Residency · Residency · Obstetrics Gynecology

Pelvic Organ Prolapse: Evaluation and Management

Overview

Pelvic organ prolapse is the descent of pelvic organs, including the uterus, bladder, rectum, and vaginal apex, into or through the vaginal canal. Up to 50% of parous women have some degree of prolapse on examination, though only 3 to 6% are symptomatic. The prevalence increases with age, parity, and other risk factors. Prolapse significantly impacts quality of life but is not life-threatening, and treatment decisions are driven by symptoms rather than exam findings alone.

Anatomy and Pathophysiology

Pelvic Floor Support

The pelvic floor provides support through three distinct levels. Level I (apical support) is provided by the cardinal-uterosacral ligament complex, which suspends the uterus and vaginal apex. Level II (lateral support) consists of the paravaginal attachments to the arcus tendineus fasciae pelvis anteriorly and the rectovaginal fascia posteriorly. Level III (distal support) is formed by the perineal body, perineal membrane, and external sphincters that fuse with the vaginal wall. The levator ani muscle group, comprising the pubococcygeus, puborectalis, and iliococcygeus muscles, provides dynamic pelvic floor support. Prolapse results from failure at one or more of these levels.

Risk Factors

Vaginal delivery is the strongest modifiable risk factor, particularly when complicated by a prolonged second stage, macrosomia, or operative vaginal delivery. Increasing parity, aging with its associated loss of estrogen and connective tissue degradation, obesity, and chronic straining from constipation, chronic cough, or heavy lifting all contribute. Prior pelvic surgery, especially hysterectomy, increases risk. Connective tissue disorders such as Ehlers-Danlos and Marfan syndrome are predisposing conditions. Family history and race (with higher incidence in White and Hispanic women) also play a role.

Types of Prolapse

Anterior Compartment

A cystocele is the descent of the anterior vaginal wall with the bladder behind it. It is the most common type of prolapse. Symptoms may include urinary frequency, urgency, incomplete bladder emptying, and stress incontinence.

Apical Compartment

Uterine prolapse is the descent of the uterus and cervix. Vaginal vault prolapse occurs after hysterectomy, with descent of the vaginal apex. Apical support failure often accompanies both anterior and posterior compartment prolapse.

Posterior Compartment

A rectocele is the descent of the posterior vaginal wall with the rectum bulging into the vagina. It may cause difficulty with defecation and the need to splint, which means applying digital pressure on the posterior vaginal wall to assist stool evacuation. An enterocele is the herniation of small bowel through the peritoneum into the upper posterior vaginal wall and is distinct from a rectocele.

<image>Sagittal anatomic diagram showing normal pelvic organ support with intact Levels I, II, and III, compared with prolapse showing anterior compartment cystocele, apical uterine descensus, and posterior compartment rectocele, with labels for the bladder, uterus, rectum, and vaginal walls</image>

POP-Q Staging System

Measurement Points

The Pelvic Organ Prolapse Quantification (POP-Q) system, developed by Bump and colleagues in 1996, is a standardized and reproducible measurement system. It uses the hymen as the reference point (zero). Negative numbers indicate positions above the hymen, and positive numbers indicate positions beyond the hymen. Six vaginal measurement points are recorded: Aa and Ba for the anterior wall, C for the cervix or vaginal cuff, D for the posterior fornix (if the uterus is present), and Ap and Bp for the posterior wall. Three additional measurements include genital hiatus (GH), perineal body (PB), and total vaginal length (TVL).

Stages

Stage 0 indicates no prolapse. Stage I means the most distal portion of the prolapse is more than 1 cm above the hymen. Stage II indicates the most distal portion is between 1 cm above and 1 cm below the hymen. Stage III means the most distal portion protrudes more than 1 cm beyond the hymen but is not fully everted. Stage IV represents complete eversion of the vagina, also known as procidentia.

Evaluation

Symptoms

The most specific symptom of prolapse is the sensation of a vaginal bulge. Other symptoms include pelvic pressure or heaviness that worsens with prolonged standing or Valsalva, difficulty with bladder emptying or the need to reposition to void, difficulty with bowel movements or the need to splint, dyspareunia or sexual dysfunction, and nonspecific low back pain. Symptoms characteristically improve when the patient is supine.

Physical Exam

The examination is performed in the lithotomy position with the patient straining (Valsalva). A split speculum using only the posterior blade allows each compartment to be assessed independently. Prolapse is quantified using the POP-Q system. A cough stress test evaluates for stress urinary incontinence. Rectal examination helps distinguish a rectocele from an enterocele. Pelvic floor muscle strength is assessed using the Oxford grading system.

Additional Studies

Urodynamics should be considered before surgery if urinary symptoms are present or occult stress incontinence is suspected. A cough stress test performed with the prolapse reduced can unmask occult stress incontinence that becomes apparent only when the prolapse is no longer obstructing urinary flow. Post-void residual measurement assesses for urinary retention. Pelvic floor MRI is rarely needed but can be useful in complex or recurrent cases.

Conservative Management

Observation

Observation is appropriate for asymptomatic or mildly symptomatic prolapse. Prolapse generally progresses slowly, and many patients remain stable for years. Reassurance that prolapse is not dangerous is an important part of the clinical encounter.

