Clinical practice
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Short-IPGH system for assessment of pelvic floor disease

by Bruce Farnsworth (*) - Giuseppe Dodi (**)
(*) Centre for Pelvic Reconstructive Surgery, Sydney Adventist Hospital, Sydney, New South Wales, Australia (**) Department of Surgery, Clinica Chirurgica 2. University of Padua, Padua, Italy


Abstract: Abstract: A simple clinical tool is presented to quantify and record pelvic floor disease. The short-IPGH system enables the clinician to document a summary of the clinical status of a patient. This system creates a clinical record with the details of a complex history and examination. It is particularly helpful when reviewing a previous assessment or reporting a patient’s status to a colleague. The short-IPGH is made up of four domains which cover the basics of a pelvic floor evaluation. The data is recorded in a standard proforma which enables rapid assessment of the clinical situation. The original IPGH system was designed to process a large amount of objective data in a research environment. The short-IPGH breaks down complex data sets to create a smaller number of scoring systems that are clinically useful in everyday practice. Key words: Pelvic floor, Clinical record, Prolapse, Incontinence, Retention.


INTRODUCTION

When assessing pelvic floor problems, clinicians should make a balanced evaluation of any dysfunction which takes into account all three pelvic compartments in addition to any general medical conditions including the consequences of neurological disease. A number of systems have been devised to analyse, diagnose and quantify pelvic dysfunction. Universally, these systems are comprehensive in their attention to detail but are usually confined to one or two functional parameters or body compartments.

Pelvic floor problems are often complex and can involve multiple systems, leading to the collection of large amounts of data. While helpful as a research tool, the collation and interpretation of this data is impossible in everyday clinical practice.

The IPGH system was developed in Italy and first published in 1996.1
It is a complex tool which is designed to take a global view of pelvic floor dysfunction and to enable the clinician to quantify the problem at hand and then verify the success or failure of any intervention. The IPGH was originally designed to be used to organise data collected in medical research. In contrast, the short-IPGH is designed specifically to be used as a tool in everyday practice.

The original system is based on existing validated and partially validated classification systems. In the anterior compartment there has been a lot of work to develop standardised terminology.2, 3

The POPQ System 4 has been advocated to quantify prolapse whilst the Wexner scales 5 are popular systems for grading rectal dysfunction. Where possible, we have tried to adopt standard methods of assessment into the short-IPGH but this is not always feasible as the final system must be equally accessible and able to be interpreted by different groups of clinicians.

The short-IPGH is a practical tool for any clinician working in pelvic medicine or surgery. This modified system is designed to take the normal detailed assessment made by the pelviperineologist, whether he or she is a urologist, geriatrician or other specialist and then summarise the findings in a standardised multidisciplinary format. It can be used to track the progress of a particular patient without needing to review each detailed clinical assessment and it can be used to record and then present the summary of a patient to a colleague.

Each clinician has the freedom to decide what specific tools he or she will use to make an assessment of a particular parameter but then the results need to be quantified and recorded using the short-IPGH format. In some areas where there is a definite established system, the international standard will be used e.g., the POPQ ordinal system for staging genital prolapse. Pain is assessed using a Visual Analogue Scale (1-10). Clinicians who use the Wexner or similar scales for assessing rectal function can extrapolate the results to give a score between 1 and 4.

METHODS

In the original IPGH system information is presented as a table which can be completed by the physician using a detailed data collection sheet or entered directly into a computerised algorithm.6, 7

The short-IPGH enables the clinician to summarise and record clinical data in a standardised format. Like the original IPGH system the short-IPGH comprises four domains where “I” represents Incontinence, “P” Pelvic floor and Prolapse, “G” General factors and “H” Handicap. The assessment can then be recorded on a four-section table (Tab. 1).

short ipgh

SECTION 1: INCONTINENCE

Data sets used in the assessment of incontinence are listed with a detailed explanation of each parameter in Table 2.

incontinence

A detailed explanation of each section of the chart is provided in Table 3. table

Example : A 63 yr woman Para 3 Gravida 3, has a 10-year history of severe stress urinary incontinence with no urgency. The incontinence has a significant impact on quality of life, using 3 incontinence pads each day. She has failed physiotherapy and has undergone 3 incontinence procedures to try and correct the problem. This patient also had mild faecal incontinence for 1 year with minimal impact on quality of life (Tab. 4).

sample incontinence record

SECTION 2: PELVIC FLOOR/PROLAPSE

Pelvic floor and Prolapse (P) is divided into three sections. Pelvic floor and Prolapse also includes vaginal (V) and anorectal (A) sections. Each assessment for genital prolapse is recorded as Stage 1, 2, 3 or 4 where the stages of prolapse are equivalent to POPQ ordinal system stages. Anorectal prolapse is also quantified using a 4-stage description.

