Diagnosis of cystocele type by clinical examination and pelvic floor ultrasound

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1 Ultrasound Obstet Gynecol 2012; 39: Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: /uog Diagnosis of cystocele type by clinical examination and pelvic floor ultrasound V. CHANTARASORN and H. P. DIETZ Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, NSW, Australia KEYWORDS: cystocele; pelvic floor ultrasound; POP-Q examination; retrovesical angle ABSTRACT Objectives To use the International Continence Society pelvic organ prolapse quantification (ICS POP-Q) examination to distinguish between two types of cystocele and compare findings with pelvic floor ultrasound results. Methods We enrolled 94 patients who underwent a structured interview, physical examination using the ICS POP- Q, four-dimensional pelvic-floor ultrasound examination and multichannel urodynamic testing. Cystourethrocele (Green type II) and isolated cystocele (Green type III) were differentiated by the presence of an anterior vaginal wall groove on POP-Q examination and by measurement of the retrovesical angle on pelvic floor ultrasound. Clinical examination was performed by two observers, blinded to each other s results, and an ultrasound examination was subsequently performed by the first observer. Results The agreement between two observers for the clinical diagnosis of cystocele types was moderate (κ = and 0.544, P < ). Clinical diagnosis showed moderate to good agreement with ultrasound findings for both observers (κ between and 0.794, P 0.001). Conclusion Radiological cystocele type (Green classification) can be distinguished both clinically and on ultrasound, and agreement between methods as well as interobserver agreement for the clinical diagnosis is moderate to good. Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd. INTRODUCTION The International Continence Society (ICS) defines anterior vaginal wall prolapse (cystocele) as descent of the anterior vagina such that the urethrovesical junction (a point 3 cm proximal to the external urinary meatus) or any anterior point proximal to this is < 3 cm above the plane of the hymen 1. While this probably leads to overdiagnosis of cystocele since minor forms of anterior vaginal wall descent can probably be regarded as normal 2,3, the prolapse quantification system of the ICS can currently be regarded as the gold standard for prolapse assessment. Imaging is increasingly used for the assessment of prolapse, whether by ultrasound 4 or magnetic resonance imaging 5, and in the past prolapse was also evaluated by X-ray cystourethrography, now regarded as obsolete. The traditional radiological classification of cystoceles, originally proposed by Green 6, is based on descent of the bladder neck, retrovesical angle the angle between the proximal urethra and the trigonal surface of the bladder and the degree of urethral rotation. Green type I is described as cystocele with open retrovesical angle ( 140 ) and urethral rotation < 45. Green type II describes a cystocele with open retrovesical angle ( 140 ) and urethral rotation between 45 and 120, also called cystourethrocele. A cystocele with intact retrovesical angle (< 140 ) is defined as Green type III 6. Both cystourethrography and ultrasound can distinguish between two main types of cystocele, i.e. cystourethrocele (Green type II) and cystocele with intact retrovesical angle (Green type III) 6. For this purpose, translabial ultrasound seems particularly useful since it is non-invasive and can easily identify not just the bladder, but also surrounding soft tissues, allowing assessment of bladder neck descent, retrovesical angle and degree of cystocele descent 7. These two types of cystocele may have different etiologies and functional implications. Cystocele type III is more likely to be associated with levator trauma, i.e. avulsion injury, which is due to childbirth 8,9, associated with prolapse 10 and prolapse recurrence 11,12. A Green type II cystocele is more commonly found in patients with stress incontinence and an intact levator 13. Women with a Green type III cystocele tend to suffer Correspondence to: Dr V. Chantarasorn, 12 Soi Boonchusri, Dindang Road, Bangkok 10400, Thailand ( varis@loxinfo.co.th) Accepted: 2 November 2011 Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER

2 Diagnosis of cystocele type 711 more from voiding dysfunction than stress incontinence. The etiology of cystourethrocele is less likely to be caused by paravaginal defects than is the type III cystocele 13. On physical examination this distinction is generally ignored. The ICS pelvic organ prolapse quantification (POP-Q) examination defines staging of a cystocele by the degree of anterior wall surface descent, ignoring the state of the bladder neck. A similar POP-Q staging of cystoceles may be associated with very different clinical conditions and functional situations, which is very likely the reason for the generally poor associations observed between clinical cystocele and functional complaints such as incontinence and voiding dysfunction 14,15.Theaim of this study was to use the ICS POP-Q examination to determine type of cystocele and compare findings with pelvic floor ultrasound results. METHODS We enrolled 94 consecutive patients referred to a tertiary urogynecological clinic for urodynamic testing between June and September All patients underwent a structured local, non-validated