The 6 POPQ sites are:
- Aa: The point in the midline of the anterior vaginal wall 3 cm proximal to the urethral meatus, corresponding to the urethrovesical junction. By definition, the range of position Aa is -3 to +3.
- Ba: On the anterior vaginal wall, the most dependent position between point Aa and the vaginal cuff or anterior vaginal fornix.
- C: Cervix or vaginal cuff (posthysterectomy).
- D: Posterior fornix corresponding to the pouch of Douglas (this point is omitted in the absence of a cervix).
- Ap: The point in the midline of the posterior vaginal wall 3 cm proximal to the hymenal ring. By definition, the range of position Ap is -3 to +3.
- Bp: On the posterior vaginal wall, the most dependent position between Ap and the vaginal cuff or posterior fornix.
Two additional measurements are made in centimeters while the patient is straining:
- GH: The genital hiatus is measured from the midportion of the urethral meatus to the posterior margin of the genital hiatus.
- PB: The perineal body is measured between the posterior margin of the genital hiatus and the midportion of the anus.
While the patient is not straining, a ninth measurement is made:
- TVL: Total vaginal length is the greatest depth of the vagina.
Staging each compartment. When all 9 of these measurements have been taken, a stage can be assigned to each compartment: anterior, apex (uterine or vault), and posterior. The stages are:
- Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at -3 cm and either point C or point D is within 2 cm of TVL.
- Stage I: The most distal portion of the prolapse is 1 cm above the level of the hymen (above -1).
- Stage II: The most distal portion of the prolapse is 1cm proximal to or distal to the hymen.
- Stage III: The most distal portion of the prolapse is 1 cm below the hymen but protrudes no further than 2 cm less than the total vaginal length.
- Stage IV: Complete eversion is present.
Most parous women are stage I, II, or III. If you remember that stage II is between and including -1 and +1, it follows that stage I is above this and stage III is below this. FIGURE 3 compares POPQ examination findings of normal support and posthysterectomy vaginal eversion.
Assess urethral hypermobility. In women with stress urinary incontinence, it is important to determine whether urethral hypermobility is present, since this finding may influence surgical management.
- Q-tip test. Measure mobility by placing a lubricated sterile cotton swab within the urethra so that the tip of the swab is at the urethrovesical junction. Lubrication with xylocaine gel may reduce the discomfort of this step. Measure the angle between the swab and the horizontal plane with a goniometer both while the patient is not straining and while the patient is straining at maximum. Urethral hypermobility exists if the angle is more than 30° either at rest or with straining.8
- Indications for surgery. Ahypermobile urethra is thought to correlate with decreased support of the urethra and the urethrovesical junction, which has been implicated in the development of stress incontinence. Many surgical interventions for stress incontinence are designed to increase support to this area.
In 1996, the American College of Obstetricians and Gynecologists (ACOG) published guidelines for surgery for genuine stress incontinence due to urethral hypermobility in patients without a history of previous antiincontinence surgery.10 These criteria include:
- History and demonstration of stress urinary incontinence
- No significant urge component
- Absence of transient causes of urinary incontinence
- Normal PVR volume
- Normal voiding habits
- Absence of neurologic history or findings
- Absence of pregnancy
- Confirmation that the patient has been counseled regarding more conservative therapy
The office evaluation of pelvic floor disorders outlined in this article meets the ACOG criteria. Of course, consider surgical management only after conservative measures have been exhausted.
Evaluate pelvic floor tone. This portion of the exam assesses the strength of the pelvic-floor musculature. Place 1 or 2 fingers in the vagina and instruct the patient to contract her pelvic floor muscles (i.e., the levator ani muscles). Then gauge her ability to contract these muscles, as well as the strength, symmetry, and duration of the contraction.
The strength of the contraction can be subjectively graded with a modified Oxford scale (0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good, 5 = strong).9
Women with an external anal sphincter defect may lack the normal stellate pattern around the anus anteriorly.
Determine structure and function of the anal sphincter. This is the final part of the physical exam. Women with an external anal sphincter defect may lack the normal stellate pattern around the anus anteriorly because of the absence of contractile tissue. A rectal exam should be performed at rest and with voluntary squeezing of the anal sphincter to assess resting tone and squeeze strength of the anal sphincter muscle complex. In addition, the bulk of this complex can be palpated to determine whether a structural defect is present (usually found anteriorly).