Review of Techniques in Assessment of Pelvic Nerves and Quantification of Pelvic Organ Prolapse

Objectives: The purpose of this video is to review the steps of performing a pelvic neurologic assessment and Pelvic Organ Quantification (POP-Q) examination.

Methods: This instructional video first reviews vulvovaginal innervation and proper techniques for performing a neurologic examination through sensation testing and testing of the bulbocavernosus reflex. This neurologic assessment is then performed on a de-identified patient. The video then reviews the methods in quantifying pelvic organ prolapse with illustrated drawings. Stages of pelvic organ prolapse are reviewed with Stage 0 being no prolapse and Stage 4 being complete vaginal eversion. The POP-Q exam is then performed on two de-identified patients.



While reviewing the POP-Q examination, points of measurement (Aa, Ba, C, D, Ap, Bp, total vaginal length (TVL), genital hiatus, and perineal body) are explained and measured. Point Aa is in the midline of the anterior vaginal wall 3 cm proximal to the external urethral meatus, while point Ba is most distal position of any part of the anterior vagina. Point C represents the vaginal cuff or cervix. Point D represents the posterior fornix. Point Ap is in the midline of the posterior vaginal wall 3 cm proximal to the hymenal ring, while point Bp represents the most distal portion of the posterior vaginal wall. Total vaginal length is measured from the posterior fornix (or vaginal cuff) to the hymenal ring. Genital hiatus measures from the external urethral meatus to the posterior midline hymen. Perineal body measures from the posterior midline hymen to the midanus. Points Aa, Ba, Ap, Bp, C, and D are measured relative to the hymenal ring. Aa and Ap range from -3 cm to + 3cm, while Ba and Bp range from -3 to + TVL. All measurements except TVL are measured at maximum Valsalva. The patients are then staged according to the POP-Q staging system. Patient 1 is a 62-year-old female with Stage 2 (posterior predominant) uterovaginal prolapse and patient 2 is a 46-year-old female with Stage 2 (anterior and apical predominant) vaginal vault prolapse.

Clinical Relevance: Pelvic organ prolapse (POP) is a common and underreported ailment amongst women. In 1996, an international committee consisting of multiple gynecologic societies developed the Pelvic Organ Quantification (POP-Q) system as a standardized classification system for POP with nine measurements taken from fixed anatomic points. Given the increased complexity with this staging system, it can be difficult to teach and interpret. Assessment of pelvic neurologic status is also essential in performance of a complete and thorough pelvic exam. This video provides instruction in proper performance of both the neurologic assessment as well as the POP-Q exam.