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ORIGINAL RESEARCH |
From the *Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Good Samaritan Hospital, and Bethesda Family Medicine Residency Program, Cincinnati, Ohio.
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ABSTRACT |
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METHODS: Fifty consecutive patients with symptomatic pelvic organ prolapse were evaluated between February 2003 and August 2003. Patients were examined in the supine lithotomy and standing position at maximal bladder capacity and then in the supine lithotomy and standing position with an empty bladder. The International Continence Society's Pelvic Organ Prolapse Quantification system was used.
RESULTS: The mean descent of prolapse beyond the hymen was 0.39 cm in the full/supine setting, 1.3 cm, full/standing, 1.9 cm, empty/supine, and 2.7 cm, empty/standing. All mean paired differences in the six examination pairs (empty/standing compared with empty/supine, full/standing compared with full/supine, full/standing compared with empty/standing, full/supine compared with empty/supine, full/standing compared with empty/supine, and full/supine compared with empty/standing) were statistically significantly different. The largest mean paired difference was noted in the full/supine compared with empty/standing pair (–2.3, 95% confidence interval –2.8 to –1.8, P < .001). Age and parity were not associated with differences in measurements taken in the different examination conditions. Using a linear regression model to control for body mass index, maximal bladder capacity, and Pelvic Organ Prolapse Quantification system stage, it was found that the values were still statistically significant. Full/supine compared with empty/standing pairs were significantly more likely to be upstaged by 1 stage (P < .001), or by 2 stages (P = .049), but not by 3 stages (P = .061).
CONCLUSION: Unless a patient is examined in the standing position with an empty bladder, the full extent of the prolapse may not be appreciated.
LEVEL OF EVIDENCE: II-3
Due to the unknown effects of technique variability on Pelvic Organ Prolapse Quantification system assessment, the approved International Continence Society document suggested that a full description of technique must be included, such as type of examination table or chair, type of vaginal specula, retractors, or tractors, content of the rectum, patient position, and fullness of bladder.1 One study demonstrated that a higher degree of prolapse was noted in the upright examination as compared with the lithotomy position, although another study did not show this relationship.2,3 However, the effects of bladder fullness and patient positioning have not been previously studied.
The objective of this study was to evaluate the effect of bladder filling (empty or full) and patient position (supine or standing) on the degree of pelvic organ prolapse (of the maximally prolapsed segment) using the Pelvic Organ Prolapse Quantification system.
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METHODS |
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All patients were examined in the supine lithotomy and standing position at maximal bladder capacity (by 1 of the first 4 authors) and then subsequently in the supine and standing position with an empty bladder (by the senior author, M.K.). The senior author was blinded to the results of the initial assessments. The site of maximal descent was noted and located with reference to the plane of the hymen measured in centimeters proximal to the hymen or distal to the hymen, with the plane of the hymen defined as zero. A marked swab calibrated in centimeters was used. If no external prolapse was noted, a standard bivalved speculum was used to measure the apical points C and D while the posterior blade was used to measure Aa, Ba, Ap, and Bp. Measurements of prolapsed segments beyond the hymen did not require the use of a speculum. All points were measured with maximal straining by asking the patient to perform a maximal Valsalva effort. During the supine assessment all patients were examined on an examination table in the dorsal lithotomy position. During the standing assessment all patients were examined with their knees turned out without the use of a step. The patients were then assigned to 1 of 5 stages of pelvic organ support (0–IV) in accordance with the Pelvic Organ Prolapse Quantification system.1
The patients’ first assessment consisted of an initial void volume and postvoid residual, which was assessed with in-and-out catheterization. Next, to achieve maximal bladder capacity, a simple cystometric filling study was performed. Maximal bladder capacity was determined to be the filling volume at which a patient would "stop her car on the side of the highway to void behind a tree." Full bladder examinations (supine and standing) were performed at this point. Next, the patients were asked to empty their bladder spontaneously; void volumes were recorded and postvoid residual volumes were calculated by subtracting postvoid residual volumes from maximal bladder capacity volumes. Those patients with postvoid residuals greater than 50 mL were catheterized before the subsequent examinations in the empty bladder (supine and standing) settings. Age, parity, stage of prolapse, maximal bladder capacity, height, and weight were recorded. Body mass index (BMI) was calculated based on height and weight (kilograms per meter squared).
