Classification Schemes

The traditional Baden-Walker system uses the midvaginal plane as a landmark, and anatomic defects are graded from 0 to 4. Grade 0 is normal while a grade 4 extends beyond the hymen. In the recently adopted Pelvic Organ Prolapse Quantification (POP-Q) system, two points along the posterior vaginal wall are identified (Ap: 3 cm proximal to the hymen; and Bp: the most dependent part), and their distances from the hymen are measured in centimeters with maximum Valsalva effort (Fig. 19.2). The more traditional approach has a surgical focus, whereas the newer POP-Q simply identifies the location of specific vaginal points.

Additional factors that should be evaluated during the physical exam include associated pelvic support defects such as vaginal vault prolapse or cystocele, pelvic neuromuscular function, and vaginal mucosal estrogenation. All pelvic floor anatomic defects should be repaired during a reconstructive surgical procedure even if minimally symptomatic, as untreated anatomical defects of the anterior and apical vagina may enlarge after repair of the posterior vaginal wall. Thus, preoperative identification of specific individual defects is crucial. Appropriate levator contraction strength is a key factor in enhancing the long-term success rate of pelvic reconstructive surgery. Regular Kegel exercises should be rec

Figure 19.1. Lateral view of pelvis. Rectoceles typically develop between the levator plate and the perineal body due to weakness of the rectovaginal septum endopelvic fascia. Reprinted with permission of the Cleveland Clinic Foundation.

Figure 19.2 POP-Q classification of prolapse severity; points Ap and Bp mark the posterior vaginal wall.Other points include anterior vaginal wall (Aa, Ba), vaginal depth (D), cervix (C),total vaginal length (TVL), genital hiaturs (gh), and perineal body (pb).

ommended following pelvic reconstructive procedures. Biofeedback therapy may be necessary to instruct patients how to adequately isolate and contract their pelvic floor muscles. Poorly estrogenized thin vaginal mucosa should be treated with local estrogen prior to surgical therapy, as well as postoperatively to enhance mucosal strength.

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