Pelvic Organ Prolapse

19/6/2016 DynaMed Plus: Pelvic organ prolapse
Pelvic organ prolapse
Overview and Recommendations
Background
Pelvic organ displacement and prolapse results from loss of connective tissue and muscular support of the
pelvic floor.
The most common anatomic defect is in the anterior vaginal wall resulting in bladder prolapse
(cystocele).
When the posterior vaginal wall is affected the prolapse involves the rectum (rectocele) and
occasionally the small intestine (enterocele).
When the vaginal apex is affected the prolapse usually involves the uterus and cervix (uterine
prolapse) or if post hysterectomy the vaginal cuff (vaginal vault prolapse). The small intestine
(enterocele), colon (sigmoidocele), or bladder (cystocele) may also be involved in the prolapse.
Factors associated with an increased risk of pelvic organ prolapse include history of vaginal delivery,
advancing age, increasing parity, and obesity.
Stress urinary incontinence occurs in up to 40% of women with mild pelvic organ prolapse while
symptoms associated with urinary outlet obstruction are more likely to occur in women with advanced
prolapse.
Evaluation
Diagnosis is usually made clinically by pelvic exam and most women require little to no additional testing
beyond history and physical exam to make the diagnosis.
Urodynamic testing may be used to assess extent of urinary incontinence and efficiency of bladder
voiding.
Endometrial biopsy and/or ultrasound to assess for uterine disease may be indicated in women with a
history of abnormal uterine bleeding prior to surgical intervention for pelvic organ prolapse.
Management
Consider expectant management in asymptomatic or mildly symptomatic women.
Pelvic floor muscle training may improve symptoms of pelvic organ prolapse.
Consider pessary use in all women with symptomatic pelvic organ prolapse prior to surgical intervention
(Strong recommendation).
Surgical correction of pelvic organ prolapse is usually delayed until all anticipated childbearing has been
completed.
The surgical approach to pelvic organ prolapse is either reconstructive or obliterative.
The goal of reconstructive surgery is correction of pelvic prolapse and relief of associated
symptoms while maintaining sexual function.
The goal of obliterative surgery is to minimize surgical time and complications by correcting pelvic
prolapse by partial or total closure of the vaginal canal. This approach is usually reserved for elderly
women who do not desire to maintain use of vagina for intercourse.
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Related Summaries
Surgical management of pelvic organ prolapse
Hysterectomy
Urinary incontinence in women
Urinary retention
General Information
Description
descent of pelvic organs toward or through the vaginal opening due to loss of connective tissue support
support may be insufficient in ≥ 1 anatomic location, including(1, 2, 3)
anterior vaginal wall
most common
usually involves bladder prolapse (cystocele)
posterior vaginal wall
usually involves rectal prolapse (rectocele)
may involve small intestine (enterocele)
vaginal apex
usually involves prolapse of uterus, cervix, or posthysterectomy prolapse of vaginal cuff
(vault prolapse)
may involve small intestine (enterocele), colon (sigmoidocele), or bladder (cystocele)
Also called
pelvic relaxation
urogenital prolapse
uterovaginal prolapse
uterine prolapse
cystocele
rectocele
enterocele
Epidemiology
Who is most affected
more common in postmenopausal women(1, 2, 3)
Latina and white women may have higher risk of symptomatic pelvic organ prolapse than African
American women
based on prospective cohort study
2,270 women (aged 4069 years) were evaluated for prolapse
presence of symptomatic prolapse selfreported
1,137 women (50%) also received clinical evaluation with degree of prolapse assessed using
Pelvic Organ Prolapse Quantification (POPQ) system
selfreported symptomatic prolapse in 74 women (3%)
compared with African American women, increased incidence symptomatic prolapse in
Latina women (prevalence ratio 4.9, 95% CI 1.614.6)
white women (prevalence ratio 5.4, 95% CI 1.915.1)
no significant difference in degree of prolapse by POPQ stage among racial groups
2/26
Reference Obstet Gynecol 2009 Dec;114(6):1271 fulltext
vaginal prolapse rarely occurs in newborn period, associated with central nervous system defects or
intrauterine growth retardation (Pediatric Surgery Update 2005 Jan;24(1):2)
Incidence/Prevalence
in women presenting for routine gynecological care(3)
some loss of vaginal and/or uterine support in about 43%76%
prolapse beyond hymen in about 3%6%
1.6% prevalence reported in women aged 2039 years(4)
prevalence in United States
pelvic organ prolapse of at least stage I found in ≥ 70% women in the United States
1,004 women aged 1883 years from 6 outpatient gynecology clinics in the United States had
annual gynecologic examination with Pelvic Organ Prolapse Quantification (POPQ) and
prolapse symptom questionnaire
populationbased prevalence of pelvic organ prolapse by POPQ stage
stage 0 in 24%
stage I in 38%
stage II in 35%
stage III in 2%
stage IV in 0%
Reference Am J Obstet Gynecol 2005 Mar;192(3):795
cystocele may be most common form of pelvic organ prolapse in the United States
based on crosssectional analysis of Women's Health Initiative trial
27,342 women had pelvic exam and completed questionnaire
rates of pelvic organ prolapse in 16,616 women with a uterus
cystocele in 34.3%
rectocele in 18.3%
uterine prolapse in 14.2%
rates of pelvic organ prolapse in 10,727 women without a uterus
cystocele in 32.9%
rectocele in 18.3%
Reference Am J Obstet Gynecol 2002 Jun;186(6):1160
estimated weighted prevalence of symptomatic pelvic organ prolapse 2.9% in women ≥ 20
years old in the United States
based on analysis of crosssectional data from National Health and Nutritional Examination
Survey from 2005 to 2006, 2007 to 2008, and 2009 to 2010
7,924 nonpregnant women ≥ 20 years old evaluated via questionnaire for presence of
symptomatic pelvic floor disorders (moderatetosevere urinary incontinence, fecal
incontinence at least monthly, and pelvic organ prolapse)
weighted prevalence rate of symptomatic pelvic organ prolapse ("seeing or feeling a bulge")
2.9%
Reference Obstet Gynecol 2014 Jan;123(1):141
6% prevalence of symptomatic pelvic organ prolapse in women > 40 years old in the United
States
based on cohort study
2,001 randomly selected women > 40 years old in the United States had physical exam,
interview, and evaluation of medical records
symptomatic prolapse defined as selfreported feeling of bulge, pressure, or protrusion, or
visible bulge from vagina
symptomatic prolapse in 118 women (6%)
factors associated with increased risk for symptomatic prolapse in multivariate analysis
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vaginal delivery
1 delivery (odds ratio [OR] 2.8, 95% CI 1.17.2)
2 deliveries (OR 4.1, 95% CI 1.89.5)
≥ 3 deliveries (OR 5.3, 95% CI 2.312.3)
irritable bowel syndrome (OR 2.8, 95% CI 1.74.6)
constipation (OR 2.5, 95% CI 1.73.7)
selfreported fair or poor health (OR 2.3, 95% CI 1.14.9)
African American women were less likely to report prolapse than white women (OR 0.4, 95%
CI 0.20.8)
Reference Obstet Gynecol 2007 Jun;109(6):1396
12.6% estimated lifetime risk for surgery for pelvic organ prolapse in general population in
United States
based on populationbased cohort study
10,177,480 women aged 1889 years in the United States were followed for 24,979,447
personyears from 2007 to 2011
57,755 incidentcases of surgery for pelvic organ prolapse identified
