• Clinical science

Pelvic organ prolapse


Pelvic organ prolapse (POP or female genital prolapse) is the protrusion of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault due to decreased pelvic floor support. It is commonly seen in women of advanced age. Other risk factors include multiparity (particularly vaginal births), prior pelvic surgery, connective tissue disorders, and increased intra-abdominal pressure secondary to obesity or chronic constipation. Patients present with a sensation of vaginal pressure, discomfort, and/or pain. The protruded pelvic organ is visualized and assessed during inspection. Low-grade prolapse can be managed conservatively with pelvic floor (Kegel) exercises or a vaginal pessary to support the pelvic floor. Pelvic floor repair surgery is indicated for women with symptomatic prolapse who do not respond to or decline conservative management. Complications include urinary or fecal retention or incontinence, abdominal/pelvic pain, and avoidance of sexual activity because of embarrassment or discomfort.




  • POP is a common disorder in older women.


Epidemiological data refers to the US, unless otherwise specified.


Risk factors

POP is due to an insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina , which may be caused by:


Clinical features

  • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)
  • Lower back and pelvic pain (may become worse with prolonged standing or walking)
  • Rectal fullness, constipation, incomplete rectal emptying
  • Prolapse of the anterior (in cystocele/urethrocele); or the posterior (in enterocele/rectocele) vaginal wall, possibly with excessive vaginal discharge on inspection; , bimanual examination, and speculum examination of the patient in lithotomy position; occurs at rest and with increased abdominal pressure
  • Weakened pelvic floor muscle and anal sphincter tone

Patients with POP may present with concurrent complications!



  • Usually a clinical diagnosis relying on the Pelvic Organ Prolapse Quantitation system (POP-Q)
    • Stage 0: no prolapse
    • Stage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen.
    • Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.
    • Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.
    • Stage 4: The vagina is completely everted or uterine procidentia has occurred.


Differential diagnoses

Elongation of the cervix

  • An elongated cervix can be mistaken for a prolapse.
  • Evaluated during pelvic examination

Urethral diverticulum [5]

  • Definition: a distinct outpouching of the urethral mucosa most often located posterolaterally in the mid and distal two-thirds of the urethra
  • Epidemiology
    • Rare
    • Most commonly occurs in women (20–60 years of age)
  • Etiology
    • Acquired (most common)
      • Recurrent infection of the periurethral glands
      • Pelvic trauma (particularly involving the vagina, bladder, or urethra)
      • Gynecological surgery, periurethral procedures
      • Vaginal delivery
    • Congenital
  • Clinical features
  • Diagnostics
  • Treatment
    • Conservative management
      • Indicated for individuals with minor symptoms
      • Manual compression of the suburethral mass after voiding
    • Surgery
      • Indicated for individuals with persistent symptoms, urinary calculi in the diverticulum, or suspicion of malignancy
      • Transvaginal diverticulectomy: is a preferred procedure

The differential diagnoses listed here are not exhaustive.


Conservative treatment

First-line treatment for all cases of POP. May be definitive treatment for patients with manageable symptoms (low-grade POP) who would like to avoid complications of surgery or patients at high risk of surgical complications.

  • Insertion of a vaginal pessary to support the pelvic organs
    • A silicone or latex device that is inserted into the vagina
    • Pessary insertion is not a long-term treatment!
  • Reduction of modifiable risk factors (e.g., avoid smoking to prevent a chronic cough, weight loss, prevent constipation)
  • Kegel exercises: pelvic floor muscle training (also as a preventive measure)


Indicated for symptomatic prolapse if conservative treatment fails or the patient declines it.

  • Obliterative surgery: vagina is closed off or narrowed to provide more support for pelvic organs.
  • Reconstructive surgery (abdominal or vaginal approach): to restore the original position of the descended pelvic organs




We list the most important complications. The selection is not exhaustive.