# Pelvic Organ Prolapse: Assessment and Management ## Definition and Epidemiology Pelvic organ prolapse (POP) refers to the descent of pelvic organs such as the bladder, uterus, vaginal vault, or rectum into or beyond the vaginal canal. It is a common condition, with an estimated lifetime risk of surgery for POP ranging from approximately 12 to 19%. The prevalence of symptomatic prolapse increases with age, affecting about 3 to 6% of women. Notably, many women exhibit anatomic prolapse on physical examination but remain asymptomatic. ## Risk Factors The most significant risk factor for POP is vaginal delivery, particularly multiple vaginal births. Other contributing factors include multiparity, advancing age, and menopause. Obesity and chronic straining due to constipation, heavy lifting, or chronic cough also increase risk. Connective tissue disorders such as Ehlers-Danlos and Marfan syndromes predispose to prolapse. Prior pelvic surgery, especially hysterectomy, family history, and race—where Hispanic and White women show higher prevalence—are additional risk factors. ## Anatomy and Classification ### Compartments of Prolapse Prolapse is classified by the pelvic compartment involved. The anterior compartment involves the bladder and is termed a cystocele, which is the most common type. The apical compartment includes uterine prolapse or vaginal vault prolapse following hysterectomy. The posterior compartment involves the rectum (rectocele) or small bowel (enterocele). Often, multiple compartments are affected simultaneously. ### POP-Q Staging System (ICS Standard) The Pelvic Organ Prolapse Quantification (POP-Q) system is an objective and reproducible method for assessing prolapse, using the hymenal ring as a reference point. It involves nine measurement points: Aa, Ba, C, D, Ap, Bp, total vaginal length (tvl), genital hiatus (gh), and perineal body (pb). Key landmarks include Aa, located on the anterior vaginal wall 3 cm proximal to the hymen, ranging from -3 to +3 cm; Ba, the most distal point of the anterior wall; C, representing the cervix or vaginal cuff; D, the posterior fornix if the uterus is present; Ap, on the posterior wall 3 cm proximal to the hymen; and Bp, the most distal point of the posterior wall. ### POP-Q Stages The POP-Q system categorizes prolapse into stages based on the position of the leading edge relative to the hymen. Stage 0 indicates no prolapse. Stage I is defined by the leading edge being more than 1 cm above the hymen. Stage II includes prolapse within 1 cm above or below the hymen. Stage III involves prolapse more than 1 cm below the hymen but less than 2 cm less than the total vaginal length. Stage IV represents complete eversion or procidentia. | POP-Q Stage | Leading Edge Position | Description | |---|---|---| | 0 | N/A | No prolapse | | I | >1 cm above hymen | Minimal descent | | II | Within 1 cm above or below hymen | Moderate | | III | >1 cm below hymen, POP-Q measurement diagram showing the nine reference points (Aa, Ba, C, D, Ap, Bp, tvl, gh, pb) and their relationships to the hymenal ring ## Clinical Evaluation ### Symptoms The hallmark symptom of clinically significant POP is the sensation of a vaginal bulge or fullness, often described as tissue protruding from the vagina or a feeling that "something is falling out." This symptom is the most specific indicator of prolapse requiring intervention. Urinary symptoms such as frequency, urgency, incomplete emptying, stress urinary incontinence (SUI), and the need to splint to void are common. Bowel symptoms include incomplete evacuation, splinting, constipation, and fecal incontinence. Sexual symptoms may involve dyspareunia, decreased sensation, and avoidance of intercourse. Importantly, the severity of symptoms does not always correlate with the POP-Q stage. ### Physical Examination A thorough physical examination includes assessment in both the lithotomy and standing positions, as gravity accentuates prolapse. A split speculum, using only the posterior blade, helps isolate the compartments. The patient is asked to perform a Valsalva maneuver to demonstrate maximal prolapse. Each compartment is evaluated independently. Occult SUI should be assessed by reducing the prolapse with a pessary or speculum followed by a cough stress test. A bimanual exam is performed to exclude pelvic masses, and a rectal exam assesses for rectocele and