the basics of prolapse in the exam. Okay, welcome back from lunch. I have no financial disclosures as I said before, but I would just like to say that in this talk I'm going to use the term woman as people who have individuals with vaginas and uteri. That does not necessarily reflect all people who consider themselves women, but for the purposes of this presentation that is who I'll be referring to when I say women. These are learning objectives. Okay, they can see this. Wonderful. Okay, so prolapse is a common condition. It's the descent of the vaginal walls, uterus, or vaginal apex. It's essentially a hernia through the vagina where the organs fall through. That's how I explain it to patients and it's so common. About 40% of women that we see in the office will have prolapse on examination and that's if you look at large studies of women presenting for annual exams as well. However, only 3% are going to be symptomatic from their prolapse, which is important to remember. We'll get into the definition of, or the stages and when people have symptoms later on in the presentation. About the peak presentation is about 60 years old and 11% of women who have prolapse and other pelvic floor disorders will undergo surgery in their lifetime. So risk factors for prolapse are really being a woman having a vagina, right? That means something can fall through it. We're all at risk. So something to keep in mind, try not to discriminate when you're assessing who you think is going to have it or not. Increasing age, increasing parity, obesity are all associated with increased risk, right? So you start adding these things on, the risk of prolapse is higher. Previous hysterectomy, those patients are twice as likely to have prolapse. It's a little bit chicken or the egg. What came first? Was it the hysterectomy? Was it the prolapse? We don't know, but there is definitely removing some support which we'll get through and kind of chronic increased intra-abdominal pressure. So constipation, CrossFit, those things. What's not on here is the genetic probably risk or predisposition that we're learning more about. You know, these prolapse probably is more common in certain families, right? You see that mother, daughter, sister will have it. Also those patients who have connective tissue disorders are at higher risk of pelvic organ prolapse. And actually probably having failures with their surgery as well. So those are things to keep in mind as you think about risk factors. One thing I didn't add there was race and ethnicity and that does come up in studies. I think the biologic possibility is not necessarily there in the literature. So I didn't want to necessarily include that. We don't know that there's anatomical differences by race or ethnicity to cause differences in prolapse rate. So it's not there, but you may come across that in your literature. So when we think about prolapse and what causes prolapse, there are two kind of main theories. One is a loss of support to the vagina. So there are three levels of support in the vagina. Dr. Delancey who's still at Michigan discovered these in the late 80s when doing cadaveric studies. And so if you think about the vagina kind of as a long tube, the top of the vagina where the cervix would be, there are connections, ligaments up there, right? Your uterus sacral ligament and your cardinal ligament, that's your level one support. It keeps the vagina suspended up so it's not falling down. Then as you travel down the length of the vagina, you can see on the screen there, there's that two white sheets that connect out laterally to our arcus tendinea pelvic fascia, our endopelvic fascia. It keeps the vagina closed. In that middle picture there on the left, the vagina doesn't sit open, right? The vagina doesn't like open hole where water goes in, gas goes in. It's closed. It keeps that nice H shape and that is from our endopelvic fascia that keeps the vagina closed and keeps the bulge from coming. And then our most distal support is our perineal body where we get all those muscles kind of converging in, our ischiocavernosus, bulbous cavernosus, transverse perinei, superficial and deep, external anal sphincter come together to make our perineal body. Our perineal body is what keeps our vagina, vaginal opening narrow and closed. When the vaginal opening is gaping, we've lost that level three support. And level three support we commonly think of as our injuries with childbirth. Our second and third degree lacerations, fourth degree lacerations that cut through the perineal body is where we see a lot of that injury come from there and then you get a widened vaginal hiatus or vaginal opening. The second etiology or prolapse that we're going to go through has to do with our levator muscles. So we just talked about the vagina and the attachments to the vagina that keep its shape. The levator ani are the bowl of muscles that you see here connected to our bony pelvis and that keeps everything lifted and elevated like our hammock, so to speak. If there is injury to that hammock, the organs can fall down and through. So that's kind of normal there. And this is a sagittal view on MRI and