Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a general term that refers to herniation Herniation Omphalocele of 1 or more pelvic organs (e.g., bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess, uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy, rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy may result in POP. The major risk factors include parity Parity The number of offspring a female has borne. It is contrasted with gravidity, which refers to the number of pregnancies, regardless of outcome. Pregnancy: Diagnosis, Physiology, and Care, vaginal delivery, age, obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity, and conditions characterized by increased abdominal pressure. Affected individuals typically present with vaginal pressure and the sensation of a vaginal bulge, often with associated urinary and defecatory urges. Diagnosis is clinical and management is based on the subject's desires and symptoms. Classification of POP is using either the POP-Q staging Staging Methods which attempt to express in replicable terms the extent of the neoplasm in the patient. Grading, Staging, and Metastasis system or the Baden-Walker grading Grading Methods which attempt to express in replicable terms the level of cell differentiation in neoplasms as increasing anaplasia correlates with the aggressiveness of the neoplasm. Grading, Staging, and Metastasis system. Conservative approaches include vaginal pessaries, pelvic muscle strengthening exercises, and reducing modifiable risk factors. Surgical repair is an option for individuals with more severe symptoms.

Last updated: 28 Dec, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definitions

Pelvic organ prolapse (POP): a general term referring to prolapse of 1 or more of the pelvic organs (e.g., bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess, uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy, rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy) into the vaginal canal

  • Organs prolapse through the vaginal canal/orifice, pushing the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy with it → POP is defined by the vaginal wall that is prolapsing and the organs behind that wall
  • Anterior compartment prolapse:
  • Posterior compartment prolapse:
    • Herniation Herniation Omphalocele of the posterior vaginal wall and rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
    • Classically referred to as a rectocele
  • Apical compartment prolapse:
    • Herniation Herniation Omphalocele of the vaginal apex, which is either:
      • The uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy and cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy (normal anatomy)
      • The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy (if the subject has had a supracervical hysterectomy)
      • Vaginal cuff (if the subject has had a total hysterectomy)
    • If the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy is present, the prolapse is referred to as uterine prolapse.
    • If the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy is absent, the intestine typically prolapses behind the vaginal cuff, classically known as an enterocele.
  • Procidentia: a severe form of POP that includes herniation Herniation Omphalocele of the anterior, posterior, and apical vaginal compartments through the vaginal introitus
Types of pelvic organ prolapse

Types of pelvic organ prolapse:
Vaginal wall is outlined in a darker pink. Note how with cystoceles and rectoceles, the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess and rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy, respectively, are pushing on the vaginal walls and herniating through the vaginal orifice. With apical prolapse, the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy gets “scrunched up,” as shown in the uterine prolapse image, and may even completely evert itself, as shown with the enterocele.

Image by Lecturio.

Visualizing POP

Visualizing POP, especially apical POP, can be difficult.

  • Envision holding a sock up by the toe:
    • Your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy is the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy.
    • The sock is the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy.
  • The open part of the sock is secured to a fixed location:
    • The open part of the sock is the vaginal introitus.
    • The “fixed location” is the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy.
  • Begin moving your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy down → the lower region represents apical/uterine prolapse
  • As you keep moving your hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy down through the sock opening, the sock begins turning inside out and is similar to how prolapsed organs can end up completely “outside” the body, yet still remain covered by vaginal mucosa.

Etiology

Prolapse is due to weakness and insufficiency of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy, which normally keeps organs in place. Risk factors include:

  • Multiple parity Parity The number of offspring a female has borne. It is contrasted with gravidity, which refers to the number of pregnancies, regardless of outcome. Pregnancy: Diagnosis, Physiology, and Care (risk increases with each additional birth)
  • Vaginal delivery
  • Advancing age
  • Menopausal status
  • Increased intraabdominal pressure:
    • Chronic cough
    • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
    • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology abnormalities (e.g., Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome)
  • Family history Family History Adult Health Maintenance
  • Hysterectomy (controversial)

Epidemiology

  • The exact prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of uterine and vaginal prolapse is uncertain.
  • Peak incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: women aged 70‒79 years
  • Lifetime risk of women in the US undergoing surgery for POP: 13%
  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of POP based on reported symptoms: 3%‒6%
  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of POP identified on exam: 40%‒50%
  • Take-home message: Many women with mild POP are asymptomatic and do not require management beyond reducing modifiable risk factors to prevent symptoms from developing (e.g., weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation).

Surgical Anatomy and Pathology

Pelvic organs are supported by the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy, connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology, and the bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy. Additionally, the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy is supported by 3 levels of support along its length.

