Key Facts

Pelvic organ prolapse is a common condition resulting from weakening of the pelvic floor support structures. It can involve the anterior, posterior, or apical vaginal compartments and significantly impacts quality of life.

Epidemiology

• Up to 50% of parous women have some degree of prolapse on examination
• 10-20% are symptomatic
• Lifetime risk of requiring surgery for prolapse: approximately 11-19%
• Prevalence increases with age, particularly post-menopause

Aetiology

• Vaginal delivery (strongest risk factor): forceps delivery, prolonged second stage, large baby, multiple deliveries
• Menopause: oestrogen deficiency weakens pelvic floor connective tissue
• Chronic increased intra-abdominal pressure: obesity, chronic cough (COPD), constipation, heavy lifting
• Connective tissue disorders: Ehlers-Danlos, Marfan syndrome
• Previous pelvic surgery: hysterectomy (vault prolapse risk 0.4-1.8%)
• Genetic factors: family history in first-degree relative

Pathophysiology

• Pelvic floor support depends on: levator ani muscles, endopelvic fascia, uterosacral/cardinal ligaments
• Damage during childbirth: levator ani avulsion, pudendal nerve injury, fascial tears
• Oestrogen deficiency: collagen loss, smooth muscle atrophy
• Result: descent of bladder (cystocele), uterus, vaginal vault, rectum (rectocele), or small bowel (enterocele)

Symptoms

• Sensation of vaginal bulge or lump ('something coming down')
• Dragging or heaviness in pelvis
• Symptoms worse with standing, coughing, straining; improve when lying down

Compartment-Specific Symptoms

• Anterior (cystocele): urinary frequency, hesitancy, incomplete emptying, SUI
• Apical (uterine/vault): sensation of prolapse, dyspareunia, lower back pain
• Posterior (rectocele): difficulty defaecating, need to digitally reduce (splinting), incomplete evacuation

Examination Findings

• Visible prolapse at or beyond the introitus
• Use Sims speculum to assess individual compartments
• POP-Q staging (standardised measurement system)

Red Flags

• Ulceration of exposed prolapsed tissue (decubitus ulcer)
• Urinary retention (severe prolapse causing urethral kinking)
• Renal impairment (bilateral ureteric obstruction from massive prolapse)
• Irreducible prolapse (incarceration)

Bedside

• Pelvic examination with Sims speculum (each compartment assessed separately)
• POP-Q staging: Stage 0 (no prolapse) to Stage IV (complete eversion)
• Cough test for SUI
• Post-void residual volume (bladder scan)

Bloods

• Not routinely required
• U&Es if urinary retention or suspected renal impairment

Imaging

• Post-void residual USS: if voiding difficulty
• Renal USS: if severe prolapse with suspected ureteric obstruction
• MRI pelvis: rarely needed; useful for complex recurrence or surgical planning

Special Tests

• Urodynamics: before surgery if concurrent urinary symptoms (to unmask occult SUI)
• Cervical smear: if visualised cervix is due for screening
• Endometrial biopsy: if concurrent PMB

Non-pharmacological

• PFMT: first-line for all symptomatic prolapse (at least 16 weeks of supervised training; NICE NG123)
• Lifestyle modification: weight loss, treat chronic cough, avoid heavy lifting, manage constipation
• Vaginal pessary: most commonly ring pessary or shelf pessary; effective, non-invasive, changed every 6 months
  • Ring pessary: suitable for most grades; well-tolerated; can be self-managed
  • Shelf (Gellhorn) pessary: for more advanced prolapse
• Vaginal oestrogen: estriol cream; improves tissue quality, reduces pessary complications; recommended for postmenopausal women

Pharmacological

• Vaginal oestrogen (estriol 0.01% cream): nightly for 2 weeks, then twice weekly
• Analgesia if symptomatic
• Laxatives if constipation contributing

Surgical/Interventional

• Anterior repair (anterior colporrhaphy): for cystocele; recurrence rate 30-40%
• Posterior repair (posterior colporrhaphy): for rectocele
• Vaginal hysterectomy ± pelvic floor repair: for uterine prolapse with completed family
• Sacrocolpopexy: abdominal/laparoscopic; mesh suspension of vaginal vault to sacral promontory; gold standard for vault prolapse (5% recurrence)
• Sacrospinous fixation: vaginal approach; fixation to sacrospinous ligament
• Manchester repair: cervical amputation + plication of cardinal ligaments (uterus-preserving)
• Colpocleisis (Le Fort): obliterative procedure; for elderly/frail women not suitable for reconstructive surgery; high satisfaction but precludes vaginal intercourse

Referral Criteria

• Symptomatic prolapse not improving with conservative measures: urogynaecology referral
• Complicated prolapse (ulceration, retention, renal impairment): urgent referral
• Recurrent prolapse after surgery: specialist urogynaecology review
• Young women: fertility considerations before surgical planning

• Conservative management (PFMT + pessary): effective long-term management for many women
• Pessary use: 50-80% continue using pessary at 1 year with good symptom control
• Surgical repair: 70-90% success rate; recurrence varies by procedure (10-30% at 5 years)
• Sacrocolpopexy: lowest recurrence rate (~5%)
• Prolapse may recur in different compartment after surgery (de novo prolapse)
• Quality of life significantly improves with treatment (both conservative and surgical)

POP-Q Staging System

Pessary Comparison