Pelvic Organ Prolapse (POP)

Definition

• Berek & Novak's Gynecology, p. 1594

Epidemiology

• Prevalence of at least one pelvic floor disorder in U.S. women is approximately 23.7%, more than doubling in women 80 years and older.
• The lifetime probability of surgical correction for POP is approximately 12.6% by age 80 (roughly 1 in 5 women will have surgery for POP or stress urinary incontinence).
• Annual POP procedure rates are projected to increase by 46% from 2010-2050, with up to one-third of the female population expected to have at least one pelvic floor disorder by 2050.
• Berek & Novak's Gynecology, pp. 1594-1595

Anatomy and Support Levels (DeLancey's Three Levels)

• Campbell-Walsh-Wein Urology, pp. 3416-3417

Types of Prolapse

• Berek & Novak's Gynecology, pp. 1664-1665

Pathophysiology

1. Direct muscle trauma - Vaginal delivery causes visible levator ani defects in up to 20% of primiparous women on MRI; nearly absent after elective cesarean section.
2. Denervation injury - Pudendal nerve and S3-S5 levator nerves are vulnerable during vaginal delivery. Evidence of neuropathy is found in 24-29% of primiparous women at 6 weeks to 6 months postpartum.
3. Connective tissue failure - Altered collagen metabolism (ratio of type I:III collagen) underlies ligamentous failure. Connective tissue disorders (Ehlers-Danlos, Marfan syndrome) substantially increase POP risk.
4. Aging - Progressive loss of smooth and striated muscle with increase in collagen/connective tissue; apoptotic changes in pelvic floor tissues occur with age.
5. Chronic straining/increased intra-abdominal pressure - Worsens fascial stretching and ligament failure over time.

• Campbell-Walsh-Wein Urology, pp. 3415-3417

Clinical Features and Symptoms

• Pelvic pressure or discomfort
• Sensation of incomplete bladder or bowel emptying
• Need to splint (digitate) the vaginal wall or perineum to urinate or defecate
• Low backache
• Urinary symptoms: frequency, nocturia, urgency (OAB), difficulty voiding
• Stress urinary incontinence (SUI): prevalence of SUI actually decreases as prolapse extends beyond the hymen (due to urethral kinking causing obstruction), creating "occult SUI" that may unmask after surgical repair
• Bowel symptoms (constipation, fecal incontinence) - weak correlation with prolapse severity; constipation alone without a bulge sensation rarely justifies surgery
• Sexual dysfunction - POP negatively affects body image and sexual function

Note: There is a much stronger correlation between symptoms (bulge, need to splint) and prolapse that extends beyond the hymen.

• Campbell-Walsh-Wein Urology, pp. 3405-3406

Staging / Grading

POP-Q System (Recommended)

• Campbell-Walsh-Wein Urology, pp. 3406-3408

Evaluation

• History: Symptoms, prior deliveries, prior surgeries, bowel/bladder function, sexual activity, desire to preserve uterus
• Physical exam: Assess all three compartments (anterior, apical, posterior) with Valsalva/straining; assess levator ani and anal sphincter
• Urodynamics: Helpful pre-operatively, especially with prolapse reduction to identify occult SUI (urodynamic SUI during reduction predicts ~58% postoperative SUI risk if no anti-incontinence procedure performed)
• Pessary trial: Useful to confirm that symptoms are attributable to prolapse; improvement with pessary suggests surgical repair is likely to help

Treatment

1. Conservative / Non-surgical

• Pelvic floor muscle training (Kegel exercises): First-line for mild-to-moderate POP; strengthens the levator ani to partially compensate for structural defects.
• Lifestyle modification: Weight loss, avoidance of heavy lifting, treatment of chronic cough/constipation.
• Vaginal estrogen: Particularly in postmenopausal women; improves tissue quality and helps prevent pessary-related complications.

2. Mechanical Devices - Pessaries

• Come in wide variety of shapes and sizes (ring, Gellhorn, cube, donut); must be individually fitted.
• When correctly sized, the patient cannot feel it; too small = falls out; too large = discomfort or erosion.
• Must be removed and cleaned periodically with inspection of tissue integrity.
• Concomitant vaginal estrogen reduces erosion risk.
• Factors associated with long-term success: age ≥72, careful fitting, clear patient instructions.
• Successful pessary use improves quality of life and body image.
• Campbell-Walsh-Wein Urology, p. 3860

3. Surgical Management

Vaginal Procedures

Abdominal Procedures

Obliterative Procedures

• Colpocleisis (LeFort or total colpectomy): For women who no longer desire vaginal intercourse; high success rates with low morbidity; suitable for elderly or high-risk patients.

Mesh Considerations

• Transvaginal mesh for anterior/posterior repair was associated with serious complications (erosion, dyspareunia, pain) - the FDA restricted its use in 2019.
• Abdominal/laparoscopic/robotic sacrocolpopexy with mesh remains the standard for apical prolapse.

Concomitant Anti-Incontinence Procedures

• Women with occult SUI (demonstrated during prolapse reduction on urodynamics) should be counseled about adding a mid-urethral sling at time of prolapse repair.
• Women with OAB symptoms often have improvement after prolapse repair (anterior repair reduced frequency by 33%, urge urinary incontinence by 49% in one study).
• Berek & Novak's Gynecology, pp. 1073-1099; Campbell-Walsh-Wein Urology, pp. 3406-3410

Key Risk Factors Summary

• Vaginal delivery (most important modifiable risk factor)
• Advanced age
• Obesity and chronic increased intra-abdominal pressure
• Prior pelvic surgery (hysterectomy increases enterocele risk)
• Connective tissue disorders (Ehlers-Danlos, Marfan)
• Chronic straining (constipation, chronic cough)
• Ethnicity (White women have higher rates than African American; Hispanic and Asian women intermediate)

Recent Evidence (2024-2026)

• A 2024 systematic review and meta-analysis found reduced type III collagen RNA expression in women with POP vs. controls, supporting the role of connective tissue dysregulation in POP pathogenesis [PMID: 39352428].
• A 2025 Cochrane review examined perioperative interventions in POP surgery to optimize outcomes [PMID: 40693510].
• A 2025 meta-analysis found associations between hysterectomy and pelvic floor disorders including POP [PMID: 40120730].