interview including questions on symptoms of stress incontinence, urge incontinence, frequency, nocturia, symptoms of voiding dysfunction (stop start pattern of voiding, straining, hesitancy, poor stream) 16 and pelvic organ prolapse symptoms (dragging sensation in the vagina, vaginal lump). The structured interview was done by the second author. The physical examination was performed using the ICS POP-Q system 17. Independent uroflowmetry, multichannel urodynamic testing (Neomedix Uromac v. 3.6, Sydney, Australia) and four-dimensional pelvic floor ultrasound (Voluson 730 Expert, GE Kretz Medical Ultrasound, Zipf, Austria) were performed in all patients 7. The ICS POP-Q examination was performed on maximal Valsalva maneuver in the lithotomy position for each patient by both authors, who were blinded to each other s results. The first author performed the POP- Q examination blinded against clinical data obtained from the structured interview. A cystocele was defined as descent of the anterior vaginal wall according to ICS terminology. Staging of cystocele was done according to the ICS POP-Q system. Clinically, cystourethrocele (Green type II) was diagnosed if reference point Aa was at the same position as point Ba, implying that there was no anterior vaginal wall groove at the level of the bladder neck, indicating an open retrovesical angle (Figure 1). Cystocele type III was diagnosed if point Aa was higher than point Ba, and a groove was found between the two, indicating an intact retrovesical angle (Figure 1). Pelvic-floor ultrasonography was performed by the first author after the clinical examination using a GE Voluson 730 Expert system with an 8 4-MHz volume transducer with an 85 acquisition angle. Ultrasonography was performed with the women in the supine position with both hips flexed and slightly abducted after bladder emptying. The transducer was placed against the perineum in the midsagittal position. Ultrasound volume datasets at rest, at maximum pelvic floor muscle contraction and at maximum Valsalva were recorded for each patient as previously described 7. The best Valsalva volume was used to determine the degree and type of cystocele. Bladder neck descent, degree of retrovesical angle and urethral Figure 1 (a) Clinical appearance of Green type II cystocele (cystourethrocele), showing a smooth anterior vaginal wall without bladder neck groove (arrows), implying an open retrovesical angle. (b) Green type III cystocele, showing an anterior vaginal wall groove (arrows) suggestive of an intact retrovesical angle.

3 712 Chantarasorn and Dietz Figure 2 Ultrasound images of: (a) cystocele with open retrovesical angle (Green type II; cystourethrocele); (b) cystocele with intact retrovesical angle (Green type III). Arrows indicate bladder neck, dots outline urethra and lines indicate retrovesical angle. The configuration of bladder neck and urethra varies substantially between Green II and Green III cystoceles, even if the degree of bladder prolapse is similar. B, bladder; S, symphysis pubis; U, urethra. rotation were measured to identify cystocele extent and Green type on maximal Valsalva maneuver. A significant cystocele was diagnosed on ultrasound if any part of the bladder reached 10 mm below the symphysis pubis 18. This value is the cut-off point that performs best as a predictor of prolapse symptoms when analyzed with receiver operating characteristics curves 19. Proximal urethral rotation of 45 or more was always seen in such patients. A cystocele with open retrovesical angle ( 140 ) was classified as Green type II, one with intact retrovesical angle (< 140 ) as Green type III (Figure 2). Levator avulsion was diagnosed by tomographic imaging at maximal pelvic floor muscle contraction, as previously described 20. This study was performed under the approval of the Human Research Ethics Committee (SWAHS HREC ). Statistical analysis was performed with SPSS v.16 (SPSS Inc., Chicago, IL, USA). Cohen s κ was used to test for agreement between clinical observers on the one hand, and clinical and ultrasound findings on the other hand. A κ of was defined as moderate agreement and as good agreement, and P < 0.05 was considered statistically significant. RESULTS The mean age of the study population of 94 women was 57 (range, 32 90) years. Median parity was 3 (range, 0 10) with 85 out of 94 women vaginally parous. Twenty-one patients had had one or more operative deliveries. Mean body mass index was 29.7 (range, 19 50) kg/m 2. Of 94 patients, 78 complained of stress incontinence, 78 of urge incontinence, 28 of frequency, 47 of nocturia, 22 of symptoms of voiding dysfunction and 46 of symptoms of prolapse as defined above. Thirty-five women had had a hysterectomy and 21 anti-incontinence or prolapse surgery. Fifty-six patients had significant pelvic organ prolapse (ICS POP-Q stage 2). Multichannel urodynamics showed that 67 patients had urodynamic stress incontinence, 30 had detrusor overactivity and 31 had urodynamic evidence of voiding dysfunction. A levator ani defect was diagnosed by tomographic ultrasound imaging in 23 patients. Mean bladder neck descent was 26 (range, 4 54) mm. On clinical examination by the first observer, a cystocele type II was found in 31 patients and a type III in 17 patients. The second observer diagnosed a cystocele type II in 36 patients and a type III in 18 patients. On ultrasound, a cystocele type II was diagnosed in 21 patients and a type III in 