sphincter tone. ### Additional Evaluation Post-void residual (PVR) measurement is useful to detect urinary obstruction caused by prolapse. Urodynamic studies are indicated when urinary symptoms coexist, particularly before surgical intervention. Imaging is generally not required but may be helpful in complex recurrent cases or research settings, with MRI being the preferred modality. ## Conservative Management ### Pelvic Floor Muscle Training Pelvic floor muscle training is the first-line treatment for mild to moderate prolapse (stage I-II). This involves supervised physiotherapy often combined with biofeedback. While it may reduce symptoms and prevent progression, it does not significantly reverse the anatomic prolapse. ### Vaginal Pessary A vaginal pessary is a removable device inserted into the vagina to support prolapsed organs and is effective across all stages and compartments. Common types include the ring pessary, which is the most frequently used first-line option due to ease of self-management, the Gellhorn pessary providing stronger support for advanced prolapse but more difficult to manage independently, the cube pessary offering high retention for severe prolapse, and the donut pessary designed for large prolapse support. Fitting is often a trial-and-error process with about 70% success. Patients who can self-remove and clean the pessary are preferred; otherwise, clinic visits every 3 to 6 months are necessary. Complications include vaginal erosion, discharge, odor, and rarely incarceration. Concurrent use of topical estrogen is recommended to reduce erosion risk. Pessaries are suitable for patients who decline surgery, are poor surgical candidates, or desire future pregnancy. Photographs of common pessary types (ring, Gellhorn, cube, donut) with corresponding illustrations showing their placement and mechanism of support ## Surgical Management ### General Principles Surgery is indicated for symptomatic prolapse of stage II or higher that does not respond to conservative management. The surgical goal is to restore normal anatomy, relieve symptoms, and preserve or restore function. All involved compartments must be addressed, and if occult SUI is present, a concurrent anti-incontinence procedure should be performed. Surgical approaches include vaginal and abdominal routes, with abdominal options encompassing open, laparoscopic, and robotic techniques. ### Anterior Compartment (Cystocele) Anterior colporrhaphy is the standard vaginal approach for anterior prolapse, involving midline plication of the pubocervical fascia. It achieves an anatomic success rate of 60 to 80%, with higher rates of symptomatic improvement, although recurrence occurs in 20 to 40% of cases long-term. Paravaginal repair reattaches the lateral vaginal support to the arcus tendineus (white line) and can be performed vaginally, abdominally, or robotically, often in combination with sacrocolpopexy. ### Apical Compartment Sacrocolpopexy, performed via abdominal, robotic, or laparoscopic approaches, is considered the gold standard for apical prolapse repair. It uses polypropylene mesh to bridge the vaginal apex to the sacral promontory and can be combined with anterior or posterior repairs. The robotic or laparoscopic approach is most common today, with a success rate of 90 to 95% at five years. This procedure is durable and preserves vaginal length but carries risks including mesh erosion (3-5%), sacral hemorrhage from presacral veins, bowel injury, and ileus. Uterosacral ligament suspension (USLS) is a native tissue repair performed vaginally by suturing the vaginal cuff or vault to the remnants of the uterosacral ligaments. It has a success rate of 75 to 85%. There is a 2 to 5% risk of ureteral kinking, making intraoperative cystoscopy with intravenous indigo carmine mandatory to confirm ureteral patency. No mesh is used in this procedure. Sacrospinous ligament fixation (SSLF) is another vaginal approach where the vaginal apex is sutured to the sacrospinous ligament, typically on the right side. Its success rate ranges from 70 to 85%. Risks include pudendal nerve or vessel injury, leading to buttock pain in 5 to 10% of patients. SSLF tends to cause posterior deviation of the vagina and is associated with a higher rate of anterior compartment recurrence. No mesh is used. McCall culdoplasty is a prophylactic apical support procedure performed during