Pelvic diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy

The most internal layer of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy:

  • Functions:
    • Provides structure to the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy, separating the internal pelvic cavity from the external perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy
    • Resists intra-abdominal pressure
  • Structure:
    • Muscles begin at the tendinous arch (below and parallel to the inferior margin of the pubic bones).
    • Muscles extend posteriorly toward the coccyx Coccyx The last bone in the vertebral column in tailless primates considered to be a vestigial tail-bone consisting of three to five fused vertebrae. Vertebral Column: Anatomy → “wrap around” the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, and rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy, providing lateral support
    • Perineal body: the central tendon Central tendon Diaphragm: Anatomy and site of attachment Attachment The binding of virus particles to virus receptors on the host cell surface, facilitating virus entry into the cell. Virology for the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscles
  • Muscles of the pelvic diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy:
  • Other muscles of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy:
Muscles of the pelvic floor

Muscles of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy

Image by BioDigital, edited by Lecturio

Primary levels of vaginal support and associated pathology

  • Level I support:
    • The most proximal level of support
    • Consists of the uterosacral ligaments Uterosacral ligaments Vagina, Vulva, and Pelvic Floor: Anatomy that suspend the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy and upper vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy, and the lateral pelvic wall
  • Level II support:
    • Lateral connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology attachments along the length of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
    • Paravaginal attachments to the endopelvic fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis of the levator ani muscles Levator ani muscles Vagina, Vulva, and Pelvic Floor: Anatomy surrounding the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Level III support:
    • The most distal level of support
    • Consists of the perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy and perineal muscles
    • Supports the distal 3rd of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
  • Pathology:
    • Loss of level I support → apical prolapse into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
    • Loss of level II support → most commonly results in anterior vaginal wall and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess prolapse (cystocele)
    • Loss of level III support → 
      • Anteriorly: urethral hypermobility and incontinence
      • Posteriorly: posterior vaginal wall and rectal prolapse Rectal prolapse Rectal prolapse, also known as rectal procidentia, is the protrusion of rectal tissue through the anus. The tissue may include just the mucosa or the full thickness of the rectal wall. Common risk factors include chronic straining, constipation, bowel motility disorders, and weakening of the pelvic floor muscles. Rectal Prolapse
Levels of vaginal support

Levels of vaginal support:
Level I: the most proximal level supporting the upper vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy. Consists of uterosacral ligaments Uterosacral ligaments Vagina, Vulva, and Pelvic Floor: Anatomy connecting the upper vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy at the level of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy to the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy
Level II: support along the length of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy provided by the endopelvic fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis covering the levator ani muscles Levator ani muscles Vagina, Vulva, and Pelvic Floor: Anatomy. The fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis inserts in the tendinous arch of the levator ani muscles Levator ani muscles Vagina, Vulva, and Pelvic Floor: Anatomy just below the pubic bones.
Level III: the most distal level of support. Level III supports the lower vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the vaginal orifice and is provided by the perineal muscles and the perineal body.

Image by Lecturio.

Clinical Presentation

Individuals with POP typically present with:

  • Vaginal symptoms:
    • Sensations of:
      • Vaginal fullness
      • Pressure
      • Bulge
      • “Something falling down”
    • Symptoms typically worsen with activity, valsalva, and/or at the end of the day.
  • Urinary symptoms:
    • Incomplete emptying of urine Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat
    • Difficulty in voiding urine Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat
    • Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
  • Rectal symptoms:
    • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
    • Incomplete emptying
    • Splinting: placing fingers in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and pushing down in order to evacuate stool
    • Fecal urgency
    • Rectal fullness
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways symptoms:

Diagnosis and Classification

Diagnosis

  • Based on clinical examination:
  • Examine the subject at rest and during valsalva.
  • Take note of:
    • Which portions of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy are prolapsing (e.g., anterior wall, posterior wall, apex)
    • How far the prolapse descends (use the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy as a reference point)
    • Rectal tone
    • Urethral mobility Mobility Examination of the Breast
  • If significant prolapse is not appreciated lying down, examine the subject while they are standing up.
  • Findings are reported using either:
    • POP-Q staging Staging Methods which attempt to express in replicable terms the extent of the neoplasm in the patient. Grading, Staging, and Metastasis system
    • Baden-Walker grading Grading Methods which attempt to express in replicable terms the level of cell differentiation in neoplasms as increasing anaplasia correlates with the aggressiveness of the neoplasm. Grading, Staging, and Metastasis system
  • Assess the subject if they are experiencing stress urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (SUI):
    • Ask the subject to cough while observing the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy for leaks.
    • Should be assessed when the prolapse has reduced (sometimes, especially anterior prolapse may actually improve SUI)
    • Consider urodynamics studies, especially if planning surgery, to see if a concurrent incontinence procedure may be indicated.

