Improving Diagnostic Accuracy for Surgical Pelvic Organ Prolapse: A Sequential Protocol Combining POP-Q Examination and Transperineal Ultrasound

<b>Background/Objectives:</b> The POP-Q system is conventionally used to evaluate pelvic organ prolapse (POP). Nevertheless, differences between clinical examination and intraoperative findings can hinder appropriate surgical planning. We aimed to assess the accuracy of a sequential protocol involving clinical POP-Q assessment and, in cases of uncertain diagnosis, transperineal ultrasound. <b>Methods:</b> We conducted a prospective observational study with 314 women scheduled for POP surgery from January 2021 to December 2024. A pelvic floor specialist assessed all patients using the POP-Q system. Transperineal ultrasound was carried out only when the clinical diagnosis remained uncertain. We compared the accuracy of this sequential approach (POP-Q ± ultrasound) versus POP-Q alone, using intraoperative findings as the gold standard. Sensitivity and specificity were determined for each type of prolapse. <b>Results:</b> Of the 314 patients, 181 (57.6%) had a definitive diagnosis with POP-Q alone, whereas 133 (42.4%) required additional ultrasound. In these uncertain cases, the addition of ultrasound significantly increased sensitivity for cystocele (by 0.5-11.3%), uterine prolapse (45.5-63.7%), cervical elongation (5.2-21.4%), rectocele (5.7-16.4%), and enterocele (58.7-74.7%) (all <i>p</i> < 0.05). Specificity also improved for uterine prolapse, cervical elongation, and rectocele. The sequential protocol's performance in uncertain cases was comparable to clinical examination in straightforward cases. <b>Conclusions:</b> Applying a sequential protocol that adds transperineal ultrasound for unclear cases significantly increases diagnostic precision for surgical POP, potentially optimizing surgical planning.