Ppelvic organ prolapse

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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, uterus (cervix), or vaginal apex (vault/cuff scar after hysterectomy) through the vaginal opening, resulting from the loss of support of one or more compartments of the vagina. The vagina serves as the common wall between the bladder, the rectum, and the bowel.

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

Anatomy and Compartments

POP is described by vaginal compartment, and older terms (cystocele, rectocele, enterocele) should be used with caution because the actual anatomic structure on the other side of the bulge can be uncertain, especially after prior surgery.

Compartment	Structure Involved	Notes
Anterior	Anterior vaginal wall - typically bladder (cystocele)	Most common site; can be anterior enterocele after prior surgery
Apical	Uterus/cervix or vaginal cuff post-hysterectomy	Often includes enterocele (small bowel); frequently underdiagnosed
Posterior	Posterior vaginal wall - typically rectum (rectocele)	Can also involve small bowel/colon
Procidentia	Total vaginal eversion with complete prolapse	Most severe form

Anterior compartment is the most common site, followed by the posterior compartment, then the apex. However, clinically significant apical prolapse co-exists in 42%, 85%, and 100% of patients with stage 2, 3, and 4 anterior wall prolapse, respectively - so apical support must always be assessed.

Epidemiology

Some degree of prolapse is found in 41-90% of adult women on examination - stage 1 and 2 are so common they are considered part of the normal spectrum.
Symptomatic POP (sensation of vaginal bulge) affects 3-12% of women.
Symptoms typically do not develop until the leading edge reaches or passes the hymenal ring.
Lifetime risk of surgery: ~11-19%; reoperation rate for recurrence ~29%.
The number of U.S. women with POP is projected to increase 46% from 2010 to 2050, driven by population aging.
Most common indication for hysterectomy in women over 54 in the U.S.
Campbell-Walsh-Wein Urology, p. 3407-3411

Pathophysiology

Pelvic organ support depends on the interaction of three structures:

Levator ani muscle complex - Maintains tonic closure of the urogenital hiatus, compressing the urethra, vagina, and rectum against the pubic bone. When tone is lost, the hiatus widens and prolapse occurs.
Endopelvic fascia (ligaments) - Provides secondary support once muscular tone fails. Injury or stretching (during vaginal delivery, hysterectomy, chronic straining, or aging) leads to failure.
Perineal body

Three Levels of Support (DeLancey)

Level	Structures	Failure Results In
Level I	Uterosacral/cardinal ligament complex - suspends uterus/upper vagina to sacrum/pelvic sidewall	Uterine and vaginal apical prolapse
Level II	Paravaginal attachments - lateral attachment of mid-vagina to arcus tendineus	Anterior and posterior wall prolapse
Level III	Fusion of distal vagina to perineal body and urogenital diaphragm	Distal defects, perineal descent

Contributing Factors

Levator ani muscle trauma - Up to 20% of primiparous women have visible MRI defects; almost none in nulliparous women.
Neuropathic injury - Pudendal nerve and S3-S5 nerve roots to levator muscles; 24-29% of women show electromyographic evidence of neuropathy after vaginal delivery.
Altered collagen metabolism - Altered ratio of collagen type I:III weakens ligamentous attachments. Connective tissue disorders (Ehlers-Danlos, Marfan syndrome) are associated with elevated POP risk.
Aging - Progressive loss of smooth and striated muscle with increase in collagen and apoptotic changes.
Chronic straining/elevated intra-abdominal pressure
Campbell-Walsh-Wein Urology, pp. 3416-3417

Symptoms

The most specific symptom for POP is a vaginal bulge that can be seen or felt by the patient. Symptoms are typically not present until the prolapse reaches or passes the hymen.

Other associated symptoms:

Pelvic pressure or discomfort
Discharge, low backache
Splinting (needing to digitally push the vaginal wall to urinate or defecate)
Sensation of incomplete bladder or bowel emptying
Obstructed defecation (stool caught "in a pocket")
Urinary symptoms: SUI, urgency, frequency, nocturia - present in 40%, 29%, 30%, and 34% respectively

Important caveats:

Correlation between symptoms and prolapse severity is poor
Bowel symptoms such as constipation alone (without a bulge sensation) rarely indicate surgery
Stress urinary incontinence (SUI) paradoxically decreases as prolapse extends beyond the hymen, possibly due to urethral kinking - "occult" or "masked" SUI may be unmasked after prolapse repair
Sexual dysfunction: 38% of women with POP avoid intercourse; body image is impaired; surgery improves sexual function in most cases
Campbell-Walsh-Wein Urology, pp. 3405-3410

Evaluation

History

Onset, duration, and progression of symptoms
Urinary symptoms, bowel symptoms, sexual function
Obstetric history, prior pelvic surgery
Degree of bother and impact on quality of life

Physical Examination

Systematic assessment of anterior, apical, and posterior compartments
Levator muscle assessment and anal sphincter evaluation
Reducing the prolapse during examination to assess for occult SUI

POP-Q System (Pelvic Organ Prolapse Quantification)

The standardized validated staging system using 9 anatomical points measured in centimeters relative to the hymen (hymen = 0; above = negative; below = positive):

Stage	Description
0	No prolapse
I	Leading edge > 1 cm above hymen
II	Leading edge between -1 cm and +1 cm (at or near hymen)
III	Leading edge > 1 cm beyond hymen but < (TVL - 2) cm
IV	Complete eversion; leading edge ≥ (TVL - 2) cm

Additional Investigations

Bladder function: Urinalysis, post-void residual, urodynamics (especially if urinary symptoms are prominent)
Bowel function evaluation: For significant defecatory dysfunction
Imaging: Rarely required for primary diagnosis; defecating proctography used selectively for complex posterior compartment pathology; MRI to evaluate levator ani defects

Treatment

Treatment is indicated when POP is symptomatic and bothersome to the patient. Asymptomatic POP (stages I and II) rarely requires treatment.

