Pelvic Organ Prolapse Classification & Scoring System - FemiCushion UK

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When diagnosed with POP, your doctor may inform you that you have stage 2 cystocele. However, what does that really mean? What makes you a stage 2 instead of a stage 1? How many stages are there? Let's discuss the classification and scoring of pelvic organ prolapse so you can better understand your diagnosis.

There are different classification and scoring systems that health professionals use to accurately describe POP. The first one is the anatomical classification, which describes the primary organ that is prolapsed and is commonly used to describe the types of POP. However, it is not always possible to determine which organs are prolapsing, and this is especially true for women who have previously undergone vaginal surgery.

Anatomical Classification:

Uterine Prolapse: prolapse of the uterus
Cystocele: prolapse of the bladder (also known as bladder prolapse)
Rectocele: prolapse of the rectum
Enterocele: prolapse of the tissues surrounding the small/large intestines and upper part of the vagina

Vaginal Wall Involvement Classification:

In addition to organ classification, POP can also be classified by the vaginal wall that is involved.

Anterior Vaginal Wall
Apical Vaginal Wall
Posterior Vaginal Wall
Perineal Body Defects

Moving on from classifications are scoring systems of POP. There are two scoring systems, the Baden-Walker Halfway Scoring System, and the Pelvic Organ Prolapse Quantification System (POP-Q System).

Baden-Walker Halfway Scoring System

The Baden-Walker system divides the vagina into 6 areas: two anterior, two superior, and two posterior. The 6 areas are scored from 0-4 based on the degree that the organ has descended with the hymen as the 0 reference point. This means that a score of zero indicates the normal position of the organ and 4 describes the maximum descent of prolapse. Within scores 0 to 4, the increasing numbers indicate the descent using a halfway system as described in the table below. Additional notes are written down during the scoring, which can include the area of dominant prolapse, locations of scars, or the effort needed to demonstrate the prolapse. Doctors can also use a pelvic organ prolapse map for supporting information.

Although this system is commonly used, there are a few shortcomings that make it less reliable than the POP-Q System. One shortcoming is that the Baden-Walker system uses the halfway system, which means a 1 cm increase to the prolapse can increase the score to an assigned stage. In addition, observers are not always able to completely agree on the scoring.

Grade 0: normal positions of pelvic organs, no prolapse

Grade 1: descent halfway to the hymen

Grade 2: descent to the hymen

Grade 3: descent halfway past the hymen

Grade 4: maximum possible descent

Pelvic Organ Prolapse-Quantification System (POP-Q System)

The POP-Q System was created as a tool that is useful for both researchers and clinicians. Although this system is much more complex, it is becoming more widely used for its reliability. Another advantage of this system is that results can be compared across time. The hymen acts as the fixed reference point and the descent of the prolapse is measured in nine sites of the vagina recorded in a tic-tac-toe grid using centimeters. The tic-tac-toe grid helps improve the agreement between observers. Based on the measurements, a stage is assigned to the patient.

Stage 0: no prolapse

Stage 1: more than 1 cm above the hymen

Stage 2: less than or equal to 1cm proximal or distal to the plane of the hymen

Stage 3: more than 1 cm below the plane of the hymen, but protrudes no father than 2 cm less that the total length of the vagina

Stage 4: complete eversion of the vagina

Remember to always consult your doctor if you suspect that you have pelvic organ prolapse. It is important to get properly diagnosed by a trained health processional before starting any type of treatment.

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