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An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP)

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An Erratum to this article was published on 16 March 2016

Abstract

Introduction

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report.

Methods

This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus).

Results

A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5–10 year) review is anticipated to keep the document updated and as widely acceptable as possible.

Conclusion

A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

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Notes

  1. In the era of advanced cellphone camera technology, a woman, at times, will bring photographic evidence of the prolapse at its worst. This can add to other clinical evidence, particularly if there is a discepancy between symptoms and signs.

  2. The more formal classification of constipation is as follows:

    Rome II diagnostic criteria for constipation:

    • At least 12 weeks, which need not be consecutive, in the previous 12 months, of two or more of:

    (i) Straining in > 1 in 4 defecations.

    (ii) Lumpy or hard stools in > 1 in 4 defecations.

    (iii) Sensation of incomplete evacuation in > 1 in 4 defecations.

    (iv) Sensation of anorectal obstruction/ blockage in > 1 in 4 defecations.

    (v) Manual manoeuvres to facilitate > 1 in 4 defecations (e.g.,: digital evacuation, support of the pelvic floor).

    (vi) Less than 3 defecations per week.

    • Loose stools are not present and there is insufficient evidence for IBS (irritable bowel syndrome)

  3. A symptomatic-based subdivision of Stage II (see Appendix A) was overlooked at this time in favor of maintaining the current strictly anatomical definition of the “sign of POP”.

  4. The axis of the retroverted uterus is parallel to that of the vaginal axis with less impediment to uterine (cervical) descent. In contrast, the anteverted uterus is perpendicular to the vaginal axis with impediment to descent by the posterior vaginal wall and behind that the rectum.

  5. Detrusor underactivity: Detrusor contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span.

  6. Acontractile detrusor: The detrusor cannot be observed to contract during urodynamic studies resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. The term “areflexia” has been used where there is a neurological cause but should be replaced by neurogenic acontractile detrusor.

  7. Women with detrusor overactivity have a median UEBW of 48.0 g (95 % CI 46–51), with urodynamic stress incontinence a median UEBW of 30 g (95 % CI 29–31) and those who have associated detrusor overactivity and urodynamic stress incontinence have a median UEBW of 37.3 g (95 % CI 33–41) (p < 0.001) [37, 38]

  8. Synthetic implant such as macroplastique, are hyperechogenic whereas collagen injections are hypoechoic and can be seen as spherical structures surrounding the bladder neck.

  9. The importance of precise structural assessment of the urethral sphincter using multiple axial cross-sectional areas at set distances can assist the evaluation of women with stress urinary incontinence. It has been suggested that it may predict the severity of incontinence as well as the outcome of continence surgery since a weak sphincter will have a lower volume compared to a competent/continent urethral sphincter [39].

  10. It is acknowledged this definition may not encompass cases of (i) symptoms of voiding dysfunction without abnormality of voiding parameters; (ii) abnormality of voiding parameters without symptoms of voiding dysfunction.

  11. A more space occupying pessary.

  12. A cuboid pessary does deliver ‘support’ by suction of the vaginal walls.

  13. It was first described by Kelly in 1913 and involves dissection under the full thickness of the vaginal epithelium followed by central plication of the pubocervical fascia over the bulging bladder with excision of the ‘excess’ vaginal wall skin. The Kelly-Kennedy plication suture (Alt: bladder neck buttress) is an extrapolation of midline fascial plication involving placement of sutures under the proximal urethra and bladder neck to try and treat or prevent stress incontinence.

  14. Its essential feature is suturing the cut cardinal/uterosacral ligament complex in front of the stump of the cervix hence pulling the cervix upwards and backwards, maintaining anteversion and creating anterior vaginal wall length.: This procedure can be performed intra- or extra-peritoneally. Concurrent McCall culdoplasty or vaginal vault suspension techniques may be employed dependant on the extent of prolapse [48].

  15. Variations in technique for all abdominal mesh/graft procedures: (i) Type of mesh or graft used; (ii) Shape of mesh /graft- single piece,‘DIY’ two piece ‘Y’ mesh, Y mesh kit product; (iii) Points and length of attachment to vagina. (iv) Suture material employed / Metal stapling devices; (v) Peritoneal closure over mesh/graft.