vaginal hysterectomy, which obliterates the cul-de-sac and supports the vaginal cuff. ### Posterior Compartment (Rectocele) Posterior colporrhaphy involves midline plication of the rectovaginal fascia and achieves an 80 to 90% success rate. However, if levator plication is performed, there is a 5 to 10% risk of dyspareunia, so it should be avoided in sexually active women. ### Obliterative Procedures Colpocleisis (Le Fort procedure) involves partial or total closure of the vaginal canal and is reserved for elderly or frail women who are not sexually active. It has a very high success rate exceeding 95%, with short operative time and low morbidity. Prior to this procedure, uterine or cervical pathology must be ruled out. A concurrent anti-incontinence procedure is recommended due to the high rate of de novo SUI. Colpocleisis is irreversible, necessitating thorough patient counseling. Surgical illustrations comparing sacrocolpopexy (mesh bridging vaginal apex to sacral promontory), uterosacral ligament suspension, and sacrospinous ligament fixation approaches for apical prolapse repair ## Mesh in Prolapse Surgery: Regulatory Landscape Polypropylene mesh used in abdominal or robotic sacrocolpopexy remains available and recommended; it is a type I macroporous mesh. However, transvaginal mesh for prolapse was ordered off the US market by the FDA in April 2019 due to numerous reports of mesh erosion, pain, and dyspareunia. Although removed from the market, it was not recalled, and patients with existing mesh are managed as needed. It is important to distinguish that the ban applies only to transvaginal mesh for POP; sacrocolpopexy mesh placed abdominally and midurethral slings for SUI remain standard of care. ## Hysterectomy and Prolapse Traditionally, concomitant hysterectomy is performed during prolapse repair if the uterus is prolapsing. However, uterine-sparing options, known as hysteropexy, include sacrohysteropexy, uterosacral hysteropexy, and the Manchester repair. These preserve fertility potential and growing evidence supports outcomes comparable to hysterectomy with vault suspension. Adequate cervical cancer screening must be ensured in these cases. ## Recurrent Prolapse Recurrence rates after prolapse surgery range from 10 to 30%, depending on the procedure and compartment involved. Risk factors for recurrence include advanced stage prolapse, involvement of the anterior compartment, obesity, chronic straining, and connective tissue weakness. Management options for recurrent prolapse include repeat native tissue repair, sacrocolpopexy, or colpocleisis, tailored to patient factors. ## Clinical Pearls The most specific symptom indicating clinically relevant POP is the sensation of a vaginal bulge; if this is absent, prolapse observed on examination is unlikely to explain the patient's symptoms. It is essential to check for occult stress urinary incontinence by reducing the prolapse during a stress test, as failure to do so may result in unmasked SUI after prolapse repair. The POP-Q staging system is the standardized and reproducible method for clinical communication and research, and mastering it is crucial. Uterosacral ligament suspension requires intraoperative cystoscopy with visualization of ureteral jets or intravenous indigo carmine due to a 2 to 5% risk of ureteral kinking. The 2019 transvaginal mesh ban applies only to mesh placed vaginally for prolapse; sacrocolpopexy mesh and midurethral slings remain standard treatments. Sacrocolpopexy is the most durable apical prolapse repair, with a 90 to 95% success rate at five years, but involves synthetic mesh, so patient counseling must balance durability against mesh-related risks. Finally, colpocleisis is underutilized in the elderly population despite having the highest success rate of any prolapse procedure and minimal morbidity. ## References - AUA/SUFU Guideline on Pelvic Organ Prolapse, 2019 (amended 2023) - EAU Guidelines on Pelvic Organ Prolapse, 2024 Update - Maher C, et al. "Surgery for pelvic organ prolapse." *Cochrane Database Syst Rev*. 2023. - Barber MD, et al. "Sacrocolpopexy vs. uterosacral ligament suspension" (OPTIMAL Trial). *JAMA*. 2014;311(10):1023-1034. - FDA Safety Communication: FDA Orders Manufacturers of Surgical Mesh for Transvaginal POP Repair to Stop Selling, 2019. - Campbell-Walsh-Wein Urology, 12th Edition, Chapter on Pelvic Organ Prolapse