There is a commonly-held opinion that pelvic organ prolapse (POP) is associated with cervical elongation. One study found that about 40% of women with anterior component POP had cervical elongation, with the age of Cervical Elongation (CE), patients relatively younger than POP patients(1). CE is an extension or hypertrophy of the cervix towards the introitus with other uterine supporting tissues still in good condition. CE can occur in both parts of the cervix, supravaginal and vaginal. The presence of CE will affect the management of hysterectomy for POP. Consideration needs to be made to choosing the vaginal or abdominal approach, supravaginal or total hysterectomy, whether or not the uterus is maintained, or the choice of the apical suspension chosen. Undiagnosed CE before surgery will make surgery more complex and at risk of failing to overcome symptoms even with the apical component already supported in patients who have surgery by maintaining the uterus(3). CE is also one factor associated with high prolapse recurrence rates after suspension of the sacrospinous ligament. 
This study aimed to compare cervical length based on the Pelvic Organ Prolapse Quantification system (POP-Q) examination as an index test with sonography in patients with POP. 
We hypothesized that cervical length measurement using POP-Q, isn’t accurate in all patients, and transvaginal sonography examination of the cervix is a reliable and reproducible method(2) to assess the cervical length as it is performed in pregnant women  to assess cervical incompetency as usually.

A cross-sectional study was performed in the educational hospital's outpatient clinic between January 2020 and December 2021. One hundred women with POP entered in this study. The regional ethical committee approved the proposal. At first, POP staging, was performed according to POP-Q system, and cervical length was determined based on C-D measurements by an urogynecologist. Then, All women were underwent  transvaginal ultrasonography to measure cervical length as the distance from the internal to the external os. ( for this purpose, the Patient’s bladder should be essentially empty). SPSS/Ver24 was used for statistical analysis.

The final analysis included 100 subjects. The mean age of patients was 47.88±8.7 years, the mean BMI was 26.19±1.53 kg/m2, and the mean total vaginal length (TVL) was  9.00±1.20 cm (min 7 cm and max 11 cm ). The results of measuring the cervix length by the POP-Q method showed that the mean (SD) was 40.80±22.11 mm (the minimum length of the cervix was 20 mm, and the maximum was 110 mm). The ultrasonography results showed that these amounts were 36.8.± 6.86 mm (minimum of 28 mm and a maximum of 80 mm. 
To assess the agreement between the two measurement methods, Intraclass Correlation Coefficient (ICC) was used, and the results showed that the Intraclass Correlation is 0.476 (95%CI: 0.220-0.648). Given the obtained value for the ICC, there is a relatively weak agreement between the two indicators to measure cervical length. For this purpose, the Bland-Altman method was used, and the results showed that the amount of Bias (mean difference) and SD was 4.00 (19.20), with 95% Limits of Agreement between -33.63 to 41.63.
According to the results of the studies related to the Bland-Altman plot, the most disagreement is related to the following values:
(POPQ=100, Sono lenght=34)
(POPQ=110, Sono lenght=45)
(POPQ=110, Sono lenght=48)
(POPQ=100, Sono lenght=40)
(POPQ=100, Sono lenght=55)
 (POPQ=80, Sono lenght=36)

There is a relatively weak agreement between POP-Q and ultrasonography to measure cervical length .When the cervical length is more than 8 cm according to POP-Q, the difference between the two methods is more significant. As in these patients, cervical length in ultrasonography measured approximately half of POP-Q.

it is essential to measure the cervical length in POP patients accurately.
Because it affects our plan to choose conservative management or surgery and the kind of surgery. Different measuring techniques (POP-Q, ultrasonography, digital palpation, foley catheter…). have some pros and cons.  The POP-Q system is an acceptable method and familiar for pelvic floor specialists worldwide. However, based on this study,  it is recommended to repeat measuring by other methods like ultrasonography (that is routinely performed for  pregnant women to rollout cervical insufficiency) before choosing therapy in POP patients with doubtful results according to POP-Q measurements.

Mitchell B, Rajeev R, Kenneth G, John D. Is cervical elongation associated with pelvic organ prolapse? 2012; 23(8): 1095-1103
Beckman and ling's Obstetrics and Gynecology (Eighth Edition) 2019;147-151
Tyas P, Finish F, Lucky S, Shirley A, Kukuh W. pelvic organ prolapse Quantification accuracy for elangasio cervix diagnosis in pelvic organ prolapse patients. 2020; vol 8 , 52-60

Continence 2S2 (2022) 100303
DOI: 10.1016/j.cont.2022.100303