  16. This is usually performed in a woman with a uterus who is no longer sexually active. It can be performed in the absence of a uterus in a woman with vaginal eversion instead of total colpectomy. The Le Fort’s procedure involves denuding the vagina of skin both anteriorly and posteriorly, typically in a rectangular shape, avoiding the bladder neck and cervix. The cut edges are sewn together to achieve vaginal closure whilst leaving a bilateral epithelium-lined tunnel behind. The Labhardt procedure involves the removal of a 1 cm horse shoe shape of vaginal epithelium is removed over the posterior fourchette up to just under the urethra. By closing the incision and building up the perineum, an extremely high posterior repair almost closing the vagina is created.

  17. The vagina is totally denuded of skin, typically in sections, whilst avoiding the bladder neck region. The prolapse is then reduced by a series of successive purse-string sutures and the epithelium at the entrance closed.

  18. Refinement of previous classification [49] reflecting the average length of non-gravid uterine cervix [50] and the average length of the supportive influence of the distal segment of the uterosacral ligaments on the posterolateral vaginal wall bilaterally [51]..

  19. Mean length of Level II in women at posterior colporrhaphy found to be 5.0 cm [52]

  20. The outer edge of the vestibule is known as Hart’s line (see white line in Fig. 39 with blue line demarcating anterior and posterior vestibule).

  21. Mean length in women at posterior colporrhaphy was found to be 1.8 cm [52].

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Acknowledgments

The assistance of Prof Steven Swift is gratefully acknowledged for the Simplified POP-Q section and other helpful input. Prof John DeLancey also contributed helpful input to “Prolapse quantification” and the Appendix. We thank our invited external reviewers Prof Steven Swift, Prof Mark Vierhout, Prof Michele Meschia, Prof Doug Tincello and Prof Don Wilson for their constructive contributions. We also thank those who submitted constructive comments following IUGA and ICS website presentation of Version 12: Dr Kiran Ashok, Prof Phil Toozs-Hobson, Dr Kamil Svabik. Further helpful comments were received at an open forum at ICS Montreal from Beth Shelly, Julia Herbert, Kari Bo and Joe Lee. The talents of medical illustrator, Levent Efe were crucial to the development of this document levent@leventefe.com.au.

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Correspondence to Bernard T. Haylen.

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Conflicts of interest

BT Haylen: No disclosures.

CF Maher: No disclosures.

MD Barber: No disclosures.

SFM Camargo: No disclosures.

V Dandolu: Research grant–Allegan, Consultant-Pfizer; A Digesu: Honorarium for lectures or sponsorship to cover travel expenses at Meetings from: Astellas, Pfizer, Allergan, AMS, Medtronic, Uroplasty.

HB Goldman: Consultant – Allergan, Medtronic, Uroplasty; Speaker – Astellas, Allergan, Medtronic, Uroplasty.

M Huser: No disclosures.

AL Milani: No disclosures.

PA Moran: Speaker & consultant: Astellas and Ethicon Women’s Health and Urology. Consultant: Boston Scientific.

GN Schaer: Advisor (in Switzerland) for Astellas, Novartis, Pfizer.

MIJ Withagen: Research Grant 2010–Ethicon Women’s Health & Urology.

Additional information

International Urogynecology Journal, Vol. 27, No. 2, 2016. Copyright 2016. This material is reproduced with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc., and the International Urogynecological Association.

This document is being published simultaneously in Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ), the respective journals of the sponsoring organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA) in the February 2016 issue of each journal.

Standardization and Terminology Committees IUGA - Bernard T. Haylen, Christopher F. Maher, Paul A. Moran, Gabriel. N. Schaer

Joint IUGA / ICS Working Group on Female POP Terminology - Bernard T. Haylen, Christopher F. Maher, Matthew D. Barber, Sérgio Camargo, Vani Dandolu, Alex Digesu, Howard B. Goldman, Martin Huser, Alfredo L. Milani, Paul A. Moran, Gabriel. N. Schaer, Mariëlla I. J. Withagen.

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22922.

Appendix - Concepts and available measurements awaiting further validation

Appendix - Concepts and available measurements awaiting further validation

A: Subdivision of Stage II POP-Q:

An optional subdivision of Stage II into IIa (−1 to hymen) and IIb (hymen to +1) was considered at length. Stage IIA would then be defined as −1 to 0 (so the hymen, that is 0, is included in stage IIA) and stage IIB (>0 to +1), meaning the dependent part of prolapse beyond the hymen but no further than +1. It was felt that this might reflect a clinical difference between the two subdivisions in terms of symptoms. That change was not made at this time in part to maintain the current strictly anatomical definition of the “sign of POP”.

