Pelcic organ prolpase

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"pelvic organ prolapse"[MeSH Terms] AND management

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Pelvic Organ Prolapse (POP)

Definition

Pelvic organ prolapse is defined as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus/cervix, or the apex of the vagina (vaginal vault or cuff scar after hysterectomy), correlated with symptoms. It represents progressive herniation of the pelvic organs through the urogenital diaphragm, most commonly producing vaginal bulge symptoms.

Berek & Novak's Gynecology, p. 1593
Campbell-Walsh-Wein Urology, p. 3405

Anatomy and Support Levels

Normal pelvic organ support depends on the interaction of three components:

Endopelvic fascia - connective tissue and ligaments
Perineal membrane
Levator ani muscle complex - the main muscular support

DeLancey's three levels of vaginal support are the conceptual framework:

Level	Structure	Supports	Prolapse if lost
Level I	Cardinal-uterosacral ligaments	Uterus and upper vagina (to sacrum/pelvic sidewall)	Uterine / apical prolapse
Level II	Paravaginal attachments to arcus tendineus fascia pelvis	Middle vagina (bladder and rectum)	Cystocele, rectocele
Level III	Fusion of vaginal wall to adjacent structures (urethra, perineal body)	Distal vagina	Urethral/perineal defects

The levator hiatus (opening in levator ani through which urethra, vagina, and rectum pass) is kept closed by tonic levator muscle activity. When this tone decreases - through injury or denervation - the urogenital hiatus widens and prolapse ensues.

Campbell-Walsh-Wein Urology, p. 3416

Compartments and Types

Compartment	What prolapses	Old term
Anterior	Bladder (most common) or anterior enterocele	Cystocele
Apical	Uterus/cervix or vaginal cuff post-hysterectomy; may contain small bowel (enterocele)	Uterine prolapse
Posterior	Rectum or small bowel/colon	Rectocele
Complete (procidentia)	Total vaginal eversion with complete uterine or vaginal cuff prolapse	Procidentia

Note: Older terms (cystocele, rectocele, enterocele) are now discouraged because the anatomic structure behind the vaginal bulge is uncertain, especially after prior surgery. Compartment-based terminology is preferred.

Enterocele specifically refers to a peritoneal sac containing bowel/omentum herniated in the rectovaginal space. It is more common after hysterectomy and retropubic urethropexy.

Epidemiology

Loss of vaginal/uterine support is present in 43-90% of women
In a multicenter study of 1,004 women in routine gynecologic care: only 24% had no prolapse; Stage 1 = 38%, Stage 2 = 35%, Stage 3 = 2%
Anterior compartment is the most common site (34% in WHI), then posterior (19%), then uterine (14%)
Lifetime risk of surgery for POP: ~12.6% - effectively 1 in 5 women by age 80
Annual POP procedures in the US are projected to increase by 46% from 2010-2050
Symptomatic POP (sensation of vaginal bulge): 3-12% prevalence
Campbell-Walsh-Wein Urology, p. 3416; Berek & Novak's Gynecology, p. 1594

Pathophysiology / Risk Factors

Muscular injury:

Up to 20% of primiparous women have MRI-visible levator ani muscle defects (not seen in nulliparous women)
Vaginal delivery causes most levator ani trauma

Neuropathic injury:

Pudendal nerve (urethral/anal sphincters, perineal muscles) and levator nerves (S3-S5)
Evidence of neuropathy: 24% at 6 weeks postpartum, 29% at 6 months (virtually absent with elective C-section)

Connective tissue failure:

Altered collagen metabolism (type I/III ratio changes) in women with prolapse
Connective tissue disorders (Ehlers-Danlos, Marfan syndrome) markedly increase POP risk

Other risk factors:

Aging and menopause (estrogen deficiency)
Multiparity and vaginal delivery
Chronic increased intra-abdominal pressure (obesity, chronic cough, constipation, heavy lifting)
Prior pelvic surgery (especially hysterectomy)
Campbell-Walsh-Wein Urology, p. 3416

Clinical Features / Symptoms

The most specific symptom for POP is a vaginal bulge seen or felt by the patient.

Other symptoms include:

Pelvic pressure or discomfort
Vaginal discharge
Splinting/digitation to urinate or defecate (very suggestive of rectocele when present for defecation)
Low backache
Urinary symptoms: frequency, nocturia, incomplete emptying, voiding dysfunction
Bowel symptoms: constipation, incomplete evacuation, fecal incontinence
Sexual dysfunction / dyspareunia

Important: Correlation between bowel/urinary symptoms and severity or site of prolapse is poor. Symptoms typically do not appear until the leading edge of prolapse reaches or extends beyond the hymen.