the blue area represents the levator ani plate, okay, from the bottom of the pubic bone to your coccyx. And that red area is the urogenital hiatus, basically same thing from the pubic bone down to the anus. And this is somebody who doesn't have prolapse in this picture. And then in patients with prolapse, you can see here with Valsalva or even just at baseline that levator ani plate has stretched. So there's this ballooning and descent of those muscles, that stretch that happens. And in that urogenital hiatus, the area of the vaginal opening essentially in perineum is large. And you can see the highlighted area there is the bladder with urine inside and how that bulge is coming down and out. So this is a great picture, I think, to visualize what's actually happening anatomically when you have somebody bear down and see that prolapse. So the two causes are the loss of support with our levels of support and that injury can happen from childbirth, connective tissue injury, other type of pelvic injury and then with our levator ani. So there was a study that showed even in women that did not have tear, a visual tear after vaginal delivery, 30% or more actually had a levator injury below the vaginal epithelium, right? So even though you do not see a tear, there is still injury that's happening with vaginal childbirth. And that could be someone who has labored and then has a C-section as well. And the injuries can be from prolonged pushing, the head sitting down in the pelvis, you can have nerve injury or you can actually have avulsion of the muscle away from the wall and that will never heal, right? Patients compensate for a long time but then as you get kind of in that menopause area, hormones change, collagen changes in the tissue, they may not be able to compensate anymore and that's why we see prolapse kind of at its peak in the six-year-old women. Okay, so types of prolapse. So we can see here in the little box that that's like normal anatomy and if you look, you have your bladder, uterus, vagina and then rectum. And you can imagine almost that there's like a little kind of line right below those three organs holding everything up. If you look on the bottom left here, that's your anterior vaginal wall prolapse. You can see the edge of the bladder has dropped down into the opening of the vagina. This used to be called cysticile. We try not to use that terminology anymore. Urethraceal is next to there where we have some laxity of the urethra itself. There is uterine prolapse when the uterus descends, right? So you'll see the cervix on examination as your leading edge and then vaginal vault prolapse in patients who've had a hysterectomy before, total hysterectomy and don't have a cervix. Above the vaginal vault prolapse is the enterocele. So that is when the small bowel enters the sac of the vagina and kind of that is what's protruding out outside. Usually vaginal vault prolapse and enterocele kind of go hand in hand. That's what you're going to see there. And then the posterior vaginal wall is that back wall of the rectum which is pooching out where there's a loss of support. So a loss of support or those injury that we showed the mechanisms before can lead to these different types of prolapse that we see on examination. And probably the most common thing, well, we're going to, I'd say they're all probably common but you and you're thinking about doing a repair for prolapse or someone who's symptomatic, it's most likely going to be an anterior vaginal wall and apical prolapse that we're going to see. Very, more rarely do you see somebody with isolated posterior vaginal wall prolapse. So patients will come in, they may report pelvic pressure and heaviness, vaginal bulge, difficulty emptying bladder or rectum, splinting to defecate. Splinting is tricky but they can report that. Splinting is not always prolapse. Sometimes it's pelvic floor dysfunction so you need to assess that out a little bit. Constipation and sexual dysfunction. Sometimes insurance will want you to document these, especially if someone's going to prolapse that they're having symptoms. So it's important to put this in your HPI. But also to know what is going to get better or not after any intervention. And then you can see here, concomitant pelvic floor disorders, urinary incontinence, overactive bladder and fecal incontinence are very common. In terms of assessing prolapse when we do our history, we talked about our validated measures before to assess symptoms when somebody comes in. Our most sensitive question is from our Pelvic Floor Distress Inventory or the PFDI. And it's do you usually have a bulge or feel something falling out that you can see or feel in your vaginal area? In a patient population that has a high prevalence of prolapse, so 30% or more, this is a very sensitive question. 