Tools
Pelvic Organ Prolapse
Introduction
Pelvic organ prolapse (POP) is a condition characterized by the descent of pelvic structures, such as the anterior or posterior vaginal wall, uterus, cervix, or vaginal apex, into or beyond the vaginal canal due to weakening of the pelvic floor's supportive tissues, including muscles, fascia, and ligaments.[1] This structural weakness allows adjacent organs, such as the bladder, rectum, or small intestine, to herniate into the vaginal space, resulting in clinical manifestations including cystocele, rectocele, enterocele, or uterine prolapse.[2] Mild prolapse may be asymptomatic and fall within physiological limits, but POP becomes clinically significant when it causes symptoms such as pelvic pressure, a sensation or visible bulge in the vagina, difficulty with urination or defecation, urinary or fecal incontinence, or sexual dysfunction.[3]
Initial evaluation should involve a thorough clinical history and a detailed pelvic examination, with particular attention to associated complications such as urinary incontinence, bladder outlet obstruction, and fecal incontinence.[3][4] POP quantification (POP-Q) staging is commonly used to assess the severity and compartmental involvement of the prolapse.
Management strategies are guided by the severity of prolapse, symptom burden, patient preferences, and functional goals. Options range from conservative measures—such as watchful waiting and vaginal pessary use—to definitive surgical correction. Surgical interventions include reconstructive procedures—performed with or without synthetic or biological graft materials—as well as obliterative procedures, which may be appropriate for select non-sexually active individuals.
Etiology
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Etiology
POP is a multifactorial condition primarily driven by pelvic floor injury and connective tissue weakening. Vaginal childbirth remains the most significant risk factor, particularly when associated with high parity, large birthweight, forceps-assisted delivery, or prolonged labor—all of which can result in direct trauma to the pelvic muscles, fascia, and the levator ani complex. Other well-established risk factors include advancing age, obesity (as measured by body mass index [BMI]), genetic predisposition, and connective tissue disorders, each of which can compromise pelvic support and exacerbate descent.
Chronic increases in intra-abdominal pressure—due to factors such as persistent coughing, constipation, or heavy lifting—place additional stress on weakened tissues, accelerating the development of prolapse. A history of pelvic surgery or hysterectomy also contributes to POP by disrupting native support structures.[4] These risk factors interact dynamically throughout a woman’s lifespan, resulting in degenerative changes and symptomatic POP in susceptible individuals.[5]
Epidemiology
POP is a common condition, though its true prevalence is often underestimated due to discrepancies between symptom reporting and clinical examination findings. National surveys indicate that approximately 3% of women in the United States report symptoms of vaginal bulging, whereas physical examination reveals that 41% to 50% have some degree of prolapse.[6] POP primarily affects older women, with prevalence increasing with age and peaking at around 5% among those aged 60 to 69. Longitudinal studies show that among symptomatic women who defer treatment, approximately 78% experience no significant anatomical progression over an average follow-up of 16 months. However, about 29% of symptomatic women progress to clinically significant prolapse—defined as POP-Q descent beyond the hymen—within a year, particularly older individuals or those with more advanced baseline prolapse.[7] The incidence of POP is expected to rise by 46%, reaching an estimated 4.9 million affected women by 2050.[8]
History and Physical
A comprehensive evaluation for POP begins with a thorough medical, surgical, obstetric, and gynecological history. Particular attention should be given to symptoms of vaginal bulging and the extent to which these symptoms interfere with daily activities, sexual function, or show signs of progression over time, as many women with clinically apparent POP may be asymptomatic.[9] Evaluation should also include a detailed review of urinary function, with screening for stress or urgency incontinence, voiding difficulties, and compensatory behaviors such as manual splinting. Likewise, bowel habits should be evaluated for indications of posterior compartment involvement, including straining, incomplete evacuation, reliance on laxatives, or fecal incontinence.