Stress urinary incontinence (SUI) paradoxically decreases as prolapse extends beyond the hymen (urethral kinking causes obstruction)
Campbell-Walsh-Wein Urology, p. 3405

Grading: POP-Q System

The Pelvic Organ Prolapse Quantification (POP-Q) system is the validated, standardized grading system. It uses anatomic landmarks measured in cm relative to the hymen:

Stage	Description
Stage 0	No prolapse; all points at normal positions
Stage I	Most distal point of prolapse is >1 cm above hymen (proximal to hymen)
Stage II	Most distal point is between -1 cm and +1 cm (at or near hymen)
Stage III	Most distal point is >1 cm beyond hymen but no further than 2 cm less than total vaginal length
Stage IV	Complete vaginal eversion (procidentia)

POP-Q measures 9 defined points: Aa, Ba (anterior), C (cervix/cuff), D (posterior fornix), Ap, Bp (posterior), and gh (genital hiatus), pb (perineal body), tvl (total vaginal length).

Stages 1 and 2 in asymptomatic women are considered within normal limits and rarely require treatment.

Berek & Novak's Gynecology, p. 1595

Evaluation

History:

Prolapse-specific symptoms (bulge, pressure, splinting)
Urinary and bowel function
Sexual function
Effect on quality of life
Prior surgeries and deliveries

Physical examination:

Performed with patient straining (Valsalva) and in lithotomy
All three compartments (anterior, apical, posterior) assessed
Levator muscle strength (pelvic muscle function assessment)
POP-Q staging

Additional workup:

Urinalysis, postvoid residual
Urodynamics if urinary symptoms are present
Defecating proctography for complex posterior compartment symptoms
Pelvic MRI: can identify levator ani defects and confirm anatomy

Treatment

1. Conservative (Non-Surgical)

Observation:

Asymptomatic or minimally symptomatic POP (Stage I-II) - expectant management appropriate

Pelvic Floor Muscle Training (PFMT / Kegel exercises):

First-line conservative therapy
Strengthens levator ani, may reduce prolapse symptoms and staging
Most effective for mild-moderate prolapse

Pessary therapy (mechanical devices):

Intravaginal devices that mechanically support the prolapsing organs
Effective for many patients regardless of prolapse stage
Types: ring, Gehrung, Gellhorn, cube pessaries - choice depends on prolapse type and severity
Requires regular follow-up for cleaning, vaginal assessment
Good option for women who are not surgical candidates, wish to avoid surgery, or are pregnant

2. Surgical Management

Surgery is individualized based on compartment(s) involved, patient age/health, activity level, desire for uterine preservation, and prior treatments.

Vaginal Procedures (reconstructive):

Procedure	Indication
Anterior colporrhaphy	Anterior compartment (cystocele)
Paravaginal repair	Lateral defect cystocele
Posterior colporrhaphy	Rectocele; anatomic cure 76-96%, but limited functional benefit for constipation
Uterosacral ligament suspension (ULS)	Apical support
Sacrospinous ligament fixation (SSLF)	Apical support (vault prolapse)
Hysterectomy + vault suspension	Uterine prolapse

Uterine preservation options:

Sacrohysteropexy, Manchester repair - for women desiring to keep the uterus

Abdominal Procedures:

Abdominal sacrocolpopexy (open or laparoscopic/robotic): gold standard for apical prolapse, attaches vaginal apex to sacral promontory with mesh; highest durability
Laparoscopic/robotic sacrocolpopexy: equivalent outcomes to open with less morbidity

Obliterative Procedures:

Colpocleisis (LeFort procedure): partial or total vaginal closure; reserved for elderly or medically frail women who are not sexually active; very low recurrence but irreversible

Transvaginal mesh:

Use significantly restricted after FDA warnings (2011, 2019) regarding complications (mesh erosion, dyspareunia, chronic pain)
Now generally avoided for primary anterior/posterior repair; remains used in sacrocolpopexy (abdominal route)

Concomitant incontinence procedures:

May be offered at time of POP repair in women with stress urinary incontinence or at risk for occult SUI after prolapse reduction
Berek & Novak's Gynecology, p. 1593-1723; Campbell-Walsh-Wein Urology, p. 3405-3416

Special Considerations

Posterior compartment / Rectocele:

Posterior colporrhaphy is the standard repair; avoid levator plication to reduce risk of dyspareunia (7-26% rate)
Rectocele repair is indicated for bulge symptoms, NOT for the intent of correcting defecatory dysfunction or constipation alone (no evidence supports this)

Descending perineum syndrome:

Perineum descends beyond ischial tuberosities on Valsalva
Can lead to pudendal neuropathy from stretch injury
Associated with constipation, fecal incontinence, solitary rectal ulcer syndrome

Post-hysterectomy vault prolapse:

Apical prolapse after hysterectomy is a distinct entity; treated with vault suspension procedures (SSLF, ULS, sacrocolpopexy)

Recent Evidence (PubMed 2024-2026)

A 2024 systematic review and meta-analysis found decreased Type III collagen RNA expression in women with POP, further supporting the connective tissue etiology (PMID: 39352428)
A 2025 Cochrane review examined perioperative interventions in POP surgery (PMID: 40693510)
A 2025 meta-analysis confirmed associations between hysterectomy and pelvic floor disorders (PMID: 40120730)

Summary: POP is extremely common in women, multifactorial in origin (obstetric trauma, connective tissue changes, aging), and ranges from asymptomatic anatomic findings to complete procidentia causing significant functional impairment. Management is tailored - from observation and pessary to individualized reconstructive or obliterative surgery - guided by symptoms, staging (POP-Q), and patient goals.

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