creation date: 2026-01-26 17:14
tags: Pathologies
Pelvic Organ Prolapse
Background
Definitions
Pelvic organ prolapse (POP) refers to the herniation of the pelvic organs to or beyond the vaginal walls.
Further terminology can be used to describe the site of prolapse:
- Anterior compartment prolapse: herniation of anterior vaginal wall, associated with descent of bladder (cystocele)
- Posterior compartment prolapse: herniation of posterior vaginal segment, associated with descent of rectum (rectocele)
- Enterocele: herniation of the intestines to or through the vaginal wall
- Apical compartment prolapse: descent of the apex of the vagina into the lower vagina, to the hymen, or beyond the vaginal introitus; apex can refer to uterus and cervix, cervix alone, or vaginal vault, depending on hysterectomy status.
- Uterine procidentia: hernia of all three compartments through the vaginal introitus
Anatomy and Pathophysiology
Pelvic organ support is provided by the pelvic floor muscles and connective tissues to the bony pelvis.
Normal vaginal support consist of:
- Uterosacral/cardinal ligament complex: suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall
- Paravaginal attachments along length of vagina to the superior fascia of the levator ani muscle and arcus tendineus fascia pelvis which prevents anterior wall prolapse
- Perineal body, perineal membrane, and superficial and deep perineal muscles which supports the distal third of the vagina and prevents posterior compartment prolapse.
Loss of vaginal support through loss of muscle stretch or mediated by lower concentration of estrogen/estrogen receptors results in their respective prolapse.
Etiology and Risk Factors
Risk factors for pelvic organ prolapse are:
- Parity (risk increases with increasing parity)
- Advancing age (40% increase in risk every additional 10 years of age)
- Menopause (estrogen mediated)
- Obesity
- Hysterectomy
Other possible risk factors include:
- Race/ethnicity (higher risk in Latina and White women)
- Elevated intraabdominal pressure (eg. chronic constipation)
- Collagen abnormality
- Family history
Clinical Presentation
Signs & Symptoms
Many women with prolapse are asymptomatic.
Symptoms include:
- Vaginal or pelvic pressure
- Sensation of vaginal bulge or something falling out of the vagina
- Urinary symptoms (if bladder or urethra is affected)
- Defecatory symptoms (fecal urgency, incontinence, and obstructive symptoms)
History & Physical Exam
History should include symptoms specific to prolapse as well as associated systems.
- Urinary
- Defecatory
- Sexual
Examination should include:
- Speculum exam
- Bimanual pelvic exam
- Rectovaginal examination
- Neuromuscular examination
The POP-Q system can be used to describe the site of prolapse and severity as well as diagnosis.
Diagnosis
Criteria
Diagnosis is made clinically with the aid of the POP-Q system.
Work-up
Workup beyond history and physical is generally unnecessary. However, MRI or perineal ultrasound may be indicated for evaluation of specific pelvic support defects.
Differential
Symptoms of vaginal bulging or pelvic pressure may be due to other pelvic mass. Urinary and bowel symptoms have their own respective differential.
Red Flags / Complications
Complications include urinary and bowel symptoms which can significantly affect quality of life.
Management
Management is indicated for symptomatic women regardless of degree of prolapse.
Expectant/Conservative Management
If the symptoms are tolerable or the patient prefers conservative therapy, they can choose to avoid treatment.
Conservative management options are first line although many patients will prefer surgery eventually due to its definitive nature.
- Vaginal pessary (silicone devices to support pelvic organs)
- Pelvic floor muscle exercises
- Estrogen therapy (unclear evidence)
Surgical
Surgical candidates include women with symptomatic prolapse who have failed or declined conservative management.
A number of surgical options are available and require referral to surgery. Note that surgery is associated with recurrence/reoperation rate of up to 30% after initial surgery.