12.6% estimated cumulative incidence of prolapse surgery in general population for women
until age 80 years
19% estimated lifetime risk of surgery for pelvic organ prolapse in general population in Western
Australia
based on crosssectional analysis of agespecific incidence rates of firsttime prolapse surgery from
2001 to 2005 in Western Australia
44,728 incidentcases of firsttime surgery for pelvic organ prolapse
19% estimated cumulative incidence of prolapse surgery in general population for women ≤ 85
years old
Reference Obstet Gynecol 2010 Nov;116(5):1096
Likely risk factors
vaginal delivery (most common)(1, 2, 3)
spontaneous and operative vaginal delivery each associated with greater risk of pelvic organ
prolapse 510 years postdelivery compared to cesarean delivery without labor
1,011 women evaluated for pelvic floor outcomes (stress incontinence, overactive bladder,
anal incontinence, and prolapse symptoms) by questionnaire 510 years after first delivery
compared to cesarean delivery without labor
spontaneous vaginal delivery associated with increased risk of pelvic organ prolapse to
or beyond hymen (adjusted odds ratio [OR] 5.6, 95% CI 2.214.7)
≥ 1 operative vaginal delivery associated with increased risk of
prolapse symptoms (adjusted OR 6.8, 95% CI 1.727.8)
pelvic organ prolapse to or beyond hymen (adjusted OR 7.5, 95% CI 2.720.9)
Reference Obstet Gynecol 2011 Oct;118(4):777 fulltext, editorial can be found in Obstet
Gynecol 2011 Oct;118(4):774, commentary can be found in Obstet Gynecol 2012
Jan;119(1):182
advancing age(1, 2, 3)
increasing parity(2, 3)
increasing parity associated with increasing risk of pelvic organ prolapse
based on 2 crosssectional studies with widely variable rates of prolapse
504 evermarried women in eastern Lebanon aged 1560 years were assessed by interview,
physical exam, pelvic exam, and laboratory testing
prevalence of pelvic organ prolapse by parity
3.6% in nulliparous women
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6.5% in primiparous women
22.7% in secundiparous women
32.9% in triparous women
46.8% in tetraparous women
Reference Menopause 2012 Nov;19(11):1235
1,961 women ≥ 20 years old had physical exam and interview
2.9% overall weighted prevalence of pelvic organ prolapse
prevalence of pelvic organ prolapse by parity
0.6% with 0 births
2.5% with 1 birth
3.7% with 2 births
3.8% with ≥ 3 births
Reference JAMA 2008 Sep 17;300(11):1311 fulltext
obesity(1, 2, 3)
body mass index ≥ 25 kg/m2 and ≥ 2 vaginal deliveries each associated with increased risk of
symptomatic pelvic organ prolapse
2,640 French women aged 5059 years from GAZEL cohort responding to questionnaire evaluating
quality of life, prevalence, and risk factors associated with symptomatic pelvic organ prolapse
symptomatic pelvic organ prolapse in 3.6%
symptomatic pelvic organ prolapse associated with
body mass index ≥ 25 kg/m2 (adjusted odds ratio [OR] 1.4, 95% CI 12)
2 vaginal deliveries (adjusted OR 2.5, 95% CI 1.25)
≥ 3 vaginal deliveries (adjusted OR 3.6, 95% CI 1.77.6)
Reference Obstet Gynecol 2009 Mar;113(3):609 fulltext
family history of pelvic organ prolapse associated with increased risk of developing pelvic organ
prolapse
based on systematic review
systematic review of 9 casecontrol studies and 7 cohort studies evaluating family history of pelvic
organ prolapse in 4,354 women (2,413 with pelvic organ prolapse)
family history of pelvic organ prolapse associated with increased risk of pelvic organ prolapse (odds
ratio 2.58, 95% CI 2.123.15) in 8 studies with 3,048 women
Reference Int Urogynecol J 2012 Oct;23(10):1327 fulltext
Possible risk factors
obstetric factors(2, 3)
young age at first delivery (< 25 years old)
prolonged second stage of labor
infant birth weight > 4,500 g (9.9 lbs)
episiotomy
forceps delivery
spontaneous perineal laceration and forceps delivery each associated with increased risk of
pelvic organ prolapse
449 women with ≥ 1 vaginal birth evaluated for pelvic floor outcomes (stress incontinence,
overactive bladder, anal incontinence, and prolapse symptoms) via questionnaire and
gynecologic examination 510 years after delivery of first child
≥ 1 spontaneous perineal laceration in 57%
pelvic organ prolapse to or beyond the hymen on examination in 14%
pelvic organ prolapse symptoms in 4%
≥ 1 spontaneous perineal laceration associated with increased risk of pelvic organ prolapse to
or beyond the hymen (odds ratio [OR] 2.34, 95% CI 1.134.86)
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forceps delivery associated with increased risk of pelvic organ prolapse (OR 1.95, 95% CI
1.033.7)
Reference Obstet Gynecol 2012 Feb;119(2 Pt 1):233 fulltext
increased intraabdominal pressure due to(1, 2, 3)
chronic cough associated with smoking or lung disease
straining due to chronic constipation
repeated heavy lifting
laborer/factory worker occupation associated with increased risk of severe pelvic organ
prolapse
1,004 women presenting for routine gynecologic care were evaluated for pelvic organ
prolapse with assessment by Pelvic Organ Prolapse Quantification (POPQ)
POPQ stage 0 in 25%
stage I in 37.7%
stage II in 35%
stage III in 2.3%
no stage IV
severe pelvic organ prolapse was defined clinically as the leading edge being 1 cm or
more beyond the hymeneal ring
overall prevalence of severe pelvic organ prolapse 4.3%
laborer/factory worker occupation associated with increased risk of severe pelvic organ
prolapse
Reference Int Urogynecol J Pelvic Floor Dysfunct 2006 Jun;17(4):340
previous pelvic surgery, such as hysterectomy or previous prolapse surgery(1, 2, 3)
preoperative prolapse grade ≥ 2, previous surgery for prolapse or urinary incontinence,
history of vaginal delivery, and sexual activity each associated with increased risk of pelvic
organ prolapse in women following hysterectomy
based on casecontrol study
114 women having surgery for pelvic organ prolapse were compared with 236 controls who
had hysterectomy
incidence of pelvic organ prolapse requiring surgery after hysterectomy was 1.3 per 1,000
womenyears
risk factors for pelvic organ prolapse
preoperative prolapse grade ≥ 2 (adjusted odds ratio [OR] 12.6, 95% CI 4.634.7)
previous pelvic organ prolapse or urinary incontinence surgery (adjusted OR 7.9, 95%
CI 1.348.2)
history of vaginal delivery (adjusted OR 5, 95% CI 1.319.7)
sexual activity (adjusted OR 6.2, 95% CI 2.714.5)
vaginal hysterectomy not associated with increased risk when adjusted for preoperative
prolapse
Reference Obstet Gynecol 2007 Sep;110(3):625
other risk factors(1, 2, 3)
connective tissue disorders such as EhlersDanlos syndrome or Marfan syndrome
joint hypermobility
shape or orientation of bony pelvis (loss of lumbar lordosis and less vertically oriented pelvic inlet)
selective estrogenreceptor modulators
menopause
collagen type 3 alpha 1 rs1800255 genotype AA associated with increased risk of pelvic organ
prolapse
based on systematic review of observational studies
systematic review of 21 observational studies evaluating association between genetic
epidemiology and pelvic organ prolapse
collagen type 3 alpha 1 (COL3A1) rs1800255 genotype AA associated with increased risk of
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pelvic organ prolapse compared to reference genotype GG (odds ratio 4.79, 95% CI 1.91
11.98) in analysis of 2 studies
Reference Am J Obstet Gynecol 2014 Oct;211(4):326 fulltext
greater levator ani deficiency associated with increased risk of clinically significant pelvic
organ prolapse
based on retrospective cohort study