Pelvic Floor Muscle Training (PFMT)

Kegel exercises strengthen the levator ani. Supervised pelvic floor physical therapy is more effective than instruction alone. These exercises can reduce symptoms and slow progression, particularly for Stage I and II prolapse. There is moderate evidence for symptom improvement but less evidence for anatomic improvement.

Pessary

A pessary is the first-line conservative treatment for symptomatic prolapse. These silicone devices are placed in the vagina to support the prolapsed organs. The ring pessary is the most commonly used type, fits around the cervix, and can often be self-managed by the patient. The Gellhorn pessary, with its suction-cup design, provides better support for advanced prolapse. The donut pessary is also used for advanced prolapse. The cube pessary is suction-based and must be removed daily. Fitting is done by trial and error, starting with a ring pessary in most cases. Follow-up visits every 3 to 6 months are needed for cleaning, inspection of the vaginal mucosa, and assessment for erosion or ulceration. Concurrent use of vaginal estrogen is recommended to maintain mucosal integrity and reduce erosion. Complications include vaginal discharge, odor, erosion or ulceration, bleeding, impaction if neglected, and rarely fistula formation. Between 70 and 90% of women can be successfully fitted, and many use a pessary long-term.

<image>Illustrations of common pessary types used for pelvic organ prolapse: ring pessary with and without support, Gellhorn pessary with its suction-cup disc, donut pessary, and cube pessary, with diagrams showing proper positioning within the vagina for each type</image>

Surgical Management

Indications

Surgery is indicated for symptomatic prolapse that has failed or declined conservative management, or when the patient prefers definitive treatment. The goal is to restore anatomy and improve quality of life.

Anterior Compartment Repair

Anterior colporrhaphy involves plication of the pubocervical fascia as a native tissue repair. It has the highest recurrence rate of all prolapse repairs at 20 to 40%. Paravaginal repair addresses lateral detachment defects.

Apical Repair (Most Critical)

Sacrocolpopexy, performed abdominally or robotically, is the gold standard for apical prolapse. Permanent polypropylene mesh is used to attach the vaginal apex to the sacral promontory. Success rates are 90 to 95% at 5 years. The procedure can be combined with supracervical hysterectomy. Risks include mesh erosion (3 to 5%), sacral hemorrhage, and bowel injury. Uterosacral ligament suspension (USLS) is a native tissue vaginal approach that suspends the vaginal cuff to the uterosacral ligaments. Success rates are 80 to 85%, and there is a risk of ureteral kink, making intraoperative cystoscopy mandatory. Sacrospinous ligament fixation (SSLF) is a vaginal approach with unilateral fixation to the sacrospinous ligament. Success rates are 70 to 85%. It may predispose to subsequent anterior wall prolapse due to deviation toward the fixed side, and there is risk of pudendal nerve or vessel injury. Colpocleisis (Le Fort procedure) involves partial or complete closure of the vaginal canal. It is reserved for women who are not sexually active and are poor surgical candidates. It is the fastest, simplest procedure with the highest success rate at approximately 95%, but it is irreversible and eliminates vaginal intercourse.

Posterior Compartment Repair

Posterior colporrhaphy involves plication of the rectovaginal fascia. Aggressive levatorplasty should be avoided because it causes dyspareunia. Options include site-specific defect repair versus traditional midline plication.

Hysterectomy in Prolapse Surgery

Hysterectomy has traditionally been performed concurrent with prolapse repair. Uterine-sparing procedures (hysteropexy) are increasingly offered, including sacrohysteropexy, the Manchester procedure, and sacrospinous hysteropexy. These may preserve uterine function and sexual satisfaction but require ongoing cervical screening and management of any future uterine pathology.

Mesh in Prolapse Surgery

Abdominal and robotic sacrocolpopexy using mesh is well-supported by evidence and has low complication rates. Transvaginal mesh for prolapse, however, was the subject of an FDA order in 2019 requiring manufacturers to stop selling it due to safety concerns including erosion, pain, dyspareunia, and infection. Transvaginal mesh for prolapse is largely abandoned in the United States. Importantly, transvaginal mesh for stress urinary incontinence (midurethral slings) remains available and effective and is a distinct issue from prolapse mesh.

Clinical Pearls

Treat symptoms, not exam findings. Many women with Stage II prolapse are asymptomatic and need only reassurance.

Pessary is a highly effective and underutilized first-line treatment that should be offered to all symptomatic patients before surgery.

Apical support is the key to any successful prolapse repair. Failure to address the apex is the most common reason for surgical failure.

Always perform a cough stress test with prolapse reduced before surgery to unmask occult stress incontinence that may require a concurrent anti-incontinence procedure.

Intraoperative cystoscopy is mandatory after uterosacral ligament suspension to rule out ureteral obstruction.

Transvaginal mesh for prolapse repair has been effectively removed from the US market by FDA action. Abdominal mesh sacrocolpopexy remains the gold standard for apical repair.

Colpocleisis is an excellent option for elderly women who are not sexually active. It has the highest success rate and lowest morbidity of all prolapse surgeries.

References

• ACOG Practice Bulletin No. 214: Pelvic Organ Prolapse (2019)
• Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24:1783-1790
• FDA Safety Communication: Urogynecologic Surgical Mesh (2019)
• Maher C et al. Surgery for women with pelvic organ prolapse. Cochrane Database Syst Rev. 2023
• Bump RC et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction (POP-Q). Am J Obstet Gynecol. 1996;175:10-17
• Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300:1311-1316

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