POP-Q staging Staging Methods which attempt to express in replicable terms the extent of the neoplasm in the patient. Grading, Staging, and Metastasis system

The American Urogynecologic Society (AUGS) and the Society of Gynecologic Surgeons (SGS) recommend using the POP-Q staging Staging Methods which attempt to express in replicable terms the extent of the neoplasm in the patient. Grading, Staging, and Metastasis system over the Baden-Walker system because the former is the only validated method for the objective measurement of a prolapse.

  • The POP-Q system is best for:
    • Tracking progression of prolapse over time
    • Response to treatment
    • Standardizing research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest
  • The POP-Q system is used to stage prolapse based on 9 measurements:
    • 6 of the measurements compare defined/fixed points in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy during valsalva:
    • 3 additional measurements are used to provide a more comprehensive picture.
Table: Classification based on stages
Stage 0 No prolapse
Stage I The most distal portion of the prolapse is > 1 cm proximal to the level of the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy.
Stage II The most distal portion of the prolapse is within 1 cm or less of the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy.
Stage III The most distal portion of the prolapse is > 1 cm distal to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy, but no further than 2 cm less than the TVL.
Stage IV The vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy is completely everted (within 2 cm of +TVL) or uterine procidentia has occurred.
TVL: total vaginal length
Points and landmarks for pop–q system examination

Points and landmarks used in the POP-Q system:
The stage is defined by the largest number associated with each compartment. For example, if Aa AA Amyloidosis = 0 and Ba = +2, then an individual would have stage 3 anterior prolapse.
The measurements:
Total vaginal length (tvl): the distance between the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy and the deepest point of the posterior fornix Fornix Vagina, Vulva, and Pelvic Floor: Anatomy (point D) if a cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is present, or the vaginal cuff (point C) if the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is absent
Aa AA Amyloidosis: midline of the anterior vaginal wall, 3 cm proximal to the external urethral meatus
Ba: the lowest point of prolapse of any part of the anterior vaginal wall that is between point Aa AA Amyloidosis and the vaginal apex; if there is no prolapse, defined as -3
Ap: midline of the posterior vaginal wall, 3 cm proximal to the posterior hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy
Bp: lowest point of prolapse of any part of the posterior vaginal wall that is between point Ap and the vaginal apex; if there is no prolapse, defined as -3
C: distance from the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy to the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy or vaginal cuff
D: deepest point of the posterior fornix Fornix Vagina, Vulva, and Pelvic Floor: Anatomy (only measured in women with a cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy)
Genital hiatus (gh): the distance between the external urethral meatus (anteriorly) and the posterior midline hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy
Perineal body (pb): the distance between the posterior midline hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy and the midanal opening

Image: “Points and landmarks for POP–Q system examination” by Department of Urology, Sf.loan Clinical Emergency Hospital, Bucharest, Romania. License: CC BY 2.0

Baden-Walker Grading Grading Methods which attempt to express in replicable terms the level of cell differentiation in neoplasms as increasing anaplasia correlates with the aggressiveness of the neoplasm. Grading, Staging, and Metastasis System

  • An easier but less precise system of assessing a prolapse
  • Compares the maximal point of descent of the prolapse to the hymen Hymen A thin fold of mucous membrane situated at the orifice of the vagina. Vagina, Vulva, and Pelvic Floor: Anatomy during valsalva
  • All 3 compartments (anterior, posterior, and apex) should be assessed and can be graded separately
  • Grading Grading Methods which attempt to express in replicable terms the level of cell differentiation in neoplasms as increasing anaplasia correlates with the aggressiveness of the neoplasm. Grading, Staging, and Metastasis:
  • Note: Baden-Walker grades are approximately comparable to POP-Q stages.
An 87-year-old woman with uterine prolapse stage iv

An 87-year-old woman with stage IV (POP-Q) and grade 4 (Baden-Walker) uterine prolapse

Image: “An 87-year-old woman with uterine prolapse Stage IV” by Asama Vanichtantikul et al AL Amyloidosis. License: CC BY 4.0

Management

Management of POP is based on stage/grade, symptoms, and overall well-being of the subject. All cases should be offered conservative management. Some individuals with more severe symptoms may desire surgery.