220 urogynecologic patients (mean age 57 years, median parity 2) had threedimensional
ultrasound scans and levator ani deficiency score calculated and categorized as mild,
moderate, or severe
clinically significant pelvic organ prolapse defined as POPQ stage ≥ II
compared with minimal levator ani deficiency, increased risk of clinically significant pelvic
organ prolapse associated with
moderate levator ani deficiency (adjusted odds ratio [OR] 3.2, 95% CI 1.37.7)
severe levator ani deficiency (adjusted OR 6.44, 95% CI 2.417.4)
Reference Obstet Gynecol 2013 May;121(5):1017
Factors not associated with increased risk
cesarean delivery associated with similar incidence of pelvic floor disorders as nulliparity
4,458 women aged 2584 years completed Epidemiology of Prolapse and Incontinence
Questionnaire to assess for pelvic floor disorders
pelvic organ prolapse in 7%
compared to cesarean delivery, vaginal delivery associated with increased risk of pelvic organ
prolapse (adjusted odds ratio 1.82, 95% CI 1.043.19)
no significant difference in prevalence of any pelvic floor disorders comparing cesarean
delivery and nulliparity
Associated conditions
bowel dysfunction (in 7%31%)(2, 3)
may be associated with muscular and neuropathic pelvic floor injury after vaginal delivery, and/or
effects of aging
anal incontinence associated with pelvic floor disorders
100 women with pelvic floor disorders (pelvic organ prolapse stage ≥ II and/or urinary
incontinence) were matched to 90 controls (stage 0/I pelvic organ prolapse without urinary
incontinence) and evaluated by RockwoodThompson fecal incontinence severity index
(RTFISI) and endoanal ultrasound
RTFISI based on 061 point scale assessing frequency and type of anal incontinence (higher
score associated with more severe incontinence)
comparing women with pelvic organ prolapse vs. controls
anal incontinence in 54% vs. 17.8% (p < 0.001)
mean RTFISI score 22.3 vs. 12.7 (p = 0.006)
anal sphincter defects on ultrasound in 52% vs. 30% (p = 0.007)
anal incontinence significantly associated with sphincter injury in both cases (p < 0.001) and
controls (p = 0.002)
Reference Obstet Gynecol 2005 Dec;106(6):1266
collagenassociated disorders may be associated with pelvic organ prolapse
210 women (110 with pelvic organ prolapse, 100 without pelvic organ prolapse) and their first and
seconddegree family members were evaluated for collagenassociated disorders
7/26
comparing women with pelvic organ prolapse vs. women without pelvic organ prolapse (p < 0.01
for each)
varicose veins in 27% vs. 6%
joint hypermobility in 19% vs. 2%
rectal prolapse in 25% vs. 0%
mother with pelvic organ prolapse 70% vs. 20%
sisters with pelvic organ prolapse 34% vs. 4%
Reference Int Urogynecol J 2012 Mar;23(3):313 fulltext
hip fracture associated with moderatetosevere pelvic organ prolapse
based on subgroup analysis of randomized trial
1,192 women with moderatetosevere pelvic organ prolapse were followed for mean 7.4 years
2,156 incident fractures occurred during followup
moderatetosevere pelvic organ prolapse (any type) associated with incident hip fracture (hazard
ratio [HR] 1.83, 95% CI 1.162.89)
in women with no history of hormone therapy, moderatetosevere rectocele associated with
increased risk for
incident spine fracture (HR 2.61, 95% CI 1.046.56)
lower arm fracture (HR 1.87, 95% CI 1.063.29)
Reference Menopause 2011 Sep;18(9):967 fulltext
Etiology and Pathogenesis
Causes
disruption or dysfunction in levator ani muscle tone and/or connective tissue support for pelvic organs
results in organ displacement and prolapse(2, 3)
specific underlying cause likely multifactorial and varies by patient(2, 3)
Pathogenesis
loss of tone in levator ani muscles (pubococcygeus, puborectalis, and iliococcygeus) due to neurologic
injury (denervation) or direct trauma leads to(2, 3)
transition of levator ani from horizontal to semivertical orientation
widening of urogenital hiatus (distance between posterior midline hymen and external urethral
meatus)
bowllike pelvic configuration
transmission of abdominal pressure to pelvic floor and reliance on connective tissue support for
pelvic structures
over time, increased abdominal pressure on pelvic floor and altered collagen metabolism can lead to
stretching and tearing of connective tissue (endopelvic fascia) and loss of pelvic visceral support(2, 3)
History and Physical
History
Chief concern (CC)
most women are asymptomatic(1, 2)
symptoms vary by position of uterus and pressure on surrounding pelvic structures, and may not correlate
with stage or severity of prolapse(1, 2, 3)
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may present with ≥ 1 of the following(1, 2, 3)
vaginal symptoms
sensation of or visible bulge or protrusion from vagina (considered only symptom specific to
pelvic organ prolapse)
pelvic pressure or heaviness
feeling of something "falling out" of vagina
urinary dysfunction
stress incontinence
frequency
urgency
obstructed voiding, including
weak or prolonged urinary stream
urinary hesitancy
feeling of incomplete emptying
bowel dysfunction(1, 2, 3)
incontinence of flatus or liquid or solid stool
straining during defecation
urgency
sense of blockage or obstruction during defecation
feeling of incomplete emptying
manual pressure (splinting) on perineum or vagina to begin or complete defecation (more
common with posterior vaginal prolapse)
digital evacuation to complete defecation
dyspareunia
rarely painful but patients may mistakenly attribute other sources of pelvic and/or low back pain to
prolapse(3)
History of present illness (HPI)
sensation of or actual vaginal bulging may vary over time(1, 2, 3)
may be asymptomatic or mildly symptomatic in the morning with protrusion worsening throughout
the day
may be worse after excessive standing, heavy lifting, coughing, or physical exertion
may progress with increasing body mass index but not reversed by weight loss
symptoms of urinary dysfunction may change with disease severity(1, 2, 3)
stress urinary incontinence may occur with mild prolapse and improve or resolve as prolapse
progresses beyond hymen
women with prolapse beyond hymen more likely to report symptoms of obstructed voiding,
including position change and/or manual pressure on prolapsed area (splinting) to begin or complete
urination
symptoms associated with pelvic organ prolapse may include urinary splinting, digital assistance
during defecation, and vaginal bulge (level 2 [midlevel] evidence)
based on diagnostic cohort study without blinding of reference standard or test under investigation
1,912 women attending pelvic floor disorder clinics for symptoms related to pelvic organ prolapse
were evaluated by pelvic floor dysfunction questionnaire followed by clinical exam
reference standard was clinical exam with prolapse ≥ 0 cm beyond hymen
pelvic organ prolapse in 861 women (45%) by reference standard
pelvic organ prolapse symptoms included
urinary splinting in 152 patients (7.9%)
digital assistance during defecation in 303 patients (15.8%)
vaginal bulge in 706 patients (36.9%)
all 3 symptoms together in 55 patients (3%)
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Diagnostic Performance of Urinary Splinting, Digital Assistance, and Vaginal Bulge for Detection
of Pelvic Organ Prolapse:
Symptom Sensitivity Specificity PPV NPV
Urinary splinting 18.1% 96.9% 73.7% 71.1%
Digital assistance during
32% 87.4% 34% 86.4%
defecation
Vaginal bulge 66.6% 87.3% 81.2% 76.1%
All 3 symptoms together 5.7% 99.4% 89.1% 56.3%
Abbreviations: NPV, negative predictive value; PPV, positive predictive value.
