Pelvic Organ Prolapse

Descent of one or more pelvic organs from their normal anatomical position. It results from weakness or damage to the supporting pelvic floor musculature, connective tissue, and ligamentous structures.

It is extremely common, particularly among parous and older women. Characteristic symptoms are a vaginal bulge sensation with associated bladder, bowel, and sexual dysfunction, so quality of life is substantially affected.

The organs and terms involved are:

• the anterior vaginal wall with the bladder, termed cystocele
• the posterior vaginal wall with the rectum, termed rectocele
• the uterus and cervix, termed uterine prolapse
• following hysterectomy, the vaginal vault

Management is individualised according to prolapse severity, compartment involvement, symptomatic burden, and the woman's preference for conservative versus surgical treatment.

Pathophysiology and classification

• The pelvic floor is a complex, integrated system of muscles (predominantly the levator ani group), connective tissue, and ligamentous structures that support the pelvic organs. Prolapse results from damage or weakening of these structures.
• The most common cause is the cumulative effect of vaginal childbirth. It is the single most significant risk factor, because of direct mechanical and neurological trauma to the pelvic floor during delivery.
• Risk increases with the number of vaginal deliveries and with delivery complications, including a large infant or instrumental delivery.
• Other contributors are advancing age, menopause-related connective tissue and hormonal changes, obesity, and any condition producing chronically raised intra-abdominal pressure (including chronic cough or chronic constipation with straining).
• Prolapse is classified by the anatomical compartment involved (anterior, posterior, or apical/uterine). The pattern and combination of compartments vary between women.
• Severity is graded using a structured staging system, most commonly the Pelvic Organ Prolapse Quantification system. It assesses descent of each relevant anatomical point relative to the hymenal ring, giving an objective, standardised framework for assessment and communication.
• Prolapse frequently affects multiple compartments simultaneously, because the supportive structures are shared across these sites. Assess all compartments rather than focusing on a single area.

• The core presenting symptom is a sensation of vaginal bulging or pressure, often described as "something coming down", or a visible or palpable bulge at or beyond the vaginal introitus.
• It is typically worse with prolonged standing or at the end of the day, and improves with lying down. This reflects the gravitational relationship between posture and prolapse descent.
• Urinary symptoms are common, particularly with anterior compartment prolapse. They include stress urinary incontinence, voiding difficulty or incomplete bladder emptying, and recurrent urinary tract infection.
• Significant prolapse can sometimes mask underlying stress incontinence through a kinking effect on the urethra. This "occult" stress incontinence may become apparent only after surgical prolapse correction.
• Voiding difficulty is particularly relevant to significant cystocele, given the direct mechanical effect on bladder emptying.
• Bowel symptoms are particularly associated with posterior compartment prolapse (rectocele). They include difficulty with defecation and, in some women, the need for manual splinting: digital pressure on the posterior vaginal wall or perineum to facilitate complete defecation.
• Sexual dysfunction includes dyspareunia and reduced sexual confidence or activity related to the prolapse and its symptoms.
• The broader psychological and quality of life impact is frequently significant but sometimes underexplored. It warrants sensitive, proactive enquiry.

• Full clinical history is the essential foundation of assessment. It explores the nature and severity of urinary, bowel, and sexual symptoms, and relevant obstetric and surgical history.
• Perform pelvic examination in the supine position and, where the prolapse is not fully apparent supine, in the standing position, given the gravitational effect on severity.
• Examine during Valsalva manoeuvre (bearing down). This allows assessment of the compartment or compartments involved and formal staging using the Pelvic Organ Prolapse Quantification system or a similar structured framework.
• In women considering surgical repair, assess for occult stress urinary incontinence by examining with the prolapse manually reduced, simulating the effect of surgical correction. This informs surgical planning and counselling.
• Urodynamic studies or defecography are considered in selected cases. They characterise the functional impact and mechanism of associated bladder or bowel symptoms in more detail, particularly where surgery for these symptoms is planned.

• Conservative management is appropriate first-line treatment for milder prolapse. It is also an important adjunct across the full spectrum of severity.
• It comprises pelvic floor muscle training, following broadly similar structured principles to those for stress urinary incontinence and ideally delivered under specialist pelvic floor physiotherapy guidance.
• Lifestyle modification addresses modifiable contributing factors, including weight management and treatment of chronic cough or constipation where relevant.
• Vaginal pessaries are available in a range of designs according to the pattern and severity of prolapse. They provide effective, non-surgical mechanical support.
• They are particularly valuable for women wishing to avoid or defer surgery, for those not medically fit for surgery, or as a trial to assess symptomatic response before committing to surgery.
• Regular, structured follow-up and pessary care are essential. Vaginal irritation can occur and, with prolonged use without monitoring, more significant local tissue complications.
• Topical vaginal oestrogen addresses the local atrophic changes of postmenopausal oestrogen deficiency. It may improve tissue quality and tolerance of a pessary, and is a valuable complementary measure in appropriately selected postmenopausal women.
• Surgery is considered for women with significant, symptomatic prolapse not adequately managed conservatively, or who prefer a more definitive approach. The procedure is individualised to the compartment or compartments involved and the woman's circumstances.
• Native tissue repair, using the woman's own tissue to restore normal anatomical support, is the generally preferred approach in contemporary practice for the great majority of presentations.
• This reflects important safety concerns about synthetic mesh in prolapse surgery, which have led to substantial regulatory restriction in several jurisdictions. The considerations are broadly analogous to those for stress urinary incontinence.
• Vaginal hysterectomy is a surgical option for apical (uterine) prolapse. For women wishing to preserve their uterus, uterine-sparing suspension procedures are an alternative. The approach is individualised to patient preference and clinical circumstances.
• Counsel the woman on the full range of management options, incorporating her symptom pattern, severity, and preference for conservative versus surgical treatment.
• Discuss realistically the potential for recurrence after any treatment, given the ongoing relevance of her individual risk factor profile.