96% sensitivity. So when the patient says yes to this question, they probably do have prolapse before you even do your exam. And the specificity is a little bit lower but still pretty good. For a lower prevalence, say you are in a general OBGYN clinic, there's less prolapse, you've had a wider range of patients, the sensitivity is going to be much less. So if they say they feel a bulge, you're like, oh, I'm not actually sure if they're going to have prolapse or not. And that's kind of what I think about with my younger patients who are like 20 and noliparous who come in. You know, it's probably, it may not be prolapse. And the specificity is high. So if they say no, then probably a good chance, no, they're not going to have surprise prolapse on exam. But I will say sometimes you are surprised because I'll get the history from the resident and they're like, I'm like, oh, it's not prolapse. And then I'm like, oh, it is prolapse. OK, you know, I was wrong. So I think keeping an open mind as always is important when we're evaluating our patients. Prolapse is dynamic. And I think this is especially true in some of the younger patients in their 30s and 40s. I've seen like they'll come in. They're telling me they have prolapse. I don't really see anything. I have them stand up, bear down. I still don't see much. And then I will get a picture in my chart and I'm like, oh, that's definitely your cervix. Like you definitely have prolapse, you know. And so I think there are day to day changes that can happen, but also hormonal changes in the cycle. I don't think we know enough about how that impacts prolapse or not, but probably has to do with that level one support and those ligaments being stretchy and not. But prolapse can change. So just because someone says they have it, you don't see it. Now with my chart or Epic, whatever system you have, it's great. You can take a picture. You can send it to me in a secure way so I can see your prolapse. And then prolapse can be exacerbated by all these different activities here with the bladders full, physical exertion, etc. Okay, so evaluation of prolapse. I know we went through a little bit during our SUI talk earlier, but really the thing I'm going to focus on right now here is the POPQ examination. That's kind of like our core way that we measure pelvic organ prolapse. And so this was developed by the ICS in 1995 in order to, a system for us to quantify, describe, and stage pelvic support. And there are stages zero from four. There are some other systems out there like the Baden-Walker people may hear about. I never personally used that one, but I know some people really like it. But this is kind of what we use now. OGS and SGS also accepted this in 1996. It allows one provider to another to talk about prolapse and the stage and the numeric values and have that be consistent. It allows you to evaluate change with intervention pre and post as well. And so it's a nice standardized way to talk about prolapse. There are some probably shortcomings with the POPQ, but it's the best that we have right now. There are also other measurements. I know you'll probably see dynamic MRIs, especially if patients coming from colorectal that use different points. But I will always still do a POPQ in those patients and use this system to talk about their prolapse and determine management. Okay, so we're performing our POPQ. I think this is, probably don't have to say it, but consent is always important, right? If you're able to talk to the patient first, dressed, that's important. And then ask them, you know, is it okay if we do an exam to evaluate for prolapse? This is what we're going to do. And talk them through it. Some patients want to know everything. Some people are like, just do the exam. But it is important to acknowledge what you're going to do and ask the patient if it's okay to do it. If they feel like they don't want an exam, you know, that is their prerogative. But I obviously can't offer you surgery, you know, if I haven't seen things or a pessary. But they can say no, that's okay. And get to a point where we've established trust where they'll allow me to do an exam. You want them to empty their bladder. Do this with an empty bladder if possible. You're going to need them in lithotomy. You need your measuring stick, whatever you're going to use. And a speculum that will split into two, preferably. And you're going to record nine values in centimeters. And just as a reminder, your hymen is like your zero point. Anything inside the vagina or above the hymen is going to be a negative number. Anything outside of the hymen or coming towards you is going to be a positive number. Okay, so these are all of our POPQ points here. So actually there's six points. And there are three measurements. And this is a lot. And again, you guys will have the slides. And we're going to update them to make sure you have the correct ones. But on the anterior vaginal wall, we have big A and big B with the little a. The little a stands for anterior, okay. Posterior wall, we have big A and big B as well. But the P is posterior. So we're doing the same measurements, both anterior and posterior. And then we have the top of our vagina. Our cervix or our vaginal cuff is C. And the posterior fornix is D. And then we have measurements that we're going to do. Our dental hiatus and our perineal body. Both at rest and with Vasalva. To see the change that happens between the two values. And then our total vaginal length, which is a