Reference Int Urogynecol J Pelvic Floor Dysfunct 2005 MayJun;16(3):203
Past medical history (PMH)
ask about(1, 2, 3, 4)
parity, especially vaginal or forceps delivery
episiotomy
age at first delivery
infant birth weight
chronic constipation
abnormal uterine bleeding (if present and not previously evaluated) may require additional testing
during diagnostic evaluation
ask about(1, 2, 3)
connective tissue disorders, such as EhlersDanlos syndrome or Marfan syndrome
previous pelvic surgery, such as hysterectomy or surgery for prolapse
Family history (FH)
ask about family history of pelvic organ prolapse(3)
Social history (SH)
ask about(2, 3)
current or history of smoking
occupation requiring heavy lifting
Physical
Pelvic
pelvic exam(1, 2, 3)
seeing or feeling vaginal bulge with tissue prolapsing to or past vaginal opening considered most
specific symptom for pelvic organ prolapse
assess for prolapse with patient lying supine in heel stirrups and performing Valsalva maneuver
(forcible exhalation against closed nose and mouth while bearing down)
if prolapse is not evident with patient supine, patient may be assessed standing up
if bulge or prolapse is noted with Valsalva maneuver, systematic exam to assess severity and
affected organs may include assessment of
cervix or vaginal cuff (slowly remove vaginal speculum while patient performs Valsalva
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maneuver and note extent cervix or vaginal vault follows speculum through vagina)
anterior vaginal wall (with posterior vaginal wall retracted with fixed blade of speculum,
assess for prolapse as patient performs Valsalva maneuver)
posterior vaginal wall (with anterior vaginal wall retracted with fixed blade of speculum,
assess for prolapse as patient performs Valsalva maneuver)
patients with complete uterine prolapse (procidentia) may present with(2, 3)
pressure ulcers
hypertrophied vagina and/or cervix
vaginal discharge
bimanual and rectovaginal exam may help identify rectocele and abnormalities in perineal body(2)
Diagnosis
Making the diagnosis
diagnosis usually made clinically by pelvic exam during routine wellwoman evaluation or in women with
symptoms of pelvic organ prolapse such as vaginal bulge and incontinence(1, 2, 3)
seeing or feeling vaginal bulge with tissue prolapsing to or past vaginal opening considered most specific
symptom for pelvic organ prolapse(1)
grading systems used to standardize findings on physical exam(1, 2)
BadenWalker grading system
commonly used in clinical practice
evaluates anterior, apical, and posterior pelvic floor support defects
BadenWalker Grading System:
Grade Description
No prolapse
0
Normal position for each pelvic site
1 Prolapse halfway to hymen
2 Prolapse to hymen
3 Prolapse halfway past hymen
Maximum descent possible for each
4
pelvic site
Pelvic Organ Prolapse Quantification (POPQ) staging system
developed by the International Continence Society (ICS), the American Urogynecologic
Society (AUS), and the Society of Gynecologic Surgeons (SGS)
commonly used for clinical research purposes
Pelvic Organ Prolapse Quantification (POPQ) Staging System:
Stage Description
No prolapse (anterior and posterior
points all 3 cm, and cervix [C] or
0
posterior fornix [D] is between TVL
and TVL 2 cm)
Prolapse > 1 cm above hymen (< 1
I
cm) and criteria for stage 0 not met
Prolapse ≤ 1 cm above or below
II hymen (at least 1 point is 1, 0, or +1)
Prolapse > 1 cm below hymen
III Most distal prolapse ≤ 2 cm less than
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TVL
Complete eversion of lower genital
tract
IV
Most distal prolapse TVL 2 cm
beyond hymen
Abbreviation: TVL, total vaginal length.
vaginal sites measured with POPQ staging system
points Aa and Ba (anterior points)
points Ap and Bp (posterior points)
point C (cervix or vaginal apex)
point D (posterior fornix, not measured posthysterectomy)
additional measurements may include
genital hiatus (GH)
perineal body (PB)
total vaginal length (TVL)
Reference Am J Obstet Gynecol 1996 Jul;175(1):10
testing usually not necessary for diagnosis but may be done to assess complications or as part of
presurgical assessment
Differential diagnosis
uterine leiomyoma prolapsed submucosal myoma may present as vaginal bulge or pressure
bladder diverticula presenting as vaginal bulge in 2 patients in case series (Obstet Gynecol 2011
Aug;118(2 Pt 2):415), editorial can be found in Obstet Gynecol 2011 Aug;118(2 Pt 2):411, commentary
can be found in Obstet Gynecol 2011 Nov;118(5):1182
primary invasive vaginal carcinoma presenting as irreducible third degree uterovaginal prolapse in 60
yearold woman in case report (Arch Gynecol Obstet 2007 Nov;276(5):563)
Skene gland abscess presenting as painful periurethral mass in case report (Obstet Gynecol 2012
Dec;120(6):1459), reaffirmed 2015 Jul
urethral leiomyoma presenting as exophytic periurethral mass in 27yearold woman in case report (J
Minim Invasive Gynecol 2009 JulAug;16(4):507)
Testing overview
most women require little to no additional testing beyond history and physical exam
additional testing may be indicated depending on symptoms, prolapse stage, and treatment plan(2, 3)
urodynamic testing may be used to assess extent of urinary incontinence and efficiency of bladder
voiding
imaging not usually necessary to identify location and severity of prolapse but may be used to
locate pelvic support defects prior to surgical repair
endometrial biopsy and/or ultrasound to assess for uterine disease may be indicated in women with
history of abnormal uterine bleeding prior to surgical intervention for pelvic organ prolapse(4)
Imaging studies
radiographic assessment to identify location and severity of prolapse usually unnecessary(3)
contrast radiography or dynamic magnetic resonance imaging (MRI) have been used to locate pelvic
support defects prior to surgical repair, but clinical benefit has yet to be determined(3)
ultrasound may help detect uterine disease in women with history of abnormal uterine bleeding prior to
surgical intervention for pelvic organ prolapse(4)
imaging in patients with defecatory dysfunction may include(2, 3)
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anal manometry and/or dynamic defecography (may be indicated in patients with severe defecatory
dysfunction)
endoanal ultrasound (may help identify anal sphincter defect in patients with fecal incontinence)
translabial threedimensional ultrasound appears to have moderate sensitivity and specificity for
diagnosing major levator ani defects in women with pelvic organ prolapse (level 2 [midlevel]
evidence)
based on diagnostic cohort study without validation
140 women having primary surgery for pelvic organ prolapse quantification (POPQ) stage II or
more cystocele had translabial threedimensional ultrasound and MRI (best available reference
standard) of the pelvic floor before surgery
41 major levator ani defects detected on MRI
diagnostic performance of translabial threedimensional ultrasound in detecting major levator ani
defects
sensitivity 78%
specificity 86%
positive predictive value 71%
negative predictive value 90%
positive likelihood ratio 5.64
negative likelihood ratio 0.25
Reference Obstet Gynecol 2014 Dec;124(6):1190
Other diagnostic testing
urodynamic testing(1, 2, 3)
multichannel urodynamic testing in patients with severe urinary incontinence, irritative voiding
symptoms, or voiding dysfunction may help identify patients most likely to benefit from surgery
assessment of voided volume with full bladder, and postvoid residual urine volume with
catheterization or bladder ultrasound may help evaluate efficacy of bladder emptying
Valsalva and cough stress testing with prolapse reduced in subjectively stresscontinent patients
may help identify occult stress incontinence, although no current consensus on best method to
reduce prolapse for stress testing or how stresstesting results may affect treatment
recommendations
Treatment
Treatment overview
conservative (expectant) management
consider watchful waiting in asymptomatic or mildly symptomatic women with early stage prolapse
without descent beyond hymen
pelvic floor muscle training (Kegel exercises)
characterized by systematic contraction of pelvic floor muscles by conscious contraction,
electrical stimulation, or biofeedback training
often used adjunctively to symptomdirected therapy such as pessaries
pelvic floor muscle training may improve prolapse symptoms in women with pelvic organ
prolapse (level 2 [midlevel] evidence)
mechanical support (pessary)
consider pessary use in all women with symptomatic prolapse prior to surgical intervention
