noting any
change. Record the value.
Vaginal Examination
Slightly lubricate the speculum and insert into the vagina,
assessing epithelial tissue. Identify presence/absence of
cervix at the vaginal apex and any signs of erosion or
a b n o rmal tissue.
TVL
Patient is in resting position (no straining).
Reduce the prolapse, if necessary, to obtain tru e
vaginal length.
Holding the cotton-tipped portion of the pre-marked
swab, slide the swab stick into the vagina to its greatest depth, identifying point C and/or D. Record the
value of TVL, C, and/or D.
Apical (Superior) Aspect of Vaginal Wall
Point C
Holding speculum with one hand, measure the distance from the midline hymen to the most distal
aspect of the cervix or the vaginal cuff if the patient
has had a hysterectomy and the cervix is missing.
Record this value.
220
Range of -3 (no prolapse) to + value equal to length
of vaginal eversion.
Posterior Aspect of Vaginal Wall
Ap
Adjust the blade of the speculum to retract the anterior wall of the vagina. Slide the pre-marked swab 3
cm in from the ex t e rnal urethral meatus on the post e rior wall of the vagina. Gently hold the swab in that
position and ask the patient to slowly bear down to
again achieve maximal straining. O b s e rve the distance that the swab stick moved back out of the vagina. Measure the distance from that point to the urethral meatus and record.
Range of -3 (no prolapse) to +3 cm (maximal prolapse).
Bp
With the speculum remaining in that position, visually identify the most dependent portion of the posterior wall. Place the swab at that point, and again, have
the patient bear down to achieve maximal straining.
Measure the distance from that point to the urethral
meatus. Record that value.
Range of -3 (no prolapse) to + value equal to the
length of the vaginal eversion.
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
Figure 2.
Anatomical Markings Identifying Points on the POP-Q Examination
Gh: Genital hiatus, a normal value of less than 4 cm. Values larger than 4 cm
may indicate we a kened levator ani muscle strength
Pb: Pe rineal body, site from posterior midline of the hymen to the mid-anal
opening
Hymen: The hymen is given a value of “ 0 .” Replaces an imprecise term
“introitus.”
Aa: Site at midline on anterior vaginal wall, site of urethrovesical crease,
approximately 3 cm from external urethral meatus. May be palpable in
some patients or indistinguishable.
Value -3 cm (no prolapse) to +3 cm (indicating a prolapse).
Ba: This is the 2nd point on the anterior vaginal wall. It represents the most
dependent (distal) point on this wa l l . Value will be -3 cm (no prolapse) up to
any value the length of the vagina (indicates some level of prolapse).
Ap: Site at midline on the posterior vaginal wall, approximately 3 cm from
hymen. Value, relative to hymen -3 to +3 cm.
Bp: This is the 2nd point on the posterior vaginal wa l l . It represents the most
dependent (distal) point. Value -3 cm (no prolapse) up to any value the
length of the vagina.
C: Most dependent (distal) aspect of cervix or vaginal cuff (post-hysterectomy).
Value: With no prolapse = negative number equal to TVL. With prolapse =
positive number up to or equal to TVL.
D: Site that identifies fornix. Only has a value if cervix is present.
Value: With no prolapse = negative number equal to TVL. With prolapse =
positive number up to or equal to TVL.
TVL: Length of vagina from the hymen to vaginal greatest depth, with prolapse
reduced and at rest, no straining.
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
and surgery (ACOG Committee on
Practice Bulletins – Gynecology,
2007; Herbruck, 2008). Discussion
should begin with patient education regarding the risk factors for
developing a prolapse and possible techniques to prevent worsening of the prolapse. Asking the
patient to identify her goals
regarding these health concerns is
important and can provide the
template for discussion. Patients
most satisfied with their tre a tment choice and outcomes have
identified specific goals re g a rding
expected outcomes.
Basic goals for conservative
management involve increasing
the strength and support mechanisms of the pelvic floor muscles,
which may prevent worsening of
the prolapse or perhaps delay the
need for surgery. Teaching
patients about healthy bowel and
bladder habits is also a factor
in conservative management
(Shariati, Maceda, & Hale, 2008).
Lifestyle changes, such as incre a sing fluid intake, increasing daily
consumption of fruits and vegetables, increasing fiber through diet
or supplements, and exercising,
can improve constipation, which
will reduce straining to defecate
(Kahn et al., 2005; Shariati et al.,
2008). Weight loss, reduced
straining with defecation, and
proper lifting techniques can
lessen the increase in abdominal
pressure considered to be a risk
factor for prolapse (Kahn et al.,
2005). Smoking cessation programs may reduce a chronic
smoker’s cough, which also might
reduce the sudden increase
in intra-abdominal pressure
(Schaffer et al., 2005). Pelvic floor
muscle training can be done by
physical therapists or nurses.