It is a more dynamic description which also takes into account irreducibility of the involved viscera. An examination of the Genitalia (Gn) is recorded together with hysterectomy (x), previous conservative therapy (Py) and pelvic muscle function (PCT, Prel) (Tab. 5).

Prolapse assessment

Detailed descriptions of the components of this assessment are listed in Table 6. table

Example : An Example of a prolapse assessment is shown below (Tab. 7).

Example  prolapse assessment

This patient has a Stage 2 cystocoele but no posterior, superior or vaginal Pouch of Douglas prolapse (enterocoele). The vaginal prolapse has been evident for 3 years. This is a recurrent prolapse and there have been three previous vaginal repair operations.

The effect of the prolapse on the patient’s quality of life is moderate, but the patient has severe urinary retention requiring self catheterisation and severely affecting her quality of life. There is no posterior colpocoele, no haemorrhoids, no mucosal prolapse and no previous surgery for anorectal prolapse.

There is however a small rectocoele extending into the perineum associated with a degree of constipation which has been present for 5 years and is also affecting quality of life. There has been no previous surgery for constipation. External genitalia are normal. She has not had a hysterectomy but has undergone unsuccessful pelvic rehabilitation treatment. She has weak pelvic muscle contraction. There is good relaxation of the pelvic floor.

SECTION 3: GENERAL HEALTH FACTORS

G records the general health of the patient where 0 = no health problems, 1 = minimal health problems, 2 = significant health problems, 3 = severe health problems.

Level 3 medical conditions are defined as those diagnoses that pose an immediate and significant threat to the patient. Level 3 problems include stroke, heart attack, pulmonary embolus, other cardiac disease or previous thromboembolic disease. They require a comprehensive pre-operative medical and anaesthetic workup.

Level 2 diagnoses are medical problems that are unlikely to increase morbidity and mortality if anticipated prior to surgery. Any potential risk is reduced by precautionary medical treatment. Level 2 problems might include diabetes, treated cancer, peripheral vascular disease or inflammatory bowel disease. Level 2 medical conditions require a preoperative anaesthetic consultation.

Level 1 diagnoses represent a small or insignificant risk and do not require any special intervention.

Men (mental function) is measured on a scale of 0–3 where 0 = normal, 1 = slight impairment, 2 = moderate impairment and 3 = severe impairment. Mob (Mobility) is graded using a similar scale.

S relates to sexual function. N = not active or interested, 0 = normal function, 1 = minor irritation or problems, 2 = moderate sexual dysfunction, 3 = severe sexual dysfunction.

Sexual function is included in the general domain so as to emphasise the variety of factors which can affect sexuality beyond physical problems in the pelvic floor.

general health

Example : The patient presented below has minimal general health problems, mild mental problems such as depression, and good mobility. She is not sexually active.

Example general health assessment

SECTION 4: HANDICAP INCLUDING PAIN

The handicap (H) defines the severity of the patient’s specific disability due to the symptoms of pelvic floor disease and is represented by the maximum quality of life score recorded in any part of the short-IPGH record. Pain is assessed on a scale of 0-10 using a visual analogue scale. The doctor index (D) is the number of doctors (n) that the patient has consulted for pelvic floor problems.9, 10, 11

handicap and pain assessment

Example : The patient below has seen two doctors for her current problems and has severe pelvic pain. The maximum QOL recorded elsewhere in her assessment is 2.

Example of handicap and pain assessment

CASE REPORT

In order to further understand the Short-IPGH system in clinical practice a case report is presented : 65y Para 2 Gravida 1.

case report

This 65-year-old woman has been pregnant twice but delivered only once. She reports severe urinary incontinence for 2 years with severe urgency in association with a Grade 3 cystocoele which has been present for 5 years.

She uses 4 pads each day and has undergone unsuccessful pelvic floor rehabilitation as well as one previous incontinence procedure. The problem is causing a severe impact on her QOL. Mild faecal incontinence has been present for 1 year. She has had no previous surgery for this condition. It is only having a minimal effect on her QOL.

Moderate urinary retention has been present for 3 years and is causing moderate impact on quality life. Examination reveals a Stage 3 cystocoele, no posterior defect, slight uterine prolapse but no enterocoele. She has undergone a previous hysterectomy but no previous prolapse surgery. There is a moderate effect on QOL due to the cystocoele.

In the posterior compartment there was no evidence of haemorrhoids, mucosal prolapse, rectocoele, or edrocoele. There have been no previous surgical procedures for anorectal prolapse and the quality of life associated with rectal prolapse is normal. There is no constipation. External genitalia examination is normal.

