ICS 1999, Denver
Informally discussed posters
Pelvic floor
Effect of patient position on the clinical evaluation of pelvic organ prolapse

M.D. Barber, A.R. Lambers, A.G. Visco, R.C. Bump
Division of Gynecologic Specialties, Duke University Medical Center, Durham, North Carolina, USA

Aims of Study: To compare the severity of pelvic organ prolapse between examinations performed in dorsal lithotomy position and examinations performed upright in a birthing chair using the International Continence Society's Pelvic Organ Prolapse Quantification System (POPQ).

Methods: One hundred and eighty-five consecutive women who presented to the Pelvic Floor Dysfunction Clinic at an academic medical center between April, 1997 and September, 1998 were included in the study. All patients were examined in the dorsal lithotomy position at their initial patient visit and then, at a second visit, in a birthing chair at a 45% angle. All examinations were performed by the same examiner and with the patient performing maximum valsalva. Degree of pelvic organ prolapse was assessed using the POPQ. Methods, definitions, and descriptions conform to the standards recommended by the International Continence Society. The nine site-specific measurements and the stage of pelvic organ prolapse were compared using Wilcoxon signed-rank test and Pearson correlation coefficients. Multivariate analysis was used to identify if any patient characteristics were associated with a significant change in stage or POPQ values with a change in exam position.

Results: When examined in the dorsal lithotomy position, 65 patients (35%) were Stage 0 or I, 74 patients (40%) were Stage II, 39 patients (21%) were Stage III and 7 patients (4%) were Stage IV. When examined upright, 128 patients (69%) had the same stage of prolapse while 48 (26%) increased their stage and 8 (4%) decreased their stage. Of patients who were Stage 0 or I when examined in lithotomy, 22 (34%) were Stage II or greater when examined upright. Similarly, of patients who were Stage II in lithotomy, 17 (23%) were Stage III or greater when examined upright. There was a statistically significant increase in the degree of prolapse at the POPQ measurements Aa, Ba, C, Ap, Bp, GH, and PB (p<.002 for each point), but not at point D or in the measurement of total vaginal length (TVL). The change in POPQ measurements was 2.5 cm or more at points Ba, C, Bp and GH in ten percent of patients. The correlation coefficient for each site was: Aa .83, Ba .91, C .87, D .69, Ap .78, Bp .87, GH .79, PB .70 and TVL .81. Multivariate analysis identified no patient characteristics that were independently associated with a significant increase in POPQ values with change in exam position.

Conclusion: The degree of pelvic organ prolapse assessed with the patient in the lithotomy position correlates well with assessment performed upright, however, overall there is an increase in the degree of prolapse with urpright exam. There are a notable percentage of patients in which upright examination demonstrates Stage III or IV prolapse that was not apparent in lithotomy position.