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Uterovaginal (UV) Prolapse - Complete Gynaecological Overview

Definition

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Epidemiology

• Affects up to 40% of women at some point in their lifetime. - Bailey & Love's Short Practice of Surgery, 28th Ed., p. 1611
• The prevalence of symptomatic prolapse ranges from 3-12%; asymptomatic prolapse on examination is present in the majority of adult women.
• Prevalence of at least one pelvic floor disorder is 23.7% in U.S. women; more than doubles in women aged 80+.
• Lifetime probability of undergoing surgical correction by age 80: 1 in 5 women; cumulative risk for POP surgery is 12.6%.
• Annual risk of POP surgery increases progressively until age 73 (4.3 per 1,000 women).
• POP is more common in Caucasian and Hispanic women compared to African-American women. - Campbell-Walsh-Wein Urology, p. 3404

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Pelvic Support Anatomy - Three Levels (DeLancey's Classification)

Level I (Apical Support)

• Provided by the cardinal and uterosacral ligaments - condensations of areolar connective tissue.
• Origin: lateral borders of sacral vertebrae S2-S4; travel retroperitoneally to insert at upper vagina and cervix.
• Also includes paracervical fascia and upper paravaginal fibromuscular connective tissue.
• The ureter is closest to the uterosacral ligament at or just posterior to its insertion on the posterolateral cervix.

Level II (Lateral Support)

• Provided by the arcus tendineus fasciae pelvis (ATFP) - the "white line."
• The anterior vaginal wall is suspended laterally by paravaginal attachments from the ATFP.
• Lateral detachment from the ATFP results in paravaginal defects causing anterior compartment prolapse.

Level III (Distal Support)

• Provided by the perineal body, perineal membrane, and external anal sphincter complex.
• Loss leads to perineal descent and distal posterior vaginal wall defects.

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Types of Uterovaginal Prolapse

1. Anterior Compartment (Cystocele / Urethrocele / Cystourethrocele)

• Most common segment to prolapse.
• Represents descent of the anterior vaginal wall, most commonly with the bladder (cystocele), but can also represent an anterior enterocele (especially after prior surgery).
• Cystourethrocele = combined prolapse of bladder + urethra.
• Symptoms: sensation of vaginal lump, urinary urgency (OAB symptoms), recurrent UTIs, voiding difficulty.

2. Apical Compartment (Uterine Prolapse / Vaginal Vault Prolapse)

• Descent of the uterus and cervix (or vaginal cuff post-hysterectomy).
• Involves failure of Level I support (cardinal/uterosacral ligament complex).
• Procidentia = complete prolapse of the uterus through the introitus (stage IV); associated with vaginal discharge, ulceration of vaginal mucosa, and bleeding.
• Enterocele: a peritoneal sac containing small intestine ± omentum descending in the rectovaginal space. Can be asymptomatic or cause defecatory dysfunction and pelvic pain.

3. Posterior Compartment (Rectocele)

• Weakness of the posterior vaginal wall, usually involving the rectum.
• Symptoms: difficulty defecating, sensation of incomplete rectal emptying, need to "splint" (digitally reduce the posterior vaginal wall) to defecate.
• Can also include small bowel or colon even in the presence of an intact uterus.

4. Vaginal Vault Prolapse

• Occurs after hysterectomy when the vaginal cuff descends.
• Can include enterocele component.

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Risk Factors

• Campbell-Walsh-Wein Urology, p. 3404; Bailey & Love, p. 1611

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Pathophysiology

1. Connective tissue defects: Cardinal and uterosacral ligament laxity; changes in collagen composition and quantity (types I and III collagen ratio altered).
2. Levator ani muscle damage: Vaginal delivery can cause levator ani avulsion injury or nerve damage, leading to pelvic floor descent under loading.
3. Neurological injury: Pudendal nerve stretch/injury during labour impairs pelvic floor muscle tone.
4. Oestrogen deficiency: Reduces tissue strength and elasticity in postmenopausal women.
5. Increased intra-abdominal pressure: Chronic constipation, heavy lifting, obesity - all force pelvic organs downward against weakened supports.
6. Apical detachment: Uterine prolapse involves detachment from the uterosacral ligament complex and lateral wall detachment from endopelvic connective tissue.

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Clinical Features / Symptoms

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Grading / Staging: POP-Q System

POP-Q Reference Points

POP-Q Stages

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Evaluation

History

• Nature of the bulge, onset, duration, impact on quality of life.
• Urinary symptoms (frequency, urgency, incontinence, voiding difficulty).
• Bowel symptoms (constipation, fecal incontinence, straining, splinting).
• Sexual function.
• Obstetric history, prior pelvic surgery.

Physical Examination

• Patient in lithotomy position; examination ideally at maximum Valsalva to reproduce maximal descent.
• Evaluate all three compartments (anterior, apical, posterior) systematically.
• Assess levator ani muscle tone and integrity.
• Assess anal sphincter complex.
• Half-speculum exam to isolate each compartment individually.
• POP-Q measurement using a marked ring forceps or cotton-tipped applicator.

Bladder Function Evaluation

• Post-void residual (PVR) measurement - large cystocele may cause significant urinary retention.
• Urodynamic studies when urinary symptoms are prominent or before surgical planning.
• Assess for occult SUI: reduce prolapse (with ring forceps or pessary) and re-test for stress incontinence.