The PC muscle function test shows mild weakness. Pelvic muscle relaxation is normal. This patient has some health issues of significance such as diabetes or hypertension. Her mental state is normal but her mobility is moderately impaired. She is still sexually active but with moderate problems. Handicap assessment reveals her maximum QOL is 3. She has seen two doctors regarding her current pelvic floor problems and at present does not complain of any pain.

DISCUSSION

The short-IPGH allows a large amount of clinical information to be presented in a short format. The changes from the original IPGH system have been made to make it easier to record the data and easier to remember the various components of each assessment. Different specialists have different understandings of similar terminology, or different terminologies for the same conditions.

Colorectal surgeons and gynaecologists are speaking about different things when they talk about a rectocoele. The short-IPGH is a first step along the path of developing a common language at the basic clinical level to enable the information about a patient to be recorded in a standardised way. It has to be emphasised, however, that this system is dependent on the quality of the information obtained. It does not pretend to be an objective instrument of measurement, as each component of the assessment is subjective unless obtained through validated tests. The short-IPGH may prove to be an important step in eventually developing a common data set and choosing a set of clinical tools that objectively record important information.

Our experience has shown that completion of this proforma at the conclusion of taking a history and examination provides an excellent summary of the patient in the medical record. This simple process highlights the salient points of the history and is available as a starting point for the next clinical visit.

It avoids having to scan the entire history of a patient to try and remember the important issues and it is much more sensible to record the details of the patient’s history into the short-IPGH proforma when the information is still fresh in the doctor’s mind. ( Appendix 1 ) table

CONCLUSIONS

The short-IPGH presented here is a compromise. It is not intended to upset any clinician by appearing to reduce the importance of the detailed analysis of the particular area of history or examination that he or she likes to record. This system is put forward as a practical attempt to develop a common multidisciplinary terminology and enable clinicians to compare patient data and understand each other’s assessment. Studies are now underway to validate the short-IPGH system in the context of a multidisciplinary pelvic floor clinic.

REFERENCES

  1. Artibani W, Benvenuti F, Di Benedetto P, Dodi G, Milani R. Staging of female urinary incontinence and pelvic floor disorders. Proposal of ipgh system. Urodinamica, Neurourology, Urodynamics & Continence 1996; 6: 1-5.
  2. The ICS Committee on Standardisation of Terminology. Final Draft on the Standardisation of Terminology of Female Pelvic Organ Proplapse and Pelvic Floor Dysfunction. Chairman: A. Mattiasson, Subcommittee on Pelvic Organ Prolapse and Pelvic Floor Dysfunction, Chairman: R. Bump, 1994.
  3. Abrams P, Blaivas JG, Stanton SL, Andersen JT. Standardisation of Terminology of Lower Urinary Tract Function. On: Clinical Neuro-Urology, edited by RJ Krane and MB Siroky, Little Brown & C, 2nd edition, 1991; p. 651.
  4. Bump RC, Mattiasson A, Bo K, Brubaker L, DeLancey JOL, et al. The Standardisation of Terminology of Female Organ Prolapse and Pelvic Flooor Dysfunction. Am. J Obstet Gynecol. 1996; 175: 10.17.
  5. Jorge JMN, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36: 77-97.
  6. Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 1996; 39: 681-685.
  7. Dodi G, Lucio P, Spella M, Belluco E, Amadio L, Marcato L. La raccolta dati nel paziente pelvi-perineologico. Pelvi-Perineologia 2006; 25: 19-27.
  8. Altomare DF, Spazzafumo L, Rinaldi M, Dodi G, Ghiselli R, Piloni V. Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome. Colorectal Dis 2007; 18: E-pub.
  9. Sandler RS, Drossman DA, Nathan HP, Mckee DC. Symptom complaints and health care seeking behavior in subjects with bowel dysfunction. Gastroenterology 1984; 87: 314-8.
  10. Smith RC, Greenbaum, DS Vancouver IB, Henry RC, Reinhart MA, Greenbaum RB, Dean HA, Mayle IE. Psychosocial factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome. Gastroenterology 1990; 98: 293-301.
  11. Whitehead WE, Bosmajian L, Zonderman AB, Costa PT, Schuster MM. Symptoms of psychologic distress associated with irritable bowel syndrome. Gastroenterology 1988; 95: 709-14.

Correspondence to: Dr. Bruce Farnsworth
Centre for Pelvic Reconstructive Surgery Suite 505, San Clinic - Sydney Adventist Hospital
185 Fox Valley Rd - Wahroonga 2076 Australia
Tel: +61 2 9473 8555 Fax: +61 2 9473 8559
drbruce505 @ yahoo.com.au