Urogynecology and Pelvic Reconstructive Surgery
Pelvic organ prolapse is quantified with the POP-Q system, which uses six points (Aa, Ba, C, D, Bp, Ap) plus genital hiatus, perineal body and total vaginal length. Stage 0 is no prolapse, stage 1 is more than 1 cm above the hymen, stage 2 is between 1 cm above and 1 cm below the hymen, stage 3 is more than 1 cm below the hymen but not completely everted, and stage 4 is complete eversion.
Urinary incontinence is classified as stress (leak with effort), urge (with urgency) or mixed. Urodynamics are useful before surgery in complex cases and demonstrate detrusor overactivity or intrinsic sphincter deficiency. Conservative treatment - pelvic floor muscle training, weight loss, pessaries - comes first. Surgery includes anterior or posterior colporrhaphy, vaginal hysterectomy with McCall culdoplasty, sacrocolpopexy for apical prolapse, and midurethral slings for stress incontinence. Mesh use carries specific regulatory warnings and requires informed consent.
Traps: mistaking point D for the cervix when it represents the posterior fornix; offering surgery before conservative measures; missing occult stress incontinence after prolapse reduction; and failing to recognise vesicovaginal fistula after obstructed labour or hysterectomy.
Rule of thumb: stage 2 prolapse means the leading edge lies within 1 cm above or below the hymen.