A power calculation (
= 0.01, power 90%) determined that 32 patients in total were required to detect a clinically important difference of 2 cm between points of maximal straining, with a variance of 1 cm.2 Two-tailed t tests were used to compare the points of maximal straining between paired samples. A partial Bonferroni adjustment was performed to decrease the risk of a type I error. Spearman rank correlation was used to identify whether any patient characteristics (age, parity, stage of prolapse, BMI, and maximal bladder capacity) were associated with a significant change in Pelvic Organ Prolapse Quantification system measurements. A linear regression model was used to determine whether mean pair differences were still statistically significant after controlling for multiple potential confounding variables. Continuous variables are expressed as the mean ± standard deviation or 95% confidence interval (CI). Ordinal variables, such as stage of prolapse, are expressed as median (range). Spearman rank correlation was used to determine whether a correlation between the likelihood of upstaging was associated with compartment of prolapse (anterior or apical or posterior) or severity of initial prolapse in the full/supine condition. Pearson 
2 was performed to determine whether significant differences were noted in upstaging in comparing the paired samples. Statistical analysis was performed using SAS (SAS Institute Inc., Cary, NC).
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RESULTS |
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The mean descent of prolapse beyond the hymen at various examination conditions is shown in Table 1. Table 2 shows that mean maximal prolapse was significantly different in all 6 combinations of patient positioning and bladder status. The greatest difference was seen in the full/supine compared with empty/standing conditions. In all patients, the compartment that was maximally prolapsed was the same in all examination conditions.
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Using Spearman rank correlation, maximal bladder capacity, BMI, and stage were significantly associated with differences in measurements taken in each examination condition, whereas age and parity were not. Using a multiple linear regression model we controlled for BMI, maximal bladder capacity, and stage of prolapse. The regression results were unchanged from the reported univariate results in Table 2. Using points Ba, C, or Bp, no correlation was noted between the likelihood of upstaging associated with compartment of prolapse (anterior, apical, or posterior) or severity of initial prolapse in the full/supine condition.
The effect of examination condition on stage of prolapse is summarized in Table 3. When examined in the empty/standing condition, 21 (42%) had the same stage of prolapse, 24 (48%) were upstaged one stage, 3 (6%) were upstaged 2 stages, and 2 (4%) were upstaged 3 stages compared with the full/supine condition. Full/supine compared with empty/standing pairs were significantly more likely to be upstaged by 1 stage (P < .001), or by 2 stages (P = .049), but not by 3 stages (P = .061) compared with the other groups.
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DISCUSSION |
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We hypothesize that a more favorable pelvic tilt is produced in the standing position. In the dorsal lithotomy position, the vagina is directed posteriorly toward the sacrum, but the axis is almost horizontal in the upright position.6 Thus, a patient must work against gravity to fully reveal the degree of prolapse on examination in the supine position. It has been suggested that the standing position does not provide the same degree of pelvic tilt provided by a birthing chair, which allows greater hip flexion and more closely resembles the orientation of the McRoberts maneuver used for shoulder dystocia in labor and delivery.3 However, the birthing chair is not available in many centers for outpatient gynecologic examinations. We examined the patients in the standing position without the use of a step. This was done to eliminate the effect that one flexed thigh might have on pelvic tilt and thus extent of prolapse. We also hypothesize that a full bladder inhibits the performance of a full Valsalva maneuver, possibly related to the fear of urinary leakage during the episode of increased intra-abdominal pressure. In addition, during the bladder storage phase there is increased pelvic floor muscle tone and stimulation of somatic nerves to the striated urogenital sphincter.7
Our study also indicates that the maximal extent of prolapse may be influenced by the combination of bladder volume and patient positioning. Our data suggest that an empty bladder and the standing position are the optimal conditions for demonstrating maximal extent of prolapse. This is due to the additive effects of a more favorable pelvic tilt produced in the standing position and the lack of inhibition of a full Valsalva maneuver due to a full bladder. A mean difference of 2.3 cm was noted between the empty/standing and the full/supine conditions. In addition, 29 (58%) of these patients were upstaged by 1–3 stages. In the full/standing compared with empty/supine conditions, only 11 (22%) experienced a difference in 1 stage, which may be explained by the canceling out of the effects of pelvic tilt/gravity and Valsalva effort in each pair. Our findings also suggest that bladder volume may have a greater effect on the demonstrable degree of prolapse compared with patient position. When comparing the mean paired differences in the standing compared with supine condition (by combining the full standing compared with empty standing group with the full supine compared with empty supine group) to the full compared with empty bladder conditions (by combining the empty standing compared with empty supine group with the full standing compared with full supine group), a greater mean paired difference was noted in the latter (–1.45 compared with –0.85). The effect of Valsalva maneuver and increased intra-abdominal pressure is, therefore, likely more important in eliciting maximal prolapse than the effect of pelvic tilt.