measurement of how long the vagina is. Kind of gently lifting up that prolapse, okay. Because that's going to give us an idea of how much redundant vagina we have. And what surgical approaches might be good for the patient. And so we're looking for descent of one or more of these vaginal walls, anterior, posterior or uterus to describe prolapse. And so here's our anterior wall where you have those two marks, our AA and our BA. The AA is basically the area right underneath the urethra. When I was first learning to do the POPQ, this was kind of a confusing concept for me. But I just think about that, almost like if you put a Foley in somebody, where that Foley balloon is, between the Foley balloon and the urethral meatus, that's your AA point. And you want to watch and see what happens with that point when the patient basalvas. And I'll show you some pictures there. But generally, looking at prolapse, especially if it's a stage two or more, there's going to be something big coming out in your face. And I think of that big B as big bulge. What is bulging out? Let's not get lost in the sauce with all these points. What is sticking out at us? That's the most important thing. So front wall, back wall is kind of the same thing. That AP on the back wall is really telling me about that level three support in their perineal body. And then C, I think, is kind of the easiest. It's the cuff, it's the cervix, what's there. And D is that point kind of right behind there. You want to record all these values with cough or basalva. And usually for my anterior and posterior wall, I split my speculum to look at them more closely. Genital hiatus is from your mid urethra to your posterior forchette, that measurement, so with or without basalva. And your perineal body is from your posterior forchette to your mid anal opening. As the prolapse gets worse, usually your genital hiatus gets larger and your perineal body gets smaller. Sometimes you'll be surprised. It looks like they have no prolapse and they have them bared down and you're like, wow, the GH went from three to like six. That's how dynamic the prolapse in these muscles can be. This is step-by-step here of how you're going to perform your POPQ. And again, I've asked Wade to upload the most current version so you guys have this. But first thing you're going to do is just look. Just look, see what's going on. And then you want to measure your GH and your PB at rest. Then I have them cough or basalva. Watch that cough though because if they have stress incontinence you don't want to get urine on you. So put your hand up. And if you see there's no urine coming out, you can keep going. Then I do my GH and my PB with basalva. And then for me at this point, I will put a small speculum in to get my total vaginal length. So I'll push everything up. And I'll put my measurement stick in, my POPQ stick. I'll measure how long the total vaginal length is. And I would say for me, typically if they have stage 3 prolapse, it's probably going to be somewhere between 10 and 12 centimeters is the vaginal length of prolapse. Normal vaginal length, depending on what study you read, is 6 to 8 centimeters. So you know it's longer. And then I will split my speculum. I'll split it. And I'll put it on the posterior wall. And I'll put my POPQ stick on the hymen. And I'll have the patient bear down to see how far out that bulge comes towards me. And then I'll flip it the other way to do the posterior wall. And lastly, I do my cervix. For me, I put one finger in the vagina to feel my cervix because I feel like at least when I'm working with new people and trainees, they push the cervix up with the speculum. So I like to feel where that cervix is kind of naturally resting and have the patient push down. And then I know, OK, it's about minus 3 from the hymen. I just kind of know the lengths of my finger here. But you can also measure it too. But you don't want to push that cervix up and say they don't have apical prolapse because really what I'm thinking about is, is there an apical component to this prolapse that I need to address? And 9 times out of 10, if they have anterior wall prolapse, there is an apical component. And that is what, you know, if you're working with physicians, what they're going to want to know is what that apical component is. So we can talk about the apical suspension portion. And also it's good too for pest refitting as well. OK. So for the POPQ, it's like what do I see? What is coming out at me? Is it the anterior wall? Is it posterior wall? Is it the cervix or the cuff? I think that's kind of a really like nitty gritty way to just think about it and then work back from there to get your points. And then how many centimeters is that bulge beyond the hymen? Is it 1 centimeter? Is it 2? Is it 3? Sometimes it's really obvious. And sometimes it's right there at the opening. But usually when I have patients who come in and they're symptomatic from prolapse, there is stage 3. They're beyond that 1 centimeter of prolapse. Rarely will I get somebody who's a stage 2 that's symptomatic. They tend to be younger patients. And then is stress incontinence present? You'll want