Comment on “Phenotypes of Pelvic Organ Prolapse”

The prevalence of pelvic organ prolapse (POP) continues to rise, with an estimated annual case count of 4.9 million by 2050. The Pelvic Organ Prolapse Classification system (POP-Q) has been the standard for measurement, reporting, and communication about POP in research since 1996; previous studies have shown it to be reliable and consistent, but it also has limitations. The system of staging POP is now outdated when compared with current evidence and guidelines, and it does not take into account much of the nuance that is now recognized in POP presentation and phenotypes. This study aimed to characterize clinically meaningful phenotypes of POP using the existing POP-Q framework, as well as identify the frequency and overall characteristics of each phenotype. This was a retrospective study using data from the University of Iowa between December 2017 and January 2023. Inclusion criteria were POP surgery and documented POP-Q, as well as a complete Pelvic Floor Distress Inventory-20 (PFDI-20) within a year before POP surgery. Phenotypes were using a definition of POP inclusive of either anterior and/or posterior vaginal wall descending to at least the hymen or the apex (cervix or cuff) descending to at least half the total vaginal length (TVL), as well as POP existing in 1 or more compartments of the vaginal canal. The 3 identified phenotypes for single-compartment POP were: isolated anterior wall (A), isolated posterior wall (P), and isolated apical (C). The 3 phenotypes for POP in 2 compartments were: anterior and posterior wall (AP), anterior-predominant and apical (AC), and posterior-predominant and apical (PC). The phenotype representing prolapse of all 3 compartments was anterior, posterior, and apical (APC). “No prolapse” (0) was used to define patients with POP symptoms with less anatomic degrees than specified in these phenotypes. Final analysis included 501 patients, with 46.1% AC, 3% AP, and the others accounting for the remaining percentage, ranging from 6.4% to 10.4%. Compared with the AC phenotype, the 0, P, C, and PC phenotypes were seen in younger patients, and the A phenotype was seen in older patients. P, PC, and APC phenotypes had a higher body mass index (BMI) than the AC phenotype, and the 0, A, P, C, and AP types had more POP in stages 1 and 2 compared with the AC phenotypes. The P phenotype had higher scores in the colorectal-anal distress inventory domain, as well as the splinting with bowel movements and stress incontinence. Overall scores on the PFDI-20 were higher (worse symptoms) in the P phenotype compared with the AC phenotype, and lower in the C phenotype compared with AC. These results present a new method of designating clinical phenotypes of POP while using the existing validated framework presented in POP-Q. These findings suggest that differing phenotypes may have differing underlying mechanisms and also vary in clinical presentation. This is consistent with previously published literature on subtypes of POP but novel in the differences reported in the PFDI-20 scores. Future research should focus on validating these findings in patients not undergoing surgery as well as in a larger and more diverse population. (Summarized from Sayler Z, Weston K, Johnson CM, et al. Phenotypes of pelvic organ prolapse. Urogynecology (Phila). 2025;31(12):1101-1108. doi: https://doi.org/10.1097/SPV.0000000000001640)