Bowel Function Evaluation

• Defecating proctogram (evacuation proctography) for suspected significant rectocele or enterocele.
• Anorectal manometry for suspected sphincter dysfunction.

Imaging

• Dynamic (defecation) MRI is increasingly useful for all three compartments - provides detailed multicompartment assessment of pelvic floor anatomy.
• Pelvic floor electromyography (EMG): growing utility for assessing neuromuscular integrity.

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Management

Non-Surgical / Conservative Management

1. Lifestyle Modifications

• Avoidance of constipation (high-fibre diet, adequate hydration, stool softeners).
• Weight reduction in obese patients.
• Avoidance of heavy lifting.

2. Pelvic Floor Muscle Training (PFMT)

• Recommended for at least 16 weeks for grade 1-2 prolapse.
• Supervised physiotherapy is more effective than unsupervised.
• Strengthens levator ani, narrows the genital hiatus, and reduces prolapse symptoms.

3. Topical Oestrogen (Vaginal)

• Indicated for oestrogen deficiency.
• Increases tissue strength and elasticity in vaginal and pelvic floor tissues.
• Also used prior to surgical repair to optimise tissue quality.

4. Vaginal Pessaries

• Mechanical devices that support the prolapsed organs.
• Replaced every 3-6 months.
• Main complications: vaginal ulceration, infection, discharge, bleeding.

• Berek & Novak's Gynecology, p. 1618-1619

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Surgical Management

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Surgical Treatments by Compartment (Table 87.12, Bailey & Love)

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Abdominal Approaches

• Abdominal sacrocolpopexy: Considered the "gold standard" for vault prolapse; synthetic mesh attached from vaginal apex to anterior longitudinal ligament at S1/S2.
• Laparoscopic/Robotic sacrocolpopexy: Equivalent outcomes to open; less blood loss, faster recovery.
• Abdominal uterosacral suspension: Re-suspends vaginal apex to uterosacral ligaments; can be combined with hysterectomy.

Vaginal Obliterative Procedures (Colpocleisis)

• Suitable for elderly, sexually inactive women with good life expectancy but poor surgical risk.
• Very high success rates (95-98%), low morbidity.
• Permanent loss of vaginal function.

Transvaginal Mesh (TVM)

• Use is now highly restricted in many countries (FDA warnings 2019) due to serious complications (mesh erosion/extrusion through vaginal epithelium, dyspareunia, chronic pelvic pain, organ perforation, infection).
• Native tissue repair is now preferred; mesh reserved for specific recurrent prolapse cases.

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Uterine Preservation vs. Hysterectomy

• Hysterectomy has historically been performed routinely at UV prolapse repair, but high-level evidence does not uniformly support this.
• Uterine-preserving procedures (sacrospinous hysteropexy, uterosacral ligament suspension with uterus in situ, Manchester repair) have comparable outcomes and are increasingly preferred in younger women.
• However, hysterectomy at the time of repair has been performed to facilitate access to uterosacral ligaments for apical suspension. - Berek & Novak's, p. 1654

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Management of Co-existing Urinary Symptoms with POP Repair

• Prolapse repair alone can resolve OAB symptoms in >50% of women (anterior compartment repair reduces frequency by 33%, urge incontinence by 49%, voiding difficulty by 74%).
• Occult SUI: Urethral kinking by large prolapse can mask genuine SUI. Reduce prolapse with pessary/ring forceps and stress test; if SUI unmasked, consider concurrent anti-incontinence procedure.
• Failure to recognise POP at the time of UI surgery significantly increases the need for subsequent prolapse surgery.

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Summary of Treatment Approach

UV Prolapse Confirmed
│
├── Symptomatic? ──No──→ Reassurance + PFMT
│
└── Yes
    │
    ├── Mild (Stage 1-2)
    │   → PFMT ≥16 weeks + lifestyle + topical oestrogen ± pessary
    │
    ├── Moderate-Severe (Stage 2-4) + Wishes Non-Surgical
    │   → Pessary (ring / Gellhorn / donut) + follow-up q3-6mo
    │
    └── Surgical Candidate
        ├── Wants uterine preservation → Hysteropexy / Manchester repair
        ├── Consents to hysterectomy → Vaginal hysterectomy + vault suspension
        │   (SSLF or USLS vaginal) or sacrocolpopexy (abdominal/laparoscopic)
        ├── Rectocele → Posterior colporrhaphy
        ├── Cystocele → Anterior colporrhaphy ± paravaginal repair
        └── Elderly / not sexually active → Colpocleisis

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Key Points Summary

1. UV prolapse affects up to 40% of women; anterior compartment is the most common site.
2. The POP-Q system is the validated standard for staging; stage is determined by the most dependent point.
3. Point D (posterior fornix) differentiates true apical descent from cervical elongation.
4. Vaginal bulge is the most specific symptom; urinary/bowel symptom correlation with prolapse severity is poor.
5. Pelvic floor muscle training for ≥16 weeks is the first-line treatment for stage 1-2.
6. Ring pessary is the most commonly used mechanical device; replaced every 3-6 months.
7. Sacrocolpopexy (abdominal/laparoscopic) is the gold standard for vault prolapse.
8. Transvaginal mesh is now heavily restricted due to serious complications.
9. Occult SUI must be screened for before surgical repair by reducing the prolapse and stress-testing.
10. Colpocleisis is the preferred procedure in elderly, sexually inactive women with high surgical risk.

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