to document that as well. So if they're leaking throughout the exam. So these are our prolapse stages. I feel like it's hard to look at this. So I'm going to go to the next slide. But just so you can see here. I like this picture because it helps me think about the prolapse. I feel like green is like go. That's where most of the prolapse is going to be when you see it in the office. The yellow is kind of like we're getting warm here. That's right around the hymen area where you're going to see it. Once somebody is in that hymen or beyond, we can offer them a surgical approach. Yeah. So stage 2, the leading edge. So the biggest bulge that's coming out at you has to be between minus 1 to 1 centimeter inside the hymen to 1 centimeter beyond the hymen, which includes that 0. I mean it's kind of a tricky way that they did that. But again, that's I think one of the limitations of the POPQ. But just knowing that usually if they're stage 2 or beyond, then you can offer them surgical intervention. And that's when most people at 0 are going to start to feel symptomatic for their prolapse. So usually I'm like, OK, are they a stage 2? Seems like they're more than that, right? Are they stage 4? Are they all the way out? So that's that TVL, that total vaginal length you got somewhere between 10 and 12. Are they plus 10 centimeters? Are they plus 12? Yes. Then that is stage 4. Right? But most patients are going to be somewhere between stage 2 and stage 4. It's a huge stage. I mean they should have made the green much longer, but it can be 7 centimeters of stage 3. Which for me as a surgeon, that is like not helpful because it's a huge stage. So I do actually want to know what is BA? What is BP? Because then I can talk to patients about risk of recurrence and failure and things like that based on the surgical approach. Okay. So this is stage 2. And I tried to left AA, right? So our big A, that first 3 centimeters under the urethra, you can see the meatus there kind of underneath the clitoris. And I made that little line to kind of show where that 3 centimeter mark would be towards your bladder neck. But it's basically flush, right? With the hymen. So that's a 0. And then that big bulge, B, that point there that's coming out furthest at us is about the same, maybe a little bit beyond, like plus 0.05. So that's that stage 2 there. And same thing on the posterior wall. This may be a stage 3 here, but that big bulge, what's coming out at us, it's definitely more than a centimeter, but probably not fully out there. And then stage 4, you know, this is big, kind of high-pressure prolapse, totally out. And that's her cuff. She has no cervix present anymore, but it's still C. I don't know, just looking at this, it's probably at least plus 10 or 11 centimeters there. And then this is somebody who has their cervix there. And you can kind of see it, but it's all the way out. And so for me personally, once you're at stage 4, it doesn't really matter, like B, A, B, P. It's all the way out at that point. But it's more that stage 3 where those B, A, and B, P are important. Okay. Treatment options. So really, we can offer treatment to anybody who's symptomatic. And our goals are to improve symptoms and minimize the progression. And we can observe, you know, watch and see. You can offer physical therapy, pessary, or surgical options if they are a stage 2 or more. And there's no stepwise approach. Doesn't have to be a stepwise approach if they're at that stage 2. They just need to have prolapse beyond the hymen, and they need to be symptomatic, which I think is important because a lot of people come to me and they're like, oh, the doctor said I have to have surgery, or like they said I shouldn't have surgery. And you're like, well, really, you have all of these options. These options are yours. It's not for me to tell you what you should do or not. And this was an interesting study. This was a focus group where they prioritized what women thought was important after surgery, what they wanted their treatment outcomes to be. And this was actually rated based on this small focus group. But the first thing that they wanted was resolution of the bulge, which makes sense, right? Like we want to get rid of that. But there were also other things that were important to them outside of just restoring normal anatomy. Improvement in physical function, being able to walk, exercise, run. Improvement in sexual function, wanting better orgasms, wanting to not feel ashamed about their body with sex. Improvement in body image, and then social function as well. So I love this, that women wanted to prioritize their vagina, but also prioritize their physical health were the two most important things. And you can bring this to your patients when you're talking about what their goals are for treatment. OK. So in the last few minutes, I want to talk about some considerations. If you're working collaboratively with surgeons or physicians, what things you might want to be thinking about when you're doing the POPQ. A big thing that comes up is uterine sparing or not. I think there has been a shift in the last five to 10 years in the United States with