Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, 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) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. The major risk factors include parity, 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 Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis system or the Baden-Walker grading Grading Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. 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.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Overview

Definitions

Pelvic organ prolapse (POP): a general term referring to prolapse of 1 or more of the pelvic organs (e.g., bladder, uterus, 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) 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 with it → POP is defined by the vaginal wall that is prolapsing and the organs behind that wall
  • Anterior compartment prolapse:
    • Herniation of the anterior vaginal wall and bladder
    • Classically referred to as a cystocele
  • Posterior compartment prolapse:
    • Herniation 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
    • Classically referred to as a rectocele
  • Apical compartment prolapse:
    • Herniation of the vaginal apex, which is either:
      • The uterus and cervix (normal anatomy)
      • The cervix (if the subject has had a supracervical hysterectomy)
      • Vaginal cuff (if the subject has had a total hysterectomy)
    • If the uterus is present, the prolapse is referred to as uterine prolapse.
    • If the uterus is absent, the intestine typically prolapses behind the vaginal cuff, classically known as an enterocele.
  • Procidentia: a severe form of POP that includes herniation 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 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, 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 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 is the uterus.
    • 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.
  • 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.
  • 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 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 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, which normally keeps organs in place. Risk factors include:

  • Multiple parity (risk increases with each additional birth)
  • Vaginal delivery
  • Advancing age
  • Menopausal status
  • Increased intraabdominal pressure:
    • Chronic cough
    • 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 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
  • Hysterectomy (controversial)

Epidemiology

  • The exact prevalence of uterine and vaginal prolapse is uncertain.
  • Peak incidence: women aged 70‒79 years
  • Lifetime risk of women in the US undergoing surgery for POP: 13%
  • Prevalence of POP based on reported symptoms: 3%‒6%
  • Prevalence 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, smoking cessation).

Surgical Anatomy and Pathology

Pelvic organs are supported by the pelvic floor, connective tissue, 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. 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 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

The most internal layer of the pelvic floor:

  • Functions:
    • Provides structure to the pelvic floor, separating the internal pelvic cavity from the external perineum
    • 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 → “wrap around” the urethra, 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, 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, providing lateral support
    • Perineal body: the central tendon and site of attachment for the pelvic floor 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:
    • A group of muscles collectively known as the levator ani muscles:
      • Puborectalis: the innermost muscle, originating from the tendinous arch just below the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones and forming a sling around 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; in direct contact with the lateral 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 and the lateral and posterior 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
      • Pubococcygeus: the middle muscle, connecting the tendinous arch/pubic bones to the coccyx
      • Iliococcygeus: the most lateral layer, connecting the ischial spines to the coccyx
    • Coccygeus
  • Other muscles of the pelvic floor:
    • Piriformis
    • Obturator internus
Muscles of the pelvic floor

Muscles of the pelvic floor

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 that suspend the uterus 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 to the sacrum, and the lateral pelvic wall
  • Level II support:
    • Lateral connective tissue 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
    • Paravaginal attachments to the endopelvic fascia of the levator ani muscles 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
  • Level III support:
    • The most distal level of support
    • Consists of the perineum 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
  • 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
    • Loss of level II support → most commonly results in anterior vaginal wall and bladder 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. Consists of uterosacral ligaments 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 at the level of the cervix to the sacrum
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 provided by the endopelvic fascia covering the levator ani muscles. The fascia inserts in the tendinous arch of the levator ani muscles 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 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
    • Difficulty in voiding urine
    • 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 and pushing down in order to evacuate stool
    • Fecal urgency
    • Rectal fullness
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain symptoms:
    • Dyspareunia
    • Lower back and pelvic pain that is exacerbated on activity
    • Vaginal pain if the prolapse is severe and erosion or ulcerations are present

Diagnosis and Classification

Diagnosis

  • Based on clinical examination:
    • Visual inspection
    • Speculum examination: To assess POP, it is best to use only a single blade to examine the anterior and posterior walls separately.
    • Bimanual pelvic examination: helpful in assessing apical prolapse
    • Rectovaginal 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 are prolapsing (e.g., anterior wall, posterior wall, apex)
    • How far the prolapse descends (use the hymen as a reference point)
    • Rectal tone
    • Urethral mobility
  • 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 Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis system
    • Baden-Walker grading Grading Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis system
  • Assess the subject if they are experiencing stress urinary incontinence (SUI):
    • Ask the subject to cough while observing the urethra 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 Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis system

The American Urogynecologic Society (AUGS) and the Society of Gynecologic Surgeons (SGS) recommend using the POP-Q staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. 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
  • 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 to the hymen during valsalva:
      • The hymen is defined as “0.”
      • Distance from the hymen to each point is measured in centimeters during a valsalva.
      • Points proximal to the hymen (toward the uterus) are given negative values.
      • Points distal to the hymen (toward the introitus) are given positive values.
    • 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.
Stage II The most distal portion of the prolapse is within 1 cm or less of the hymen.
Stage III The most distal portion of the prolapse is > 1 cm distal to the hymen, 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 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 = 0 and Ba = +2, then an individual would have stage 3 anterior prolapse.
The measurements:
Total vaginal length (tvl): the distance between the hymen and the deepest point of the posterior fornix (point D) if a cervix is present, or the vaginal cuff (point C) if the cervix is absent
Aa: 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 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
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 to the cervix or vaginal cuff
D: deepest point of the posterior fornix (only measured in women with a cervix)
Genital hiatus (gh): the distance between the external urethral meatus (anteriorly) and the posterior midline hymen
Perineal body (pb): the distance between the posterior midline hymen 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 System

  • An easier but less precise system of assessing a prolapse
  • Compares the maximal point of descent of the prolapse to the hymen during valsalva
  • All 3 compartments (anterior, posterior, and apex) should be assessed and can be graded separately
  • Grading:
    • Grade 0: no prolapse, normal position for each compartment
    • Grade 1: descent halfway to the hymen
    • Grade 2: descent to the hymen
    • Grade 3: descent halfway past the hymen
    • Grade 4: maximum descent possible
  • 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. 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
    • Reduce straining with defecation (i.e., constipation) via dietary changes and medications.
    • Avoid smoking to reduce chronic cough.
  • Kegel exercises:
    • Pelvic floor muscle training
    • Usually used as a primary prevention technique
    • Also aids in controlling 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
    • Supports the pelvic organs and restores pelvic anatomy
    • Multiple shapes available (see image)
    • Fit in the office by a clinician
    • Vaginal estrogen cream is often used as an adjunct to prevent vaginal erosions.
    • Can be removed by the individual at home as often as desired, or every 3‒6 months by a clinician in the office
    • Indications:
      • All individuals who have suffered POP
      • SUI
      • Poor surgical candidates
    • Complications:
      • Vaginal erosions
      • Urinary retention
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, 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, 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 and the bladder
    • 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, 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 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
    • 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, cervix, and/or uterus to the internal structures
      • Usually involves permanent sutures and/or the use of a mesh
      • Examples: sacrocolpopexy (cervix to sacrum); uterosacral ligament suspension (sutures shorten/tighten the uterosacral ligaments)
  • 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 to prevent further prolapse
    • Reserved for women who no longer desire vaginal penetration and who cannot tolerate more extensive surgeries
  • Complications:
    • Risk of failure (may be as high as 50% for some procedures)
    • Mesh erosion, if a mesh is used
    • Chronic pelvic pain, especially if “mesh kits” were used during the suspensory procedure
    • Injury to the surrounding organs (e.g., bladder, ureters, urethra, bowel)
    • Bleeding
    • Infections

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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