The physical examination should begin with inspection of the external genitalia and vaginal mucosa for signs of atrophy, irritation, or ulceration. A focused pelvic examination is then performed using a split-speculum technique during a Valsalva maneuver or coughing to elicit maximum prolapse, with careful evaluation of all 3 compartments—anterior, apical, and posterior. Standardized prolapse grading systems, such as the POP-Q system or the Baden-Walker Halfway Scoring System, provide objective staging and facilitate consistent documentation of prolapse.[10][11]
If prolapse is not fully appreciated in the supine position, examination should be repeated with the patient upright.[12] A single-blade Sims speculum may be used to improve visualization of the vaginal apex and to sequentially inspect the anterior and posterior vaginal walls for evidence of cystocele or rectocele, respectively. Additionally, pelvic floor muscle strength should be assessed and documented as absent, weak, normal, or strong, as this evaluation is crucial for guiding an individualized management plan.[9]
Evaluation
Evaluation of POP integrates patient-reported symptoms with a standardized physical examination to accurately determine the type and severity of pelvic support defects. The assessment begins with a thorough history, including symptoms such as pelvic pressure or a sensation of vaginal bulge, urinary or fecal incontinence, voiding or defecatory dysfunction, and sexual discomfort.[4]
The pivotal physical assessment utilizes the POP-Q system, which objectively measures the descent of the anterior, apical, and posterior vaginal compartments relative to the hymen during a Valsalva maneuver, providing reliable staging from 0 to 4.[13] Although imaging studies (such as dynamic magnetic resonance imaging [MRI] and defecography) may assist in complex or multicompartment prolapse, the clinical pelvic examination remains the cornerstone of evaluation.
Adjunctive tests, such as post-void residual measurement, urodynamic studies, or stress-cough testing with and without prolapse reduction, are appropriate for assessing coexisting urinary dysfunction.[12] Importantly, both the patient's symptomatic presentation and the objective POP-Q stage guide management decisions, allowing treatment to be tailored to the severity of prolapse and its impact on urinary, bowel, and sexual function.
Treatment / Management
Both conservative and surgical management may be appropriate depending on the patient’s age, desire for future fertility and sexual function, symptom severity, and comorbid conditions. The affected compartment also influences treatment choice. Management goals include symptom relief, preservation or improvement of sexual function, prevention of new support defects and incontinence, and restoration of adequate pelvic support.[14]
Observation and close follow-up are appropriate for women with mild, asymptomatic cases. Most women do not experience symptoms until the bulge protrudes beyond the vaginal opening. Pelvic floor muscle training (Kegel exercises) allows a systematic contraction of the levator ani muscles, strengthening the pelvic floor. Kegel exercises have been proven to improve symptoms of stress, urge, and mixed urinary incontinence and can be useful in women with mild POP.[15](A1)
Two-thirds of patients with symptomatic POP opt for pessary management, and up to 77% continue use after 1 year.[16] Pessaries are devices that are typically made of medical-grade silicone and inserted into the vagina to restore normal pelvic anatomy. Suitable for all stages of prolapse, they can prevent progression and delay the need for surgery. Approximately 85% of patients are successfully fitted for a pessary.[17] However, fitting may be challenging in patients with a short vaginal length, wide vaginal opening, or history of hysterectomy. The initial choice is usually a ring pessary, folded for insertion and positioned between the pubic symphysis and posterior vaginal fornix. A proper fit remains at least one fingerbreadth above the introitus when the patient bears down. After fitting, patients should sit, walk, and void to ensure comfort and avoid urinary retention. They must be instructed on regular removal and cleaning—ranging from nightly to monthly—based on individual needs.
When considering surgical intervention for POP, it is important to assess and discuss the patient’s goals regarding future fertility and sexual function. A range of abdominal and vaginal procedures are available to restore pelvic floor support and relieve symptoms. Colpocleisis—an obliterative procedure involving closure or shortening of the vaginal cuff—offers an anatomic success rate of 98% and a subjective success rate of 93%.[18] However, before performing this procedure, it is essential to counsel the patient that coital function will no longer be possible. For individuals who wish to preserve sexual function, a range of reconstructive surgical options should be explored.