It is important to examine the limitations of this study. We obtained a convenience sample of the first 50 consecutive patients that presented with symptomatic pelvic organ prolapse. Because this was not a random selection, our study group may not be representative of the entire population. In addition, we cannot draw any conclusions regarding the effect of bladder volume and patient positioning on those with stage I prolapse, because we limited our patient selection to those with symptomatic prolapse. Finally, 5 examiners obtained the Pelvic Organ Prolapse Quantification system values: the first four authors in the supine lithotomy and standing position at maximal bladder capacity, and then subsequently the senior author in the supine and standing position with an empty bladder. We acknowledge that this is a drawback of the study methodology. However, this protocol was chosen because it accurately reflected the standard of practice in our clinic. We did not estimate interexaminer reliability. However, two studies have shown good reproducibility of the Pelvic Organ Prolapse Quantification system measurements.4,8 For example, in a study by Hall et al,4 7 examiners (including 2 attending faculty members, 3 urogynecology fellows, and 2 third-year residents) were randomly paired to perform Pelvic Organ Prolapse Quantification system examinations on 48 subjects, each blinded to the results of the other examination. Their study showed that correlations for each of the Pelvic Organ Prolapse Quantification system measurements were highly significant and staging was highly reproducible. In our study, the senior author performed all the empty-bladder examinations and was blinded to the results of the full-bladder examinations, thus reducing any potential bias and nonrandom misclassification errors.
Our results suggest that the maximal extent of prolapse may be best assessed in the standing position with an empty bladder. This can be performed in a majority of patients except those with physical or motor impairments that may prevent a standing examination. In the morbidly obese patient, the standing position may be the only feasible option (other than the sitting position), because patient size and weight may prohibit placement on an examination table in the supine position. Upstaging of the Pelvic Organ Prolapse Quantification system examinations may affect management, especially if large differences are noted between the initial and final examinations. Although we did not analyze this specifically with our patient population, depending on local practice, more severe degrees of prolapse may be treated differently. Management differences may include whether an abdominal or vaginal repair is performed, whether a hysterectomy is performed, whether certain compartments will be surgically treated or left intact during surgery, whether an augmented repair is performed, whether a pessary is determined to be appropriate management, or whether further imaging or laboratory studies are necessary to evaluate renal function and status. In addition, increasing severity of pelvic organ prolapse may associated with specific symptoms that are related to urinary incontinence, voiding dysfunction, fecal incontinence, constipation, and sexual dysfunction whose treatment may also be affected.9 Future study is needed in these areas.
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Footnotes |
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Presented at the American Urogynecologic Society 2003 Annual Meeting, September 10–13, 2003, Hollywood, Florida.
The authors thank Meg Doerzbacher, RN, MSN, and Aprylle Corbin, who helped to analyze the data.
Reprints are not available. Address correspondence to: Dr. Scott E. Woods, Bethesda Hospital, Bethesda Family Medicine Residency Program, 4411 Montgomery Rd, Suite 200, Cincinnati, Ohio 45212; e-mail: liverdoctor{at}yahoo.com.
10.1097/01.AOG.0000131619.97936.e2
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REFERENCES |
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2. Barber MD, Lambers A, Visco AG, Bump RC. Effect of patient position on clinical evaluation of pelvic organ prolapse. Obstet Gynecol 2000;96:18–22.
3. Swift SE, Herring M. Comparison of pelvic organ prolapse in the dorsal lithotomy compared with the standing position. Obstet Gynecol 1998;91:961–4.[Abstract]
4. Hall AF, Theofrastous JP, Cundiff GW, Harris RL, Hamilton LF, Swift SE, et al. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol 1996;175:1467–70.[Medline]
5. Visco AG, Wei JT, McClure LA, Handa VL, Nygaard IE. Effects of examination technique modifications on pelvic organ prolapse quantification (POP-Q) results. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:136–40.[Medline]
6. Berek JS, Adashi EY, Hillard PA, editors. Novak's gynecology. 12th ed. Baltimore (MD): Williams & Wilkins; 1996.
7. Benson TJ, Walters MD. Neurophysiology of the lower urinary tract. In: Walters MD, Karram MM, editors. Urogynecology and reconstructive pelvic surgery. 2nd ed. St. Louis (MO): Mosby; 1999. p. 15–24.
8. Kobak WH, Rosenberger K, Walters MD. Interobserver variation in the assessment of pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:121–4.[Medline]
9. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332–7.[Medline]
This article has been cited by other articles:
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  A. M. Weber and H. E. Richter Pelvic Organ Prolapse Obstet. Gynecol., September 1, 2005; 106(3): 615 - 634. [Abstract] [Full Text] [PDF]
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