Pelvic Organ Prolapse
Descent of pelvic organs through pelvic floor defects: cystocele, rectocele, enterocele, uterine.
Also known as: POP, cystocele, rectocele, uterine prolapse, vaginal prolapse, enterocele
Overview
Symptomatic descent of one or more of the anterior vaginal wall (cystocele), posterior vaginal wall (rectocele), uterus/apex, or vaginal vault (post-hysterectomy) through the pelvic floor. Severity is graded by the POP-Q (Pelvic Organ Prolapse Quantification) system.
Epidemiology
Lifetime risk of surgery for prolapse or incontinence ~13%. Prevalence increases with age and parity; nearly 50% of parous women have some degree of prolapse on examination but only a minority are symptomatic.
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Risk factors
- Vaginal childbirth (particularly multiple, instrumental, or with large infants)
- Aging, menopause and estrogen deficiency
- Obesity, chronic constipation or chronic cough (COPD)
- Connective tissue disorders (Ehlers-Danlos, Marfan)
- Prior pelvic surgery (especially hysterectomy)
- Heavy lifting, family history
Pathophysiology
Pelvic floor support depends on the levator ani musculature, endopelvic fascia, and uterosacral/cardinal ligament complex. Childbirth and aging weaken and stretch these structures, allowing descent of pelvic organs. Estrogen loss reduces collagen content of vaginal tissues.
Clinical presentation
Symptoms
- Vaginal bulge or 'something falling out' — most specific symptom
- Pelvic pressure or heaviness worsening with prolonged standing
- Urinary symptoms: incomplete emptying, urgency, splinting (manual reduction to void), recurrent UTI
- Bowel symptoms: incomplete defecation, need to splint the posterior vaginal wall or perineum to defecate, constipation
- Sexual symptoms: dyspareunia, decreased sensation, embarrassment
Signs / physical exam
- POP-Q assessment with patient in lithotomy and on Valsalva — describes leading edge of anterior, posterior, and apical compartments relative to the hymen
- Stage 0 (no prolapse) to Stage IV (complete eversion)
- Speculum or Sims retractor used to isolate compartments
- Look for ulceration of exposed tissue in advanced prolapse
Differential diagnosis
- Stress urinary incontinence — Leakage with cough/sneeze/Valsalva; may coexist with cystocele or be unmasked after prolapse repair
- Urinary tract infection — Dysuria, frequency, urgency; UA positive
- Vaginal mass (cyst, malignancy) — Discrete mass not reducible; biopsy if suspicious
- Urethral diverticulum — Anterior vaginal wall tender mass, post-void dribbling, dyspareunia; MRI diagnostic
- Hemorrhoids or rectal prolapse — Anorectal symptoms; rectal exam distinguishes
Diagnostic workup
Diagnostic criteria
Clinical exam using the POP-Q system. Symptoms are required for treatment; asymptomatic prolapse generally needs no intervention.
Labs
- Urinalysis to exclude UTI
- Post-void residual to assess voiding dysfunction
Imaging
- Imaging not routinely required; consider urodynamics if concomitant incontinence and planning surgery
- MRI or dynamic ultrasound only in complex or recurrent cases
Diagnostic algorithm
| POP-Q Stage | Leading Edge Relative to Hymen |
|---|---|
| 0 | No prolapse |
| I | >1 cm above hymen |
| II | Within 1 cm of hymen (above or below) |
| III | >1 cm below hymen but not full eversion |
| IV | Complete eversion of vagina |
Treatment
First-line
- Observation if mild and minimally symptomatic
- Lifestyle: weight loss, treat constipation (fiber, hydration, stool softeners), manage chronic cough, avoid heavy lifting
- Pelvic floor muscle training (Kegel exercises) +/- supervised physical therapy — may reduce symptoms in mild prolapse
- Vaginal pessary — first-line nonsurgical management; fitted by trained clinician; many shapes (ring, Gellhorn, donut, cube); requires periodic cleaning and follow-up
- Vaginal estrogen (estradiol cream or tablet, conjugated equine estrogen cream) in postmenopausal women to improve tissue quality and pessary tolerance
Surgical (when symptoms warrant and conservative measures fail)
- Reconstructive: anterior or posterior colporrhaphy, apical suspension (uterosacral or sacrospinous ligament suspension; sacrocolpopexy — abdominal/laparoscopic, gold standard for apical prolapse)
- Vaginal hysterectomy with apical suspension is common when uterine prolapse present
- Obliterative (colpocleisis): for women who do not desire vaginal function; lower morbidity, very high success
- Transvaginal synthetic mesh for prolapse repair was banned by FDA in 2019 due to high complication rates
Second-line / adjunct
- Anti-incontinence procedure (midurethral sling) may be performed concurrently in selected patients with stress incontinence (occult or overt)
Complications
- Vaginal ulceration and bleeding from advanced prolapse or ill-fitting pessary
- Recurrent UTIs from incomplete emptying
- Defecatory dysfunction and chronic constipation
- Recurrence after surgical repair (~10-30% over 5 years)
- Surgical complications: mesh erosion (with sacrocolpopexy), de novo dyspareunia, urinary or fecal incontinence
PANCE pearls
- Pessaries are first-line for symptomatic prolapse — they are safe, effective in 60-80%, and avoid surgery; offer to all patients including those who desire future fertility.
- Vaginal estrogen markedly improves tissue quality in postmenopausal women and is appropriate adjunct to either pessary or surgical management.
- Stage of prolapse does not strictly determine the need for treatment — symptom burden and patient preference do.
- Always inquire about hidden ('occult') stress incontinence after reducing prolapse, as some women develop new SUI postoperatively.
- Transvaginal mesh for prolapse repair is no longer FDA-approved; mesh remains used in abdominal sacrocolpopexy and for midurethral slings, which have a different regulatory status.
References
- ACOG PB 214 — ACOG Practice Bulletin 214: Pelvic Organ Prolapse (Obstet Gynecol 2019, reaffirmed)
- AUGS — AUGS Position Statement on Vaginal Mesh (2019)
- OPTIMAL Trial — Barber et al., JAMA 2014 — uterosacral vs sacrospinous suspension
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