Adequate support of the vaginal apex has been recognized as a critical component of successful surgical repair for advanced POP. Although some techniques rely on a woman's native tissues and ligaments for suspension, many incorporate biological grafts or mesh to support the uterus. Transvaginal approaches offer shorter operative and recovery times, whereas abdominal approaches tend to provide more durable outcomes and lower recurrence rates.[19](A1)
One of the most widely performed transvaginal suspension procedures is sacrospinous fixation, which involves attaching the vaginal apex to the sacrospinous ligament of the coccygeus muscle. Advantages include avoiding the morbidity of an abdominal incision, preserving vaginal function, and enabling simultaneous repair of anterior and posterior compartment defects through a single surgical site.[20] However, this technique shifts the vaginal axis posteriorly, which may contribute to the development of new anterior compartment defects.[21] Associated complications that have been reported include intraoperative hemorrhage due to laceration of the pudendal artery, vaginal shortening, sexual dysfunction, and injury to the pudendal nerve.[22](B3)
The iliococcygeus suspension is another transvaginal approach that provides excellent apical support by attaching the vaginal apex to the fascia of the iliococcygeus muscle.[23] As this technique preserves the vaginal axis, anterior compartment prolapse is rare. However, vaginal shortening can occur due to the ischial spines being positioned inferiorly relative to the normal vaginal apex. An alternative transvaginal approach is uterosacral suspension, which involves plicating the uterosacral ligaments at the midline and attaching them to the vaginal cuff. A notable disadvantage of this method is the close proximity of the uterosacral ligaments to the ureters.[19](A1)
In recent years, abdominal sacrocolpopexy has emerged as the preferred procedure for POP and can be performed via laparotomy, laparoscopy, or robotic-assisted techniques. Since Lane first described the procedure in 1962, numerous refinements have been made. Birnbaum later proposed anchoring the suspensory mesh to the sacrum, although this approach carries a significant risk of hemorrhage due to potential laceration of the presacral vessels.[24] Various suspensory materials have been used in abdominal sacrocolpopexy, including mesh, non-absorbable sutures, fascia, and dura mater. Currently, mesh-based sacrocolpopexy is considered the gold standard, offering long-term symptom relief and effective restoration of vaginal function.[25] This procedure should be considered for women who wish to preserve vaginal function or who have experienced failure with prior surgical repairs for uterine or vaginal vault prolapse.(B3)
Differential Diagnosis
POP shares overlapping symptoms with several other pelvic conditions, making differential diagnosis essential. Conditions such as urethral diverticulum, Gartner duct cysts, Bartholin gland cysts or abscesses, and vaginal neoplasms may mimic POP by presenting as vaginal or perineal masses. Additionally, anatomic variants such as cystocele, rectocele, enterocele, and prolapsed ureteroceles can resemble or coexist with POP.
Staging
The American Urogynecologic Society and the Society of Gynecologic Surgeons agreed upon a consensus document for staging POP at the 1996 International Continence Society.[26] The result was the development of the POP-Q system—a standardized and widely adopted method for assessing and staging POP in both clinical and research settings.[27] The technique measures prolapse in each compartment relative to the hymenal ring, using centimeters as the unit of measurement. Prolapse points located above (proximal to) the hymen are assigned negative values, whereas those protruding beyond the hymen receive positive values.
A total of 6 points are delineated, including 2 on the anterior vaginal wall (Aa and Ba), 2 on the vaginal apex (C and D), and 2 on the posterior vaginal wall (Ap and Bp). Additional measurements include GH (genital hiatus), PB (perineal body), and TVL (total vaginal length).[28] Prolapse is staged from 0 (no prolapse) to 4 (complete eversion). The POP-Q system provides objective and reproducible measurements that aid in diagnosis, treatment planning, and the comparison of clinical outcomes.
An alternative to the POP-Q system is the previously used Baden-Walker Halfway Scoring System for grading POP.[10] In this system, normal pelvic support is classified as grade 0. Grade 1 indicates descent halfway to the hymen, grade 2 corresponds to descent reaching the hymen, and grade 3 signifies descent beyond the hymen. Grade 4 represents complete procidentia.
