This is the first study to assess the use of the POP-Q system in the evaluation of POP and surgical decision-making among Korean obstetrician-gynecologists. The results revealed that only 48% of the respondents used the POP-Q in their clinical practice. Almost all of the POP-Q users made a surgical decision for each compartmental prolapse on the basis of the POP-Q measurements. Most respondents used stage 2 or the hymen as a threshold for prolapse to be corrected during prolapse surgery for all compartments.
Our results are in line with the findings of previous studies conducted in AUGS and ICS members. The first survey in 2004 showed that only 40% of the respondents routinely used the POP-Q system and 20% sometimes used it [7]. The second survey in 2011 showed that 76% of the respondents were currently using the POP-Q. Of those respondents who reported current use of the POP-Q, 80% used it often in daily practice, 93% used it preoperatively, 66% used it postoperatively, and 84% used the POP-Q only when participating in research or clinical trials [8]. These results showed that the POP-Q system is not being routinely used in clinical practice despite improvement in the user rate. Compared with the recent survey of AUGS and ICS members [8], our survey showed a lower rate of POP-Q use. This may be explained by the difference in the study population. Because of the lack of urogynecologic subspecialists, a significant proportion of prolapse surgeries is performed by surgeons who have a subspecialty other than urogynecology in Korea. To understand the current use of the POP-Q system in Korea, our survey was conducted in all KSOG members, and this may have lowered the user rate. Among the urogynecologic subspecialists, 70% used the POP-Q system in their practice.
We also found that there is considerable variability in the technical performance among the POP-Q users. It is unclear whether these variations are problematic. However, our survey showed that almost all surgeons determine whether each compartmental prolapse should be corrected on the basis of the degree of prolapse. Patient position and bladder volume may affect the extent of prolapse [9-11], and these factors should be standardized.
Despite criticism of the lack of clinical relevance by some AUGS and ICS members, our results showed that the POP-Q measurements are used in surgical decision-making. However, there is considerable variability in the specific criteria used to determine whether prolapse should be corrected. This finding is not surprising considering that there are no consensus statements or guidelines about such criteria [12]. Nonetheless, most respondents reported using stage 2 or the hymen as a threshold for prolapse to be corrected for all compartments. Unlike POP-Q stage 1 anterior or posterior prolapse, stage 1 apical prolapse is likely to result in prolapse symptoms [13, 14]. Recent studies suggested that specialists should consider an apical suspension procedure in patients with POP-Q point C ≥-3, ≥-5, or >-1/2×total vaginal length [13-15]. Adequate support for the vaginal apex is essential to ensure a durable surgical repair for POP, and surgical correction of the anterior and posterior walls may fail unless the apex is adequately supported [16, 17]. Standardized definitions and guidelines are needed for clinically significant apical prolapse and when an apical suspension procedure should be performed.
Lastly, we assessed how much simulated apical support was performed during the POP-Q examination. Although the degree of prolapse in each compartment can be assessed by the POP-Q examination, the impact of prolapse on one compartment of the vagina on another cannot be assessed. Several studies have demonstrated that a significant proportion of cases of anterior vaginal wall prolapse are related to apical vaginal prolapse [18-21]. Simulated apical support is a test to assess the degree of anterior or posterior vaginal wall prolapse while holding the apex at approximately the depth of the total vaginal length, and it may help determine the need of separate anterior or poster repair at the time of apical suspension [12, 22]. However, we found that this test is underused in the evaluation of POP and surgical decision-making among the POP-Q users. This may be related to the lack of a clinical study to support its clinical relevance and the limited use of an apical suspension procedure during pelvic reconstruction [23].
There are some limitations in our study. First, we could not directly contact members because of KSOG policy. Our survey was anonymous, and targeted reminders to non-respondents, which may have increased the response rate, could not be sent. Second, our survey findings may also be subjected to sampling bias. Most respondents were from a tertiary medical center; therefore, these results may be more representative of academic practices rather than general practices.