1. Nonsurgical (Conservative)

a. Pelvic Floor Muscle Training (PFMT)

First-line therapy
Strengthens levator ani to improve support and reduce symptoms
Can slow progression and improve mild symptoms

b. Pessaries (Mechanical Devices)

Available in many shapes and sizes; must be individually fitted
A correctly fitted pessary should be imperceptible to the patient
Indications: patient preference to avoid surgery, medical comorbidities, pregnancy planning
Require regular removal and cleaning; concomitant vaginal estrogen reduces complications (erosion, infection)
Factors for long-term success: age ≥72, careful fitting, clear instructions
Complications of neglect: vaginal erosion, fistula formation, infection
Improve overall QoL, body image, and genitourinary symptoms in most users

2. Surgical Management

Surgical approach is individualized based on: compartments affected, uterine status, prior repairs, patient activity level and health status, desire for uterine preservation vs. hysterectomy.

Decision framework:

Vaginal vs. abdominal (open/laparoscopic/robotic) approach
Reconstructive vs. obliterative
Native tissue vs. graft (mesh or biologic)

Apical Compartment

Procedure	Route	Notes
Sacrocolpopexy	Abdominal/laparoscopic/robotic	Gold standard for apical prolapse; uses polypropylene mesh to suspend vault to sacral promontory
Sacrospinous ligament fixation	Vaginal	Unilateral or bilateral; common for post-hysterectomy vault prolapse
Uterosacral ligament suspension	Vaginal	High success rate; risk of ureteral injury
Manchester repair / Hysteropexy	Vaginal	Uterine-preserving option

Anterior Compartment

Procedure	Notes
Anterior colporrhaphy	Native tissue plication of pubocervical fascia; anatomic success 57-80%
Paravaginal repair	Corrects lateral detachment defects; vaginal or abdominal
Mesh augmentation	Higher anatomic success than native tissue but FDA warning on transvaginal mesh use

Posterior Compartment

Procedure	Notes
Posterior colporrhaphy	Most common; anatomic cure 76-96%; not effective for constipation; de novo dyspareunia in 7-26% (higher with levator plication)
Site-specific defect repair	Identifies and repairs discrete fascial tears
Transanal repair	Colorectal approach; lower anatomic success

Note on mesh: The FDA issued a final order in 2019 withdrawing clearance for transvaginal mesh for anterior compartment repair; abdominal mesh (sacrocolpopexy) remains in use. Patients must be thoroughly counseled about risks and benefits.

Obliterative Procedures (Colpocleisis)

Lefort colpocleisis (uterus present) or total colpocleisis (post-hysterectomy)
Reserved for elderly women who are no longer sexually active and want definitive treatment with lower surgical risk
Very high success rates with low morbidity
Irreversible - precludes future vaginal intercourse

Management of Concomitant SUI

POP repair can unmask occult SUI (urethral kinking is relieved)
Consider mid-urethral sling at the time of prolapse repair, especially if urodynamics or pessary trial reveals stress incontinence
Berek & Novak's Gynecology, pp. 1593-1725
Campbell-Walsh-Wein Urology, pp. 3405-3420
Campbell-Walsh-Wein Urology (Geriatric chapter), pp. 3858-3862

Specific Types

Rectocele

Herniation of rectal mucosa through a defect in the fibromuscular layer of the posterior vaginal wall
Defects can be transverse or longitudinal through inferior, middle, or superior regions
Symptoms: obstructed defecation, need for splinting/digitation; not reliably improved by surgery unless the dominant symptom is a bulge (not constipation alone)

Enterocele

Herniation of a peritoneal sac containing bowel/omentum through the pelvic floor (typically between uterus/cuff and rectum)
More common after hysterectomy and retropubic urethropexy
Culdoplasty (McCall, Moschcowitz) performed at time of repair

Descending Perineum Syndrome

Perineal descent below the ischial tuberosities during Valsalva
Results from inferior detachment of the rectovaginal septum from the perineal body
Progressive pudendal neuropathy from stretch injury
Treatment: sacral colpoperineopexy (abdominal sacral fixation extending to perineum)

Quality of Life Impact

POP causes significant loss of QoL - estimated loss of 14.5 DALYs per woman in middle-aged women due to disability. Women often feel shame and are reluctant to discuss symptoms even with physicians (contributing to under-reporting). Surgical treatment reliably improves QoL. Hispanic and Native American women report higher degrees of bother at stage 2 compared with non-Hispanic white women.

Campbell-Walsh-Wein Urology, p. 3410

Recent Evidence (2024-2026)

A 2024 systematic review and meta-analysis (PMID 39352428) found reduced type III collagen RNA expression in POP, supporting the role of connective tissue remodeling in its pathogenesis.
A 2025 Cochrane review (PMID 40693510) examined perioperative interventions in POP surgery - an important resource for optimizing surgical outcomes.
A 2025 meta-analysis (PMID 40120730) explored the associations between hysterectomy and subsequent pelvic floor disorders, relevant to counseling women undergoing hysterectomy.

Summary: POP is a highly prevalent condition representing failure of the pelvic floor support system - muscles, fascia, and nerves working in concert. Management is symptom-driven: asymptomatic prolapse rarely needs treatment. For symptomatic women, pessaries are first-line and effective long-term in many. Surgery is individualized, multicompartmental, and should address all defects simultaneously - with apical support being paramount since significant anterior/posterior wall prolapse almost always coexists with apical descent.

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