keeping the uterus in place. This was a meta-analysis that was done in 2019 that basically showed, because traditionally we'll do a vaginal hysterectomy and a native tissue repair, uterus sacral or sacrospinous. But in Europe, a lot of patients were getting the sacrospinous or the uterus sacral without having the hysterectomy. And so this study compared doing the hysterectomy or not, and taking all this data that was out there. And they found that there are improved operative times and less blood loss without doing a hysterectomy, and that there are no worse outcomes with keeping the uterus or preserving the uterus. However, there wasn't much data past that three-year mark. But a lot of people have taken this data to say, well, maybe you're in your 30s, maybe you're in your 40s, you're not really ready yet to have a hysterectomy. We can offer you a treatment to keep your uterus. And then ultimately, you may still need a prolapse procedure down the road. But if this is what you're comfortable with now, it may be an acceptable alternative. Now, this is maybe provider-to-provider dependent. But it is data, and it's a conversation that's being had right now. Enlarged genital hiatus is something you want to look at, too. So that mid-urethra to posterior foreshut. And I put this picture back here, because it's eyeballing. It's probably about 6, 7 centimeters. And so we know that the larger the genital hiatus, the higher risk of surgical failure. There also have been studies that have shown that after birth, vaginal birth, patients who have a larger genital hiatus are at increased risk of developing prolapse down the road. So there is something about genital hiatus and prolapse developing and prolapse recurring after surgery. I don't think the studies have really shown yet that reducing the size of the genital hiatus prevents recurrence of prolapse. I think we're still trying to assess that out, because we kind of all do surgeries a little bit different. But it's something to think about. What does that genital hiatus look like with Valsalva? And this probably has to do with that level 3, like I said. And you may want to consider posterior repair or perineurophy at the time of surgery. Post-hysterectomy. So these patients have already had a hysterectomy and now have prolapse. So you want to think about that genital hiatus. How wide is it? Something else that comes up is, is the vagina foreshortened? Is it too short? So I kind of told you before, with patients who come in with prolapse who have their uterus, the vaginal length is somewhere between 10 and 12 centimeters. And that's a little long, but it gives us room to do repairs. If the vagina is too short, less than 10 or 9 centimeters, you may not have enough vagina to reach the ligament inside for a surgical repair. So the TVL in a patient who's had a hysterectomy is a really important number to record as well, because we're thinking about, will the vagina reach that sacrospinous ligament for a sacrospinous ligament fixation if they've had a hysterectomy? Coital function. Do they want to have penetrative intercourse? I am in a population of patients who are not having penetrative vaginal intercourse, and so I do a lot of copolysis, which is not necessarily the same around the country, but it is a very durable and good option for patients. So we want to ask them what their priorities are, if they want that or not. And then prior abdominal surgeries, right, and what is our approach going to be. If they've had more surgeries, there's more risk of scar tissue. You may want to avoid intraperitoneal approach. You may want to go through the vagina and be retroperitoneal. Cervical length and enlarged uterus. So this has come up too. So the cervical length, the cervix somewhere is about 4 centimeters. The difference between your C-point and your D-point, that posterior foreshed, is going to be the length of your cervix. Now if that cervical length is long, like greater than 4 centimeters, it can make a vaginal hysterectomy harder. And sometimes it's like 9 or 10 centimeters, and it's just good to know that ahead of time when you're talking about surgical approach too. Because even if I lift up their prolapse, if their cervix is 10 centimeters, it still might be hanging out, quite frankly. And so we need to have a conversation about the treatment approach. And then enlarged uterus, it's important, I didn't say this before, but I should have. When you're doing your exam, you do want to kind of feel the uterus, especially someone who's under 50, to get a sense of how big that uterus is. Because sometimes, you know, the uterus can be quite large. And if they have a larger habitus and you can't feel the uterus, you may want to get an ultrasound just to confirm that the size, based on your approach, I mean this is, you know, people may, your teams may talk to you about this, but it's something that I think about is what is the size of that uterus, and how feasible is a vaginal surgery. And people use different cutoffs, but usually once you're getting above 10 centimeters, it's starting to get big, and you want to think about your surgical approach and what