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Int Urogynecol J (2007) 18:10031005

DOI 10.1007/s00192-006-0276-6

ORIGINAL ARTICLE

A simple teaching tool for training the pelvic organ prolapse


quantification system
Ingrid M. Geiss & Paul A. Riss & Engelbert Hanzal &
Andrea Dungl

Received: 9 October 2006 / Accepted: 12 November 2006 / Published online: 12 January 2007
# International Urogynecology Journal 2007

Abstract The pelvic organ prolapse quantification (POPQ)


system is currently the most common and specific system
describing different prolapse stages. Nevertheless, its use is
not yet accepted worldwide in routine care. Our aim was to
develop a simple teaching tool for the POPQ system
capable of simulating different stages of uterovaginal
prolapse for use in medical education with hands on
training. We constructed a moveable and flexible tool with
an inverted Santa Claus cap, which simulated the vaginal
cuff and the tassel at the end representing the cervix. A
wooden embroidery frame fixed the cap and served as the
hymen, the reference point for all measurements. Inside the
cap, we sewed buttons to define the anatomic landmark
points Aa and Ap located 3 cm distal from the frame. After
explaining the device to the students, we used the three-bythree grid for recording the quantitative description of the
pelvic organ support. First, each student had to demonstrate
a specific prolapse with his cap device. Then, a prolapse
was simulated on the cap, and the student had to take the
relevant measurements and record them in the POPQ grid.
The main training effect to understand the POPQ system
seems to be the possibility for each trainee to simulate a
three-dimensional prolapse with this flexible vagina model.

I. M. Geiss (*) : P. A. Riss : A. Dungl


Department of Obstetrics and Gynecology,
Landesklinikum Thermenregion Mdling,
Sr. M. Restitutagasse 12,
2340 Mdling, Austria
e-mail: office@frauenaerztin-geiss.at
E. Hanzal
Department of Gynecology and Obstetrics,
Medical University of Vienna,
Vienna, Austria

Keywords POPQ . Teaching tool . Medical education .


Humour . Prolapse . IUGA
Objective
Our aim was to develop a simple teaching tool for the POPQ
system capable of simulating different stages of uterovaginal
prolapse. The standardization of terminology of female
pelvic organ prolapse quantification (POPQ) was published
in 1996 [1]. The system was developed by the International
Continence Society (ICS) to enhance clinical and academic
communication. Although clinicians and researchers were
encouraged to use this system, its utilization is not yet
accepted worldwide in routine care. A study done to
examine the methods of describing pelvic organ prolapse
in the peer-reviewed literature showed that the POPQ
system was the most common system used (22.6%), but
in 54.8% no or a nonstandardized staging system was used
[2]. Two questionnaire surveys demonstrated that only 44%
of the members of the International Urogynecological
Association (IUGA) and only 40.2% of the ICS and the
American Urogynecologic Society (AUGS) routinely use
the POPQ system [3, 4]. One of the main reasons for this
delayed acceptance might be difficulties in understanding.
Hands-on training is an effective way of teaching and may
help to understand complex issues by visualization [5].
We found no item in the PubMed for teaching the POPQ
system and set out to develop a simple device. It had to be
cheap, easy to understand, and capable of simulating
different stages of uterovaginal prolapse.
Technique
We constructed a flexible tool with an inverted Santa Claus
cap, which simulated the vaginal cuff; the tassel at the end was

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used as the cervix. A wooden embroidery frame fixed the cap


and served as the hymen, the reference point for all measurements. Inside the cap, we sewed buttons to define the
anatomic landmark points, Aa and Ap, located 3 cm distal
from the frame. In addition, we stitched centimeter markers on
the anterior and posterior side of the cap (see Fig. 1). After
explaining the device to the students, we used the three-bythree grid for recording the quantitative description of the
pelvic organ prolapse.
First, each student had to demonstrate different prolapse
stages with his cap device as listed on a flip chart by the
teacher. Then, a prolapse was simulated on the cap and, the
student had to take the relevant measurements and record
them in the POPQ grid. During the training lectures, at least
two students had to work with one vagina model because one
had to move the cap to the points as specified in the grid, and
the other had to fix the simulated prolapse on the cap with his
fingers. This setting very strongly encouraged communication about problems in understanding. For example, we gave
the points: Aa, Ba=0, Ap, Bp=0, C=4, and the students
had to simulate the prolapse as shown in Fig. 1a.
The training tool has been used during hands on
workshops, arranged by the annual training meeting of the
Austrian Urogynecologic Society and during the Exchange
Meetings of the International Urogynecologic Association
(IUGA) in South Africa and India (see Fig. 2).
We had the idea of using a Santa Claus cap because the
annual education meeting of the Austrian Urogynecologic
Society, training gynecologic residents, and specialists, is
always organized before Christmas time, but each kind of
cap could be used to arrange a similar device.

Fig. 1 a Cap in the resting position with prolapse down to the hymen
prolapse points Ba and Bp identical with Aa and Ap (each of them: 0). b
Everted cap simulating stage 4 prolapse, posterior view (point Ap 3 cm
outside the hymenal ring)

Int Urogynecol J (2007) 18:10031005

Fig. 2 Hands-on training demonstrating the measurement points


during the IUGA Exchange Meeting 2006 in Belgaum, India

Experience
The difficulties to simulate the flexible vaginal cuff lead to
this cap device. All trainees were able to simulate the model
of the vagina to different prolapse stages up to complete
eversion. The flexible and changeable arrangement of this
vagina model helped to understand especially the variability
of point Ba or Bp. A side effect was the humor presentation
of the funny Santa Claus cap, which made the training
session an enjoyable experience for all involved (see
Fig. 3).
The feedback of the participants showed a high level
of satisfaction about this kind of workshop. Eighty-two
participants of the annual training meeting of the
Austrian Urogynecologic Society had to evaluate the

Fig. 3 Interested students during the IUGA Exchange Meeting 2006


in Belgaum, India

Int Urogynecol J (2007) 18:10031005

workshop with a scale from 1 (very satisfactory) to 5


(not satisfactory). The POPQ workshop was evaluated
with 1.3.

Conclusion
The hands-on training with this moveable and flexible
tool is a very effective way of visualizing the POP-Q
system. The most important training effect was the
possibility for each trainee to transpose the grid with
this flexible vagina model into a three-dimensional
prolapse and to take the relevant measurements recording
them in the POPQ grid. In addition, the training tool can
be made very easily and moved quickly to any place
needed. The funny version of the cap model made
teaching this difficult issue comfortable and promoted
learning in a relaxed environment [6, 7]. Our simple and
innovative device can be used as a teaching tool for
residents and specialists.

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References
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