pessary selection usually determined by severity of prolapse and patient's cognitive status,
manual dexterity, and level of sexual activity
pessary use reported to help resolve most prolapse symptoms at 2 months in women with
symptomatic pelvic organ prolapse (level 2 [midlevel] evidence)
13/26
surgical management
surgical correction usually delayed in premenopausal women until all anticipated childbearing has
been completed
women presenting with cervical lesions or other evidence of cervical disease should be evaluated
and treated prior to prolapse repair
surgical approach to pelvic organ prolapse is either reconstructive or obliterative
reconstructive approach
goal of reconstructive surgery is correction of pelvic prolapse and relief of associated
symptoms while maintaining sexual function
procedures may be performed by vaginal, abdominal, or laparoscopic approach
(vaginal approach accounts for 80%90% of procedures)
reconstructive surgery may involve hysterectomy or may preserve the uterus
mesh may be used as a surgical adjuvant in reconstructive procedures
obliterative approach
goal of obliterative surgery is to correct pelvic prolapse by partial or total closure of
vaginal canal
colpocleisis usually reserved for elderly women who
are at high risk for complications with reconstructive procedures
prefer to avoid hysterectomy
do not desire to maintain vaginal use for intercourse
Diet
dietary modification including increased dietary fiber or fiber supplements may reduce constipation and
straining in patients with associated defecatory dysfunction(1)
Activity
pelvic floor muscle training (Kegel exercises) consists of systematic contraction of pelvic floor muscles
by conscious contraction, electrical stimulation, or biofeedback training(1, 2, 3, 4, 5)
may help strengthen pelvic muscles and improve symptoms associated with urinary dysfunction
(including stress, urge, and mixed urinary incontinence) and/or fecal dysfunction
weighted cones (Kegel cones) may help women isolate pelvic floor muscle for contraction
no standardization of intensity level or exercise duration
often used as adjuvant to symptomdirected therapy such as pessaries
pelvic floor muscle training is effective for women with stage III vaginal prolapse, including
vaginal vault prolapse after hysterectomy (RCOG/BSUG Grade B)
pelvic floor muscle training may improve prolapse symptoms in women with pelvic organ
prolapse (level 2 [midlevel] evidence)
based on Cochrane review of trials without attention control
systematic review of 6 randomized and quasirandomized trials evaluating conservative
management (physical or lifestyle interventions) for pelvic organ prolapse
4 trials compared pelvic floor muscle training vs. no active treatment in 857 women
pelvic floor muscle training associated with
significant improvement in prolapse symptoms in 3 of 3 trials reporting this
outcome
significantly reduced prolapse severity in 3 of 3 trials with usable data
inconsistent results for urinary symptoms in 3 trials; 2 trials favored pelvic floor muscle
training and 1 trial found no significant difference
2 trials compared pelvic floor muscle training plus surgery vs. surgery alone in 118 women
prolapse symptoms and severity not reported
inconsistent results for urinary symptoms; 1 trial favored pelvic floor muscle training
and 1 trial found no significant difference
14/26
Reference Cochrane Database Syst Rev 2011 Dec 7;(12):CD003882
individualized pelvic floor muscle training appears to improve symptoms in women with mild
pelvic organ prolapse (level 2 [midlevel] evidence)
based on randomized trial without attention control
287 women ≥ 55 years old with symptomatic mild pelvic organ prolapse (POPQ stage I or
mild stage II) were randomized to pelvic floor muscle training vs. watchful waiting for 3
months
pelvic floor muscle training included assessment and individualized exercise program
provided by pelvic physiotherapists in treatment sessions
pelvic floor muscle training group encouraged to practice at home 23 times per day, 3
5 days weekly
primary outcome was change in Pelvic Floor Distress Inventory20 score (0300 points)
assessing bladder, bowel, and pelvic floor symptoms (minimum clinically important
difference 15 points)
87% completed followup questionnaires and 83% completed followup appointment
comparing pelvic floor muscle training vs. watchful waiting at 3 months
selfreported symptom improvement in 57% vs. 13% (p < 0.001, NNT 3)
mean improvement in Pelvic Floor Distress Inventory20 was 18.3 points vs. 7.7 points
(p = 0.005)
mean improvement in Urinary Distress Inventory6 was 9.6 points vs. 3.1 points (p =
0.007)
no significant differences in improvement of ≥ 1 Pelvic Organ Prolapse Quantification stage,
Pelvic Organ Prolapse Distress Inventory6, ColoRectal Anal Distress Inventory8, Pelvic
Floor Impact Questionnaire7, or Pelvic Organ Prolapse/Incontinence Sexual Function
Questionnaire12
Reference BMJ 2014 Dec 22;349:g7378 fulltext
individualized pelvic floor muscle training may reduce prolapse symptom frequency in
women with pelvic organ prolapse (level 2 [midlevel] evidence)
based on randomized trial with methodologic limitations
447 women (mean age 57 years) with newlydiagnosed symptomatic pelvic organ prolapse
randomized to individualized pelvic floor muscle training for 5 sessions over 16 weeks vs.
prolapse lifestyle advice leaflet and no muscle training (control) and followed for 1 year
prolapse symptoms were assessed by pelvic organ prolapse symptom score (POPSS, range 0
28) with higher scores indicating more frequent symptoms (mean baseline score 10 in
intervention group and 9.5 in placebo group)
limitations
66% completed 12month assessment but women with ≥ 1 followup assessment were
included in analyses
authors report "significant crossover" to muscle training by patients in control group,
but specific rate not reported
individualized pelvic floor muscle training associated with greater improvement in prolapse
symptoms
at 6 months (adjusted mean difference in POPSS 2.79, 95% CI 1.913.67)
at 12 months (adjusted mean difference in POPSS 1.66, 95% CI 0.742.58)
individualized pelvic floor muscle training associated with significantly improved quality of
life overall and in sexual, bladder, and bowel function at 6 months, but not 1 year
Reference POPPY trial (Lancet 2014 Mar 1;383(9919):796), correction can be found in
Lancet 2014 Jul 5;384(9937):28, editorial can be found in Lancet 2014 Mar 1;383(9919):760
perioperative pelvic floor muscle training does not appear to improve urinary or prolapse
symptoms compared to usual care following surgery for apical vaginal prolapse and stress
urinary incontinence (level 2 [midlevel] evidence)
based on randomized trial without intentiontotreat analysis
374 women (mean age 57 years) having surgery for stage 24 apical vaginal prolapse and
stress urinary incontinence were randomized in a 2 by 2 factorial design to the following
15/26
interventions and followed for 2 years
perioperative pelvic floor muscle training vs. usual care
surgery by uterosacral ligament suspension vs. sacrospinous ligament fixation
(summarized here)
urinary symptoms were assessed by Urinary Distress Inventory (UDI) and prolapse symptoms
assessed by Pelvic Organ Prolapse Distress Inventory (POPDI) (both range 0300 with
higher scores indicating worse symptoms)
at baseline mean UDI score was 126 and mean POPDI score was 124
88% were included at 6 months and 78% at 2 years
comparing pelvic floor muscle training vs. usual care
mean reduction in UDI score at 6 months 94.6 vs. 87.9 (not significant)
mean reduction in POPDI score at 2 years 73.3 vs. 65.2 (not significant)
Reference OPTIMAL trial (JAMA 2014 Mar 12;311(10):1023), correction can be found in
JAMA 2015 Jun 9;313(22):2287
pelvic floor exercises plus perineal electrical stimulation reported to improve pelvic floor
muscle strength in women with urinary incontinence and pelvic organ prolapse (level 3
[lacking direct] evidence)
based on case series without clinical outcomes
48 women with urinary incontinence with or without pelvic organ prolapse had physical
therapy and pelvic muscle function measured at baseline and posttreatment
physical therapy included pelvic floor exercises (Kegel exercises) with aid of ball and elastic
band for 15 minutes and perineal electrical stimulation for 10 minutes once weekly for up to
15 weeks (mean 13.5 weeks)
pelvic organ prolapse in 36 women (75%)
comparing mean pelvic floor muscle strength pretreatment vs. posttreatment in women with
pelvic organ prolapse as measured by (higher score better)