Prognosis
Although POP can significantly affect quality of life, it is not life-threatening. Most patients are initially asymptomatic. Among those with bulge symptoms, many experience substantial relief with pessary use and other noninvasive treatments. Surgical intervention has a success rate of approximately 95%, with studies demonstrating marked improvement in bulge symptoms and high patient satisfaction at 2- and 5-year follow-ups, accompanied by minimal new morbidity.[29]
Complications
Concomitant urinary symptoms can be exacerbated by POP. Therefore, during evaluation, it is essential to retract the bulge and assess for signs of urinary incontinence that may be masked by prolapse.[30] Additionally, POP can lead to fecal incontinence and bowel obstruction, which can be a significant complication of POP. Many patients can describe splinting in which a finger in the vagina is required to aid in defecation.[31]
Although pessary use is highly effective, patients should be counseled about potential complications before the pessary is placed. Follow-up symptoms such as vaginal discharge, irritation, ulceration, bleeding, pain, odor, vaginal wall ulceration, fistula formation, or bowel herniation may indicate pessary-related complications.[32] Infections with anaerobic organisms—particularly bacterial vaginosis—are more common in women who change their pessaries less than once per week.[33] Vaginal ulceration and bleeding are also more frequently observed in postmenopausal women and in those who remove their pessaries infrequently.
Several complications have been associated with mesh use in the surgical treatment of POP. The application of transvaginal mesh and biological graft materials remains controversial, prompting ongoing scrutiny regarding their safety and effectiveness. In response to safety concerns, the US Food and Drug Administration (FDA) has discontinued the use of large transvaginal mesh grafts for POP repair, limiting vaginal surgeries to native tissue or biological grafts only.[34] Notable mesh-related complications include infection and dyspareunia. Meshes with pore sizes smaller than 10 μm permit bacterial infiltration while preventing macrophage access, thereby increasing the risk of infection.[35]
Postoperative and Rehabilitation Care
Effective postoperative care and rehabilitation are crucial for achieving optimal recovery and ensuring the long-term durability of surgical repair in POP. Early mobilization—including ambulation and stair climbing—is safe and may enhance patient satisfaction without increasing the risk of recurrence, compared to restrictive activity guidelines. Enhanced recovery protocols offer additional benefits, such as reduced opioid use, shorter hospital stays, and improved patient-reported outcomes.[36]
Pelvic floor physical therapy (PFPT) after surgery strengthens pelvic musculature and enhances quality-of-life outcomes, although randomized trials show mixed effects on objective anatomical recurrence at 6 months. One randomized controlled trial found that both the PFPT and control groups experienced improved pelvic floor distress scores between 3 and 6 months postoperatively, with no significant difference between the groups.[37] Despite this, supervised PFPT remains guideline-recommended, particularly for patients with persistent incontinence or pelvic floor muscle weakness.[38]
Deterrence and Patient Education
Educating patients about the high prevalence of POP can help reduce stigma and address psychosocial barriers that may delay diagnosis. The International Urogynecological Association (IUGA) and the American Urogynecological Society (AUGS) provide educational pamphlets and printable resources that outline common symptoms, diagnostic evaluations, and treatment options. Additionally, pamphlets on pessary care and home maintenance have been shown to significantly decrease complications and boost patient confidence in managing their treatment.[39]
Enhancing Healthcare Team Outcomes
Effective management of POP often begins with a general obstetrician or gynecologist, who can manage low-grade cases. However, more advanced or complicated presentations—especially those involving comorbid conditions such as stress urinary incontinence, fecal incontinence, defecatory dysfunction, or other lower urinary tract abnormalities—may require referral to a urogynecologist and the involvement of a broader interprofessional healthcare team.
As outlined by the National Institute for Health and Clinical Excellence (NICE), the healthcare team may include a urogynecologist, urologist, specialist nurse, physical therapist, and colorectal surgeon. A collaborative, patient-centered approach that also incorporates advanced practitioners, pharmacists, and other healthcare professionals ensures comprehensive and coordinated care. Each healthcare team member plays a vital role, contributing to diagnosis, treatment planning, patient education, emotional support, and medication management, while upholding ethical responsibilities such as informed consent and destigmatization. Strong interprofessional communication and clearly defined care pathways are essential for optimizing patient safety, outcomes, and overall team effectiveness.
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