B: Vaginal Anatomical Levels and Lengths:

  1. (i)

    Level I: Uterine cervix (if present) and/or upper 2.5 cm of vagina. Footnote Footnote 18

  2. (ii)

    Level II: Mid-vagina from distal end of Level I to hymen. Footnote 19

  3. (iii)

    Level III – Vaginal vestibule: Vaginal entrance (Latin: “vestibulum” = “a space at the entrance of a canal”) from hymenal ring to just below the clitoris anteriorly (anterior vestibule), labia minora laterally and anterior perineum posteriorly (posterior margin of vestibule) (Fig. 39)Footnote 20

    Fig. 39
    figure 39

    Anterior and posterior vestibule

  4. (iv)

    Posterior vestibule:Posterior hymenal ring to anterior perineum (posterior margin of vestibule) (Fig. 40)Footnote 21

  5. (v)

    Total vaginal length [4]: Posterior vaginal vault to hymen (cm), i.e., Levels I and II posteriorly.

  6. (vi)

    Total posterior vaginal length [5254]: Posterior vaginal vault to posterior margin of vestibule (anterior perineum - cm), i.e., Levels I, II and III posteriorly.

  7. (vii)

    Anterior vaginal length: Anterior hymenal ring to the anterior vaginal vault (anterior cervicovaginal junction or anterior cuff post-hysterectomy) [55] (Fig. 41).

Fig. 40
figure 40

Posterior vestibule

Fig. 41
figure 41

Vaginal Levels (I to III) and Vaginal lengths (Anterior, Total, Total Posterior)

C: Additional available intraoperative measurements.

  1. (i)

    Perineal measurements:

    1. (a,b)

      Perineorrhaphy Width (PW) and Depth (PD) [54]: Width and depth of the excised perineum (Fig. 42)

      Fig. 42
      figure 42

      Perineorrhaphy width (PW) and perineorrhaphy depth (PD)

    2. (c)

      Perineal length (PL) [54]: Distance from posterior margin of vestibule to anterior anal verge (Fig. 43).

      Fig. 43
      figure 43

      Perineal length

    3. (d)

      Mid-perineal thickness (MPT) [54]: Thickness (cm) of the mid-perineum in the midline (Fig. 44).

      Fig. 44
      figure 44

      Mid-perineal thickness

    4. (e)

      Perineal Gap (PG) [5254]: Thinned out medial area (cm) between Moynihan forceps placed bilaterally where the labia minora meet the perineum (Fig. 45).

      Fig. 45
      figure 45

      Perineal Gap

    5. (f)

      Perineorrhaphy Commencement Position (PCP): NEW Where in Level III, the perineorrhaphy is commenced, e.g., hymen, mid- vestibule, posterior margin of vestibule.

  2. (ii)

    Posterior vaginal measurements [53]:

    1. (a)

      Posterior Vaginal Vault Descent (PVVD [52, 53]: Descent of the posterior vaginal vault towards the perineal gap obtained by subtracting the inferiorly displaced vaginal vault and the anterior perineum (second figure) from the total posterior vaginal length (TPVL - first figure – posterior vaginal vault to anterior perineum). (Fig. 46 and Fig. 47)

    2. (b)

      Mid-Vaginal Laxity (MVL) (Undisplaced) [52, 53]: Laxity of the vaginal mucosa (anterior traction) midpoint in the vagina super- posteriorly and in the midline with the vaginal vault held in an undisplaced position (similar to that after vault fixation) (Fig. 48)

      Fig. 46
      figure 46

      (left): Total posterior vaginal length (TPVL)

      Fig. 47
      figure 47

      (right): Distance from vaginal vault (on traction) to anterior perineum. Posterior vaginal vault descent is the subtraction of this measurement from the TPVL

    3. (c)

      Recto-vaginal Fascial Laxity (RVFL) [52, 53]: Laxity of the rectovaginal fascia (anterior traction) midpoint in the vagina super- posteriorly (mucosa opened) and in the midline with the vaginal vault held in an undisplaced position (Figs. 49)

      Fig. 48
      figure 48

      (left): Mid-vaginal laxity (vault undisplaced)

      Fig. 49
      figure 49

      (right): Recto-vaginal fascial laxity

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Haylen, B.T., Maher, C.F., Barber, M.D. et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J 27, 165–194 (2016). https://doi.org/10.1007/s00192-015-2932-1

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