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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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
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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