perineometer (vaginal manometer measuring strength of pelvic floor muscle
contractions, scale 01.64 cm H2O) 0.76 cm H2O vs. 0.82 cm H2O (p = 0.05)
bidigital test levator ani muscle (scale 05) 3.91 vs. 4.52 (p = 0.009)
bidigital test bulbospongiosus muscle (scale 05) 3.7 vs. 4.52 (p = 0.001)
Reference Rev Bras Fisioter 2012 Apr;16(2):102 fulltext
behavior modification to reduce symptoms may include(1, 2)
timed voiding and fluid intake alterations in women with urinary incontinence
scheduled bowel movement, splinting (manual pressure to assist with bowel movements), and
laxative or enema use in women with defecatory dysfunction
smoking cessation
avoidance of heavy lifting
weight loss and aerobic exercise
may be considered as general health recommendation, although not proven specifically
beneficial for prolapse treatment or prevention
weight loss may not reduce symptoms of pelvic organ prolapse in overweight women
(level 2 [midlevel] evidence)
based on post hoc analysis of randomized trial
338 overweight women (mean body mass index [BMI] 36 kg/m2) with urinary
incontinence were randomized to intensive weightloss program vs. educational
program (no weight loss) for 6 months with evaluation at baseline and 6 months
selfreported prolapse symptoms at baseline included
lower abdominal pressure in 37%
heaviness in pelvic area in 18%
pelvic discomfort when standing in 14%
feeling of vaginal bulge in 9%
seeing vaginal bulge in 2%
no significant difference in selfreported prolapse symptoms in either the weight loss or
16/26
controls at 6 months
Reference Female Pelvic Med Reconstr Surg 2012 JanFeb;18(1):55
Mechanical support (pessary)
Indications and efficacy
supportive or spaceoccupying vaginal device (pessary) may be used for any stage or site of pelvic organ
prolapse to reduce prolapse inside vagina, support pelvic structures, and relieve pressure on bladder and
bowel(1, 2, 3)
comprised of medicalgrade silicone or latex rubber for durability, ease of cleaning, inertness, and
reduced odor and secretion absorption
may be used in women with or without incontinence
consider pessary use
in all women with symptomatic prolapse prior to surgical intervention (1)
as alternative treatment in women with stage IIIV vaginal vault prolapse after hysterectomy
(RCOG/BSUG Grade B)(5)
considered firstline treatment for prolapse by about 75% of urogynecologists(1)
about half of patients maintain pessary use up to 1 year after fitting(1, 3)
indications for pessary use include(1, 2, 3)
pregnancyrelated prolapse
contraindications to surgery in elderly and/or debilitated patients
shortterm symptom relief prior to surgical intervention
patient preference for nonsurgical alternative
contraindications for pessary use may include(2)
arthritis
dementia
comorbidities such as pelvic inflammatory disease, vaginitis, and endometriosis
patients unlikely or unable to follow instructions for care or followup
pessary use reported to help resolve most prolapse symptoms at 2 months in women with
symptomatic pelvic organ prolapse (level 2 [midlevel] evidence)
based on case series with large treatment effect compared to natural history
100 women with symptomatic pelvic organ prolapse were fitted with a pessary and evaluated after 2
months
73% had successful 2week pessary fitting trial
comparing prolapse symptoms as baseline vs. 2 months
bulge in 90% vs. 3% (p < 0.001)
pressure in 49% vs. 3% (p < 0.001)
discharge in 12% vs. 0% (p = 0.003)
splinting in 14% vs. 0% (p = 0.001)
6 women (8%) discontinued pessary use with discontinuation associated with occult stress
incontinence (odds ratio 17.1, 95% CI 1.9206)
Reference Am J Obstet Gynecol 2004 Apr;190(4):1025, commentary can be found in J Urol 2005
Mar;173(3):942
vaginal pessary reported to reduce bladder and bowel symptoms in patients with pelvic organ
prolapse (level 3 [lacking direct] evidence)
based on case series
203 consecutive women fitted with vaginal pessary for symptomatic pelvic organ prolapse were
evaluated
153 (75%) successfully retained pessary at 2 weeks; failure to retain pessary associated with
increasing parity and hysterectomy
97 completed questionnaires at 4 months
17/26
at 4 months, pessary use associated with significant improvements in
voiding in 40%
urinary urgency in 38%
urge urinary incontinence in 29%
bowel evacuation in 28%
fecal urgency in 23%
urge fecal incontinence in 20%
Reference Obstet Gynecol 2006 Jul;108(1):93
review of pessary use can be found in Am Fam Physician 2000 May 1;61(9):2719 fulltext, correction can
be found in Am Fam Physician 2002 Jul 1;66(1):30
Pessary selection
pessary selection usually determined by severity of prolapse and patient's cognitive status, manual
dexterity, and level of sexual activity(2, 3)
considerations in pessary selection(2)
Pessary Selection Chart:
Type of Beneficial
Pessary Difficulty Inhibits Daily Risk of Additional
Prolapse Best for Urinary
Type of Use Intercourse Removal Erosion Information
Suited for Incontinence
Most commonly
Ring* All Low No No Low Minimal
used
Less effective
Ring with
All Low No No Low Minimal with severe
support*
prolapse
All, including
Incontinence
with urinary Low No No Low Yes N/A
ring*
incontinence
All, especially
Donut** advanced Moderate Yes No Low No N/A
stages (III/IV)
All, especially
advanced
stages (III/IV);
Gellhorn** High Yes No Moderate No N/A
apical
(uterine/vault
prolapse)
Preferable
over cube
as last
resort
Easy to
insert but
Advanced difficult
apical Low to retain
Inflatoball** (uterine/vault Yes Yes Low No
moderate and
prolapse) requires
inflation
Avoid in
patients
with latex
allergy 18/26
allergy
Used as last
resort due to
Advanced
daily removal,
apical
Cube** High Yes Yes High No difficulty of use,
(uterine/vault
erosion risk,
prolapse)
and associated
discharge
Used
Pregnancy
Smith midtrimester in
with uterine Low No No Low No
Hodge* symptomatic
retroversion
women
Anterior and Rarely used,
posterior may be
Gehrung* High No No Low No
vaginal wall manually
collapse shaped
Abbreviation: N/A, not applicable.
* Support pessary (includes incontinence knob).
** Spaceoccupying pessary (preferred in women with genital hiatus > 4 cm).
in women without incontinence(2, 3)
ring pessary generally considered first choice as easy to insert and remove
Gellhorn or donut pessary may be considered if ring fails
combination pessaries (ring plus Gellhorn or ring plus donut) may be considered if single pessary
fails
latex Inflatoball or cube pessary may be considered as last option if patient not allergic to latex and
has an atrophic or narrow vagina
in women with incontinence(2)
ring with support and knob (knob positioned in midline of vagina under urethra) may be considered
as initial option
Gellhorn may be considered if ring fails
combination pessaries (such as ring with support and knob pessary plus a donut) may be considered
if single pessary fails
cube pessary may be considered as last option
ring pessary with support and Gellhorn pessary may offer similar symptom relief in women with
pelvic organ prolapse (level 2 [midlevel] evidence)
based on Cochrane review with limited evidence from trial with high dropout rate
systematic review of randomized or quasirandomized trials evaluating pessaries in women with
symptomatic pelvic organ prolapse
1 randomized crossover trial comparing ring pessary with support vs. Gellhorn pessary in 134
women met inclusion criteria, no significant difference in symptoms at 3 months
Reference Cochrane Database Syst Rev 2013 Feb 28;(2):CD004010
Pessary fitting
fitting is by trial and error (successful in about 50%73% patients after 12 office visits)(1, 2, 3)
19/26
fitting procedure(2, 3)
estimate vaginal length and diameter using fingers to determine correct pessary size and shape
ring pessary should fit between pubic symphysis and posterior fornix
physician should able to sweep finger between pessary and vaginal walls
with patient doing Valsalva maneuver, ensure pessary is > 1 finger breadth above vaginal introitus
patient should attempt various activities including sitting, standing, walking, bending, and urinating
to ensure pessary is retained, comfortable, and not blocking urethra
patient should be able to insert and remove pessary as necessary(2, 3)
vaginal evisceration during pessary fitting and treatment with immediate colpocleisis in case report
(Obstet Gynecol 2010 Aug;116 Suppl 2:496)
Complications
minor complications may include(2, 3)
vaginal discharge
odor
spontaneous expulsion
irritation of vaginal wall
bleeding
pain
serious complications due to pessary neglect may include(2, 3)
vesicovaginal fistulas
rectovaginal fistulas
