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.
- Definition: herniation into or descent of pelvic organs to or beyond the vaginal walls
- Anatomical overview: The pelvic floor is supported by a continuous endopelvic fascia, which consists of:
Vaginal wall prolapse
- Anterior vaginal wall prolapse: herniated anterior vaginal wall, which is often associated with a cystocele (descent of the bladder) or urethrocele (descent of the urethra); can be due to weakness of the pubocervical fascia
- Posterior vaginal wall prolapse: herniated posterior vaginal wall, which is associated with a rectocele (descent of the rectum) or enterocele (herniated section of the intestines); can be due to weakness of the rectovaginal fascia
- 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
- Vaginal wall prolapse
- POP is a common disorder in older women.
Epidemiological data refers to the US, unless otherwise specified.
- Etiology: : insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina
Risk factors: 
- Multiple vaginal deliveries and/or traumatic births (greatest risk factor)
- Low estrogen levels (e.g., during menopause)
- Increased intraabdominal pressure (due to, e.g., obesity, cough related to chronic lung disease and/or smoking, ascites, pelvic tumors, constipation)
- Previous pelvic surgery (e.g., hysterectomy)
- Connective tissue disorders (e.g., Ehlers-Danlos syndrome)
- Diabetes mellitus
- 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 (most common) or the posterior vaginal wall
- Weakened pelvic floor muscle and anal sphincter tone
Patients with POP may present with concurrent complications.
- 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 
- Definition: a distinct outpouching of the urethral mucosa most often located posterolaterally in the mid and distal two-thirds of the urethra
- Most commonly occurs in women (20–60 years of age)
- Clinical features
- Skene duct cyst
Pelvic floor dysfunction 
- Definition: inability to relax and coordinate pelvic floor muscles correctly in order to urinate and/or have bowel movements
- Risk factors: See “Etiology” above.
- Clinical features
The differential diagnoses listed here are not exhaustive.
General principles 
- All patients: : assess and address risk factors (e.g., through lifestyle modifications such as weight loss and smoking cessation)
- No treatment is required.
- Pelvic floor muscle training may be considered.
- Symptomatic POP: conservative treatment or surgery
First-line treatment for all patients with symptomatic POP.
- Vaginal pessary
- Kegel exercises: pelvic floor muscle training (also as a preventive measure)
Pessaries should be removed and cleaned regularly to prevent the development of vaginal pressure ulcers.
- Obliterative surgery: colpocleisis, a procedure that involves sewing the walls of the vagina together to provide support for pelvic organs.
Reconstructive surgery (abdominal or vaginal approach): to restore the original position of the descended pelvic organs
- Sacrocolpopexy (with vaginal vault suspension and hysterectomy): repair of apical or vaginal vault prolapse by hysterectomy and fixation of the vaginal apex to the sacrum
- Suspension techniques: fixation or suspension of the prolapsed organ by using native tissues such as endopelvic fascia, iliococcygeus muscle, uterosacral ligament, or sacrospinous ligaments
- Colporrhaphy: reinforcement of the anterior or posterior vaginal wall for the repair of cystocele or rectocele
- Sacrohysteropexy: fixation of the cervix to the sacrum for the repair of uterine prolapse
Urinary disorders 
- "Masked" urinary incontinence
- Pressure ulcers with hemorrhage