Formalized plans involving written instructions, demonstration
and return demonstration, and
periodic follow up improve the
efficacy of pelvic floor muscle
training as a treatment option
(Trowbridge et al., 2005). Electrical
stimulation and biofeedback are
additional treatment options for
conservative management.
221
Figure 3.
8-Inch OB/GYNE sw a b , previously measured in 1 cm markings, for
12 cm used to measure the reference points in assessment of pelvic
o rgan prolapse.
toms (Komesu et al., 2007). The
key to success with pessary usage
is proper choice of a pessary,
proper fit, and one with minimal
complications (Trowbridge et al.,
2005).
Implications for Practice
Table 3.
Staging System of Pelvic Organ Prolapse
Stage of Prolapse
Description of Prolapse
0
Indicates no prolapse is noted. Strong support is noted. The
a nterior and posterior anatomical points are all -3 cm.
C or D is – TVL and – (TVL-2) cm.
I
Cri t e ria for Stage 0 not met. The most distal prolapse is
greater than 1 cm above the hymen.
II
The most distal edge of the prolapse is between 1 cm above
and 1 cm below the hymen. At least 1 point must be -1, 0,
or +1.
III
The most distal edge of the prolapse is more than 1 cm
below the hymen but less than TVL -2 cm.
IV
This stage is indicative of complete procidentia. The distal
p o rtion of the prolapse is at least TVL -2 cm.
Pessaries have been used for
years to treat both pelvic organ
prolapse and urinary incontinence. The choice of which pessary to use may be based on the
type of prolapse identified and the
presenting symptoms (Trowbridge
et al., 2005). They can reduce the
222
symptoms of the bulge or pressure
sensations, as well as reduce the
need for splinting and improve
u r i n a ry incontinence (Komesu et
al., 2007; Trowbridge et al., 2005).
However, pessaries are less effective in reducing defecatory pro blems and may worsen these symp-
Pelvic organ prolapse is an
i n c reasingly common pro b l e m ,
one that is expected to increase as
the population ages, and is one
that has serious implications on
an individual’s quality of life.
Many times patients are reluctant
to discuss their symptoms, their
incontinence, or their splinting
habits to empty their bowel or
bladder. They develop complicated adaptive behaviors to adjust to
their symptoms. All patients
should be specifically queried
regarding their health status to
validate their symptoms and
behaviors, and educate them
about their treatment options.
Without the proper in-depth
assessment, patients may not be
aware how treatable their symptoms are .
Clinicians at all levels who
are involved in women’s health
must be well versed in the assessment of pelvic organ prolapse, utilizing evidence-based practice to
improve patient care outcomes.
Multiple clinical trials have validated the Brink scale tool and the
POP-Q scale (Bump et al.,1996;
FitzGerald et al., 2007; Kahn et al.,
2005; Swift et al., 2003; Weber et
al., 2001). The Brink scale and the
POP-Q assessment tool represent
an acceptable standardized means
of assessing the prolapse and provide a reference for treatment re commendations (ACOG Committee on Practice Bulletins –
Gynecology, 2007; FitzGerald et
al., 2007; Weber et al., 2001).
Clinicians need to be proficient in
perf o rming these examinations to
provide optimal care (Weber et al.,
2001).
Conclusion
As nursing re s e a rch opport unities increase, clinicians must be
UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4
proficient in the use of the validated research tools available. The
POP-Q system and the Brink scale
tool re p resent the most commonly used tools to assess and document pelvic organ prolapse and
pelvic muscle strength by urogynecologists and urologists. In
order to improve generalizability
of studies, common terminology
re g a rding prolapse stage is
mandatory.
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Urologic Nursing Editorial Board Statements of Disclosure
In accordance with ANCC-COA gove rning rules Urologic Nursing E d i t o rial Board statements of disclosure are published with each CNE offering. The statements of disclosure for
this offe ring are published below.
Kaye K. Gaines, MS, ARNP, CUNP, disclosed that she is on the Speakers’ Bureau for
Pfizer, Inc., and Novartis Oncology.
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(2008). High-fiber diet for treatment
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Cundiff, G., Davis, G., Dumchowski,
R.R., et al. (2001). The standardization of terminology for researchers in
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Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’
Bureau for Coloplast.
All other Urologic Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article.
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