fecal impaction
hydronephrosis
urosepsis
protrusion of neglected pessary through the perineal skin in case report (Obstet Gynecol 2009
Aug;114(2 Pt 2):468)
Pessary followup
no clear consensus on followup time line(2, 3)
clinical exam usually occurs at 2 weeks, 3 months, 6 months, and 1 year, although some clinicians
followup every 3 months for first year then every 6 months thereafter
packaging insert generally recommends followup every 46 weeks
women who can personally insert and remove pessary may need less frequent followup
typical followup exam(2, 3)
ask patient about vaginal discharge, bleeding, pain, discomfort, or development of new prolapse
symptoms
palpate pessary in situ, then remove pessary to assess for vaginal irritation, ulceration, or erosion
if vaginal lesions are noted, pessary should be removed until lesions heal
consider reduction in pessary size and/or different pessary shape
vaginal estrogen cream may be applied to aid healing of lesions
if no vaginal lesions are noted, pessary may be washed with soap and water, dried, and reinserted
Surgery and procedures
General information
surgical correction usually delayed in premenopausal women until all anticipated childbearing has been
completed(4)
20/26
women presenting with cervical lesions or other evidence of cervical disease should be evaluated and
treated prior to prolapse repair(4)
offer surgery to women with symptomatic posthysterectomy vaginal vault prolapse(5)
surgical approach to pelvic organ prolapse is either reconstructive or obliterative(2, 3)
Overview
hysterectomy is traditional approach for women with uterine or uterine and vaginal vault prolapse, but
fails to address underlying deficiency in apical support
reconstructive surgery
goal of reconstructive surgery is correction of prolapsed vagina and relief of associated pelvic
symptoms with maintained or improved sexual function
both open abdominal sacrocolpopexy and sacrospinous colpopexy are effective for treatment of
primary vaginal vault prolapse after hysterectomy (RCOG/BSUG Grade A)(5)
vaginal procedures
accounts for 80%90% of prolapse procedures
sacrospinous hysteropexy/colpopexy (sacrospinous ligament suspension)
most commonly performed uterinesparing vaginal procedure for prolapse
sacrospinous hysteropexy for uterine prolapse associated with faster recovery but
higher risk of recurrent uterine prolapse compared to vaginal hysterectomy (level 2
[midlevel] evidence)
transvaginal uterosacral ligament suspension reported to be effective for vaginal vault
prolapse (level 3 [lacking direct] evidence)
meshbased procedures
meshaugmented sacrospinous hysteropexy/colpopexy is modification of sacrospinous
hysteropexy using mesh instead of traditional native tissue to augment repair
several mesh kits voluntarily removed from the market following the FDA's warning
regarding the use of vaginal mesh for prolapse repair
addition of mesh to vaginal prolapse repair surgery associated with reduced prolapse
recurrence but increased risk for subsequent surgery for prolapse, stress incontinence,
or mesh exposure/pain compared to native tissue repair (level 2 [midlevel] evidence)
not recommended for firstline treatment of vaginal vault prolapse after hysterectomy
(RCOG/BSUG Grade B)
consider midurethral sling surgery when using vaginal approach for treatment in women
with vaginal vault prolapse after hysterectomy(5)
abdominal approach
abdominal sacral colpopexy associated with reduced prolapse recurrence, stress urinary
incontinence, and dyspareunia compared to vaginal sacrospinous colpopexy (level 2 [mid
level] evidence)
addition of Burch colposuspension to abdominal sacral colpopexy reduces postoperative
stress urinary incontinence compared to sacral colpopexy alone up to 2 years postsurgery, but
not associated with longer term benefit (level 1 [likely reliable] evidence)
in women with vaginal vault prolapse after hysterectomy open abdominal sacrocolpopexy is
associated with lower rates of recurrent vault prolapse, dyspareunia, and postoperative stress
urinary incontinence compared to sacrospinous colpopexy in women with vaginal vault
prolapse after hysterectomy (RCOG/BSUG Grade A)(5)
abdominal sacrohysteropexy and laparoscopic sacral suture hysteropexy each reported to improve
symptoms in women with uterine prolapse (level 3 [lacking direct] evidence)
obliterative surgery
colpocleisis (colpectomy) moves pelvic organs back into pelvis with partial or total closure of
vaginal canal
usually reserved for elderly women who
21/26
are at high risk for complications with reconstructive procedures
prefer to avoid hysterectomy
do not desire to maintain vaginal use for intercourse
colpocleisis reported to have high anatomical cure rate in women with pelvic organ prolapse (level
3 [lacking direct] evidence)
see Surgical management of pelvic organ prolapse for details
Other management
Observation
consider watchful waiting in asymptomatic or mildly symptomatic women with early stage prolapse
without descent beyond hymen(1, 2, 3)
patients who are asymptomatic or mildly symptomatic may be followedup at regular intervals and annual
wellwoman physical exam until new or bothersome symptoms develop(1, 2)
Complications and Prognosis
Complications
lower urinary tract dysfunction(1, 2, 3)
stress urinary incontinence (more common with mild prolapse)
reported to affect 40% of patients
likely occurs when loss of vaginal wall support of bladder and urethra leads to urethral
hypermobility and cystocele formation
urinary outlet obstruction (more common with prolapse beyond hymen)
postvoid residual volumes > 100 mL may occur in up to 30% with severe disease (Pelvic
Organ Prolapse Quantification [POPQ] stage III or IV)
usually occurs when worsening anterior vaginal prolapse causes urethral kinking
can also occur if large posterior vaginal prolapse leads to direct pressure on urethra
higher stages of pelvic organ prolapse associated with postvoid residual volumes > 30
mL
1,140 women seen for initial urogynecological assessment due to pelvic floor
symptoms had transvaginal ultrasonography following micturition
postvoid residual of 30 mL deemed upper limit of normal
81% postvoid residual volumes were ≤ 30 mL
postvoid residual volume > 30 mL associated with
higher stage of pelvic organ prolapse (p < 0.001)
increased incidence of recurrent urinary tract infections (p < 0.001)
increase in age (p < 0.001)
hydronephrosis occurs in about 10% women with pelvic organ prolapse, but usually
resolves after treatment of the prolapse
233 patients with pelvic organ prolapse had sonographic measurement of bilateral renal
pelvis pre and posttreatment for pelvic organ prolapse
POPQ stage I/II in 67%
POPQ stage III/IV in 33%
hydronephrosis occurs in 10.3% overall
advancedstage POPQ (stage III/IV) associated with increased risk for hydronephrosis
22/26
(odds ratio 3.4, 95% CI 1.39.2)
hydronephrosis resolved in 95% of women posttreatment for pelvic organ prolapse
Reference Int Urogynecol J 2011 Dec;22(12):1529
female sexual dysfunction, including dyspareunia
some degree of sexual dysfunction reported by about onethird of women with pelvic organ
prolapse(3)
advanced pelvic organ prolapse associated with decreased arousal, less frequent orgasm, and
increased dyspareunia in women
301 women seeking gynecologic and urogynecologic outpatient services had pelvic floor
disorders assessed using POPQ exam and Pelvic Floor Distress Inventory20 (PFDI20), and
sexual function assessed by Personal Experiences Questionnaire
PFDI20 scored on 0100 scale with higher score indicating increased pelvic floor distress
among 223 patients with current sexual partner
severity of pelvic organ prolapse
stage 0 in 14%
stage I in 47%
stage II in 29%
stage III/IV in 10%
compared to stage 0, stage IIIIV pelvic organ prolapse associated with infrequent
orgasm (p = 0.02)
high PFDI20 score associated with
decreased arousal (p < 0.01)
infrequent orgasm (p < 0.01)
increased dyspareunia (p < 0.01)
no significant difference in other sexual complaints with increasing prolapse stage
Reference Obstet Gynecol 2008 May;111(5):1045 fulltext, editorial can be found in Obstet
Gynecol 2008 May;111(5):1037
advanced pelvic organ prolapse associated with worsening of scores related to body image
47 women with stage III/IV pelvic organ prolapse and 51 controls with normal pelvic floor support
without urinary incontinence completed generalized (Short Form Health Survey) and condition
specific (PFDI20) quality of life scale questionnaires
compared to controls, women with advanced pelvic organ prolapse were