18 patients. A significant uterine prolapse (ICS POP-Q stage 2) was diagnosed in 10 patients. Seven patients had a significant enterocele and 38 had a significant rectocele (ICS POP-Q stage 2). For the diagnosis of cystocele type II by clinical examination, the agreement between observers showed a κ of 0.561, indicating moderate agreement, while the agreement between clinical examination and pelvic floor ultrasound showed a κ of and for the two observers (P 0.001). For the diagnosis of cystocele type III, the observers agreed moderately well (κ 0.544, P < ), and agreement between clinical exam and ultrasound was moderate to good (κ and 0.544, P < ) (Table 1). Table 1 Interobserver agreement (Cohen s κ) for both types of cystocele and agreement between each observer and pelvic floor ultrasound for the diagnosis of cystocele type Green type II cystocele Green type III cystocele Agreement between κ P κ P Observer 1 and Observer < < Observer 1 and ultrasound < Observer 2 and ultrasound < <

4 Diagnosis of cystocele type 713 DISCUSSION The Green radiological classification of cystocele categorizes cystocele based on the degree of retrovesical angle on maximal Valsalva maneuver and rotation of the urethral axis 6. This classification has long since fallen out of favor, together with cystourethrography, despite the fact that different types of cystocele are associated with different functional presentations and symptoms 13. In this study we have shown that it is possible to distinguish these two types of cystocele by clinical examination, with moderate to good agreement between observers and with imaging findings. In cases of cystourethrocele Green type II cystocele the vaginal wall overlying the urethra and the bladder base forms a smooth surface without a vaginal groove at the site of the bladder neck due to an open retrovesical angle. Richardson et al. 21 speculated that this appearance is due to a paravaginal break in the pubocervical segment of the endopelvic fascia between the lateral edge of the vagina and the pelvic sidewall, resulting in cystourethrocele with stress urinary incontinence. However, the concept of paravaginal defects as the main factor in the pathogenesis of cystourethrocele may not be tenable. In a recent study based on pelvic floor ultrasound, a cystourethrocele was less likely to be associated with levator avulsion than a cystocele with intact retrovesical angle, regardless of the degree of prolapse 13. It is difficult to see how the paravaginal fascia could remain intact after avulsion of puborectalis muscle insertions, given the severity of such muscular trauma. It is evident that the configuration of the bladder neck and urethra varies substantially between Green types II and III cystoceles, even if the degree of bladder prolapse is similar. Clinical manifestations and symptoms also vary. Ultrasound findings of cystourethrocele include opening of the retrovesical angle and funneling of the bladder neck, which are the most common findings in women with stress incontinence, even if they are only moderately predictive of urodynamic stress incontinence 22. These ultrasound findings are associated with normal flow rate centiles and are not predictive of voiding dysfunction 23. On the other hand, a cystocele with intact retrovesical angle tends to have a highly significant negative effect on voiding, probably due to urethral kinking 23. There are substantial limitations to this study that should be acknowledged. This was an observational series in patients presenting for urodynamic testing, limiting conclusions to similar populations. The population included patients after pelvic reconstructive surgery, which may have influenced findings and validity. We evaluated both POP-Q examination and pelvic-floor ultrasound to determine the type and degree of cystocele on maximal Valsalva maneuver, without controlling for Valsalva pressures, which may have reduced the comparability of clinical assessments and of clinical and imaging assessments. It is recognized that findings on Valsalva will vary with the quality of the maneuver. However, standardization of pressure would probably require invasive monitoring, since efforts at non-invasive standardization have been largely unsuccessful 24. Our own data suggest that the vast majority of patients in our clinic reach pressures of over 80 cmh 2 O on maximal Valsalva maneuver, and that such pressures are sufficient to reliably produce over 80% of theoretical maximal organ descent 25. In conclusion, radiological cystocele type (Green classification) can be distinguished both clinically and on ultrasound, and agreement between methods and interobserver agreement for the clinical diagnosis were moderate to good. As those two types of cystocele have very different functional implications and may also have different etiologies 13, it may be prudent to include this distinction as part of any clinical prolapse assessment. Further research into the clinical utility of this differentiation is clearly indicated. DISCLOSURES H.P. Dietz has in the past acted as consultant for AMS, CCS and Materna Inc, has accepted speaker s fees from GE, AMS and Astellas, has benefited from equipment loans provided by GE, Bruel and Kjaer and Toshiba, and has received an educational grant from GE Medical. REFERENCES 1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Kerrebroeck PV, Victor A, Wein AJ. 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