Pelvic organ prolapse

Last updated: December 1, 2021

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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.

  • Anatomical overview: The pelvic floor is supported by a continuous endopelvic fascia, which consists of:
  • Definition: herniation into or descent of pelvic organs to or beyond the vaginal walls
    • Partial/subtotal prolapse: pelvic organs are only partially outside the vaginal opening.
    • Total prolapse: pelvic organs are everted and located outside of the vaginal opening.
  • Specific sites
    • Vaginal wall prolapse
    • Uterine prolapse: descent of the uterus
    • Vaginal vault prolapse: descent of the apex of the vagina
    • Apical compartment prolapse: herniated uterus, cervix, or vaginal vault
    • Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus
  • POP is a common disorder in older women.

Epidemiological data refers to the US, unless otherwise specified.

Risk factors [1]

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:

Patients with POP may present with concurrent complications.

  • Usually a clinical diagnosis relying on the Pelvic Organ Prolapse Quantitation system (POP-Q) [2][3]
    • 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.

Elongation of the cervix

Urethral diverticulum [4]

Pelvic floor dysfunction [5]

The differential diagnoses listed here are not exhaustive.

Conservative treatment [2]

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)

Surgery [6]

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

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

  1. Aboseif C, Liu P. Pelvic Organ Prolapse. StatPearls. 2021 .
  2. Iglesia et al.. Pelvic Organ Prolapse. American Family Physician. 2017; 96 (3).
  3. Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP–Q) – a new era in pelvic prolapse staging. J Med Life. 2011; 4 (1): p.75-81.
  4. Quiroz LH AND Gutman RE. Urethral diverticulum in women. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. updated: June 4, 2020. Accessed: August 20, 2020.
  5. Grimes WR, Stratton M. Pelvic Floor Dysfunction. StatPearls. 2021 .
  6. Surgery for Pelvic Organ Prolapse. Updated: December 1, 2013. Accessed: November 5, 2017.
  7. Jundt K, Wagner S, von Bodungen V, Friese K, Peschers U. Occult incontinence in women with pelvic organ prolapse - does it matter?. Eur J Med Res. 2010; 15 (3): p.112. doi: 10.1186/2047-783x-15-3-112 . | Open in Read by QxMD
  8. Archer R, Blackman J, Stott M, Barrington J. Urethral diverticulum. The Obstetrician & Gynaecologist. 2015; 17 (2): p.125-129. doi: 10.1111/tog.12192 . | Open in Read by QxMD

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