more likely to feel selfconscious (adjusted odds ratio [OR] 4.7, 95% CI 1.418)
less likely to feel physically attractive (adjusted OR 11, 95% CI 2.951)
less likely to feel feminine (adjusted OR 4, 95% CI 1.215)
less likely to feel sexually attractive (adjusted OR 4.6, 95% CI 1.417)
pelvic organ prolapse associated with significantly lower quality of life on physical survey (p <
0.009), but not mental survey
Reference Am J Obstet Gynecol 2006 May;194(5):1455
Prognosis
disease regression and progression
spontaneous regression appears more common than progression in postmenopausal women
with grade 1 pelvic organ prolapse
based on secondary analysis of randomized trial
1,296 patients participating in Women's Health Initiative Estrogen plus Progestin Clinical
Trial at University of California Davis had annual pelvic exams with assessment of uterine
prolapse, cystocele, and rectocele over 28 years
412 women (31.8%) had pelvic organ prolapse at baseline
annual progression rates for grade 1 pelvic organ prolapse by site (per 100 womenyears)
23/26
9.5 for cystocele
13.5 for rectocele
1.9 for uterine prolapse
annual regression rates for grade 1 pelvic organ prolapse by site (per 100 womenyears)
23.5 for cystocele
22 for rectocele
48 for uterine prolapse
Reference Am J Obstet Gynecol 2004 Jan;190(1):27
overweight or obese weight classification associated with increased risk of prolapse
progression over 5 years
based on secondary analysis of randomized trial
16,608 postmenopausal women aged 5079 years participating in Women's Health Initiative
Estrogen plus Progestin Clinical Trial from 1993 to 1998 had annual pelvic exams with
assessment of uterine prolapse, cystocele, and rectocele
pelvic organ prolapse in 40.9% at baseline
at 5year analysis
weight gain in 55.7%
pelvic organ prolapse in 43.8%
in women with pelvic organ prolapse at baseline, overweight (body mass index [BMI] 25
29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) weight classification associated with increased risk
of progression of cystocele, rectocele, and uterine prolapse over 5 years (p < 0.05 for each)
10% weight loss associated with minimal change in pelvic organ prolapse
Reference Obstet Gynecol 2009 Jan;113(1):81 fulltext
progression reported in 1.6% of unrepaired asymptomatic stage 2 pelvic organ prolapse
during 72month followup in women with stress urinary incontinence having midurethral
sling procedure (level 2 [midlevel] evidence)
based on cohort analysis of data from randomized trial
597 women with stress urinary incontinence having 1 of 2 midurethral sling procedures in
randomized trial evaluated annually for 57 years
pelvic organ prolapse repair concomitant to sling surgery was allowed at surgeon's discretion
49% had stage 2 pelvic organ prolapse at baseline
23% reported pelvic organ prolapse symptoms, 70% of whom had concomitant pelvic
organ prolapse repair
15% of asymptomatic women had concomitant pelvic organ prolapse repair
3 of 189 women (1.6%) with asymptomatic stage 2 pelvic organ prolapse not having
concomitant prolapse repair had anatomical progression of prolapse during 72month follow
up
3 of 47 women (6.4%) with symptomatic stage 2 pelvic organ prolapse having concomitant
prolapse repair had repeat pelvic organ prolapse surgery
Reference Am J Obstet Gynecol 2014 Nov;211(5):550.e1
prognosis following surgery
persistent bowel symptoms common 1 year after rectocele repair
based on cohort analysis of randomized trial
117 women completed questionnaires at 1 year followup after rectocele repair with porcine
subintestinal submucosal graft augmentation vs. native tissue
rates of persistent bowel symptoms at 1 year after repair
manual splinting in 22.7%
straining in 36.8%
incomplete evacuation in 19%
obstructed defecation in 14.3%
longer history of splinting significantly associated with increased risk of persistent
postoperative splinting (odds ratio 2.25, 95% CI 1.024.93)
no significant risk factors determined for persistent straining, incomplete evacuation, or
obstructed defecation
24/26
Reference Am J Obstet Gynecol 2012 Nov;207(5):423.e1 fulltext
risk factors for reoperation in women with surgically treated pelvic organ prolapse may
include prolapse in > 2 vaginal compartments, history of multiple surgeries for pelvic organ
prolapse or urinary incontinence, and no posterior repair at initial surgery
102 women requiring reoperation following surgery for pelvic organ prolapse and 226
randomly selected women not requiring reoperation following surgery for pelvic organ
prolapse from the same hospital were evaluated
factors associated with increased risk of reoperation
prolapse in > 2 vaginal compartments (adjusted odds ratio [OR] 5.2, 95% CI 2.89.7)
history of surgery for pelvic organ prolapse and/or urinary incontinence (adjusted OR
3.2, 95% CI 1.57.1)
absence of posterior repair at initial surgery (adjusted OR 2.9, 95% CI 1.55.5)
no significant difference in reoperation rates by type of pelvic organ prolapse surgery
(vaginal, abdominal, or laparoscopic)
Reference Int Urogynecol J 2012 Jan;23(1):35
increasing age associated with increased mortality and complications during urogynecologic
surgery
based on retrospective cohort study
264,340 women who had urogynecologic surgery (including surgery for pelvic organ
prolapse) from 1998 to 2002 were evaluated for subsequent complications and comorbidities
compared to women < 60 years old, increasing age associated with increased
inhospital mortality in women aged
6069 years (adjusted odds ratio [OR] 3.4, 95% CI 1.76.9)
7079 years (adjusted OR 4.9, 95% CI 2.210.9)
≥ 80 years (adjusted OR 13.6, 95% CI 5.931.4)
risk of any perioperative complication in women aged ≥ 80 years (adjusted OR 1.4,
95% CI 1.31.5)
5,647 elderly women (≥ 80 years old) had surgery for pelvic organ prolapse
1,181 had obliterative surgery, 4,466 had reconstructive surgery
complications in 17% with obliterative surgery vs. 24.7% with reconstructive surgery
(p < 0.01)
Reference Am J Obstet Gynecol 2006 May;194(5):1411
Prevention and Screening
Prevention
lifestyle modification may help prevent prolapse by reducing modifiable risk factors, but no evidence
found to assess efficacy for prevention; modifications may include(3)
weight loss
avoidance of occupations with heavylifting
early treatment of constipation
maintenance and strengthening of pelvic floor muscles (Kegel exercises)
although cesarean delivery may be associated with lower risk for pelvic organ prolapse than vaginal
delivery, evidence is not sufficient to warrant use of elective cesarean delivery as a preventive strategy in
women without previous pelvic floor disorders (Curr Opin Obstet Gynecol 2012 Oct;24(5):318)
postpartum pelvic floor muscle training may not improve pelvic organ prolapse after vaginal
delivery in primiparous women (level 2 [midlevel] evidence)
based on randomized trial without attention control
175 primiparous women (mean age 30 years) who had vaginal delivery of singleton infant at > 32
weeks gestation were randomized to pelvic floor muscle training vs. no training for 4 months
beginning at 68 weeks post partum
25/26
pelvic floor muscle training consisted of weekly pelvic floor muscle training class led by
physical therapist plus daily home exercises with 3 sets of 812 pelvic floor muscle
contractions
all women were assessed at 6 months post partum
86% in pelvic floor muscle training group and 97% in control group completed trial, all patients
included in analyses
no significant differences in pelvic organ prolapse stage, bladder neck position, or vaginal bulging
symptoms between groups
Reference Am J Obstet Gynecol 2015 Jan;212(1):38.e1
Royal College of Obstetricians and Gynaecologists and British Society of Urogynaecology
recommendations on prevention of vaginal vault prolapse after hysterectomy
McCall culdoplasty during hysterectomy effectively prevents subsequent posthysterectomy vaginal
vault prolapse (RCOG/BSUG Grade B )
suturing the cardinal and uterosacral ligaments to the vaginal cuff during hysterectomy effectively
prevents vaginal vault prolapse after abdominal and vaginal hysterectomies (RCOG/BSUG Grade B
)
consider sacrospinous colpopexy during vaginal hysterectomy when vault descends to introitus
during closure (RCOG/BSUG Grade C )
subtotal hysterectomy is not recommended for prevention of vaginal vault prolapse after
hysterectomy (RCOG/BSUG Grade A )
Reference RCOG 2015 PDF
see Surgical management of pelvic organ prolapse for additional information
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19/6/2016 DynaMed Plus: Pelvic organ prolapse

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