the surgeons are comfortable doing. And then concomitant stress incontinence. So we said you're going to do your POPQ, you're going to do your stress incontinence exam, and you're going to do your cough stress test. And so it's important to think about, too, because say you do your POPQ and nobody, they don't leak, you know, oftentimes we'll do a full bladder, we'll backfill their bladder or we'll do simple systematics or open the back for urodynamics to determine if their bladder is full and the prolapse is reduced if they leak. If the patient reports stress incontinence and has a positive cough stress test, there's a really high chance that they're going to have stress incontinence after surgery. If they report stress incontinence but have a, or no, if they don't report stress incontinence and they have a positive cough test, reduction cough stress test, there's a high chance that they're going to leak after. And if they don't report it and they have a negative cough stress test, both full and empty bladder, the low chance that they're going to have postoperative stress incontinence. So we want to stratify what their risk of postoperative stress incontinence is. There's actually a calculator that you can use for this, too, that can go through this as well. But something to think about is the cough stress test. Okay. That's it. Thank you. Are we doing questions? Oh, there's microphones. Oh. Okay, I was like that good, huh? No questions. Hi. Hi, thank you. This is really helpful. I just had a quick question about when you have a patient and you're getting her positioned and you see how much bold she has and then once you've done your other parts and you've you've done your visualization then you never see it come out that far again and sometimes I'll just measure when she first gets positioned. Mm-hmm. And just wanted to know what you think about that and and also another question about like when you're trying to get the the AA and AB and and AP and ABP and you feel like the speculum is actually kind of holding the prolapse back and how do you kind of work with that so that you're not reducing it? Yeah, good good questions. Good point. So the first question, yeah, sometimes when you see them that first prolapse is like the maximal prolapse. Sometimes I try to get around that by having them stand up, but the older patients sometimes it's you know when they stand up it's kind of hard to get to really see the prolapse. So if you have a commode you could use that too and have them sit on the commode that like doesn't let you sometimes for urodynamics, but I measure that first prolapse that I see especially if it's out there. So my pop q-stick right on the hymen and measure it then so I know what it is and then I will use that maximum descent that I first saw because that's probably what's happening in reality. And then the second question about the the speculum being in the way. Yeah, that's a real thing, especially if there's a large apical component. Sometimes you're probably blocking the cervix from being able to come down. So when I put this speculum in I always go at like a 45 degree angle down with kind of gentle pressure and I may not put the whole speculum in. I may only use like half or a quarter so that way I'm not kind of hindering the prolapse. But also again to your point that first kind of image of the prolapse you get or have them bear down at first without obstructing anything may help you get an actual idea of what it is. And that's why I use my finger for the cervix and not a speculum because I feel like there's this opportunity to push things up. Thank you. Can you give the predictor, do you know what the predictor is called that calculates the risk of SUI after surgery? Yeah, I think that was, was it Jelosevich? And it might be on the AUGS website, but we can probably, I think I owe some other documents too. So let's share it with everybody. Hi. Hi, thank you for the lecture. So I worked with an older urogynecologist a long time ago, so I was good at visualizing. I can tell you grade one, grade two, grade three, but they don't do that anymore, right? So they now use, I have a younger urogynecologist that I'm working with and she insists that we use that POPQ. So now I've seen different people say, okay, you put the POPQ here when you're trying to do the AA and AP. So I really want to know how, where do you actually put that? Because when you're doing, like she said, the speculum, this one says pull it out as you're pulling, as the patient is pushing or coughing, right? But I feel like the POPQ is gonna fall. So it's really difficult. I just wish we, there's a practical way to show exactly where do you put your POPQ to make sure that you gain the accurate calculation. Yes, I'm also happy to talk to you kind of after this if you want and I can kind of go through a little bit more with you because I feel like it's probably a little bit more of a nuanced response than I can give up here. I would appreciate it. Yeah, no problem. It's tricky. It's definitely tricky.

pelvic organ prolapse

vaginal support

levator muscles injury

prolapse treatment

risk factors

POPQ system

surgery