Conservative management

  • Reduce modifiable risk factors:
    • Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
    • Reduce straining with defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility (i.e., constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation) via dietary changes and medications.
    • Avoid smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases to reduce chronic cough.
  • Kegel exercises:
    • Pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor: Anatomy muscle training
    • Usually used as a primary prevention technique
    • Also aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS in controlling urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
  • Vaginal pessary:
    • A medical grade silicone- or latex-based device that is inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy
    • Supports the pelvic organs and restores pelvic anatomy
    • Multiple shapes available (see image)
    • Fit in the office by a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship
    • Vaginal estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy cream is often used as an adjunct to prevent vaginal erosions Erosions Corneal Abrasions, Erosion, and Ulcers.
    • Can be removed by the individual at home as often as desired, or every 3‒6 months by a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship in the office
    • Indications:
      • All individuals who have suffered POP
      • SUI
      • Poor surgical candidates
    • Complications:
Pessaries

Different types of pessaries

Image: “Pessaries” by Huckfinne. License: Public Domain

Surgical management

Indicated in symptomatic individuals if they express a desire. Note that unless the POP is causing urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium, the decision for surgery is driven primarily by the subject’s desires after counseling on risks/benefits/alternatives.

  • Reconstructive surgery:
    • Anterior repair (anterior colporrhaphy): strengthening the “ceiling” of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, between the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
    • Posterior repair (posterior colporrhaphy): strengthening the “floor” of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, between the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy and the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy
    • Suspensory procedures:
      • To fixate parts of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy, cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy, and/or uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy to the internal structures
      • Usually involves permanent sutures and/or the use of a mesh
      • Examples: sacrocolpopexy ( cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy to sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy); uterosacral ligament suspension (sutures shorten/tighten the uterosacral ligaments Uterosacral ligaments Vagina, Vulva, and Pelvic Floor: Anatomy)
  • Obliterative surgery:
    • Surgical obliteration/closing off the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to prevent further prolapse
    • Reserved for women who no longer desire vaginal penetration Penetration X-rays and who cannot tolerate more extensive surgeries
  • Complications:
    • Risk of failure (may be as high as 50% for some procedures)
    • Mesh erosion Erosion Partial-thickness loss of the epidermis Generalized and Localized Rashes, if a mesh is used
    • Chronic pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, especially if “mesh kits” were used during the suspensory procedure
    • Injury to the surrounding organs (e.g., bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess, ureters Ureters One of a pair of thick-walled tubes that transports urine from the kidney pelvis to the urinary bladder. Urinary Tract: Anatomy, urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy, bowel)
    • Bleeding
    • Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease

References

  1. Uterine Prolapse. ScienceDirect. https://www.physio-pedia.com/Uterine_Prolapse
  2. Doshani, A., Teo, R.E.C., Mayne, C.J., Tincello, D.G. (2007). Uterine prolapse. NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034734/
  3. Jelovsek, J.E. (2020). Pelvic organ prolapse in women: Choosing a primary surgical procedure. UpToDate. Retrieved December 24, 2021, from https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-choosing-a-primary-surgical-procedure
  4. Kenton, K. (2020). Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse). UpToDate. Retrieved December 24, 2021, from https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-surgical-repair-of-apical-prolapse-uterine-or-vaginal-vault-prolapse
  5. Fashokun, T.B., Rogers, R.G. (2021). Pelvic organ prolapse in women: Diagnostic evaluation. UpToDate. Retrieved December 24, 2021, from https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-diagnostic-evaluation?topicRef=8072&source=see_link#H20
  6. Kenton, K. (2021). Pelvic organ prolapse in women: Obliterative procedures (colpocleisis). UpToDate. Retrieved December 24, 2021, from https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-obliterative-procedures-colpocleisis
  7. Lazarou, G., Grigorescu, B.A. (2021). Pelvic Organ Prolapse. MedScape. Retrieved December 24, 2021, from https://emedicine.medscape.com/article/276259-overview
  8. Chen, C.J., Thompson, H. (2021). Uterine Prolapse. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK564429/
  9. Doo, J., Khandalavala, J. (2021). Procidentia. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK542211
  10. Cheung, W.W., Khargi, R. (2021). Sacrocolpopexy. MedScape. Retrieved December 24, 2021, from https://emedicine.medscape.com/article/2048426-overview#showall
  11. Park, A.J., Muir, T.W., Paraiso, M.F.R. (2021). Surgical management of posterior vaginal defects. UpToDate. Retrieved December 24, 2021, from https://www.uptodate.com/contents/surgical-management-of-posterior-vaginal-defects
  12. Mahajan, S.T. (2020). Pelvic organ prolapse in women: Surgical repair of anterior vaginal wall prolapse. UpToDate. Retrieved December 24, 2021, from https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-surgical-repair-of-anterior-vaginal-wall-prolapse
  13. Chen, C. (2021). Uterine Prolapse. StatPearls. https://www.statpearls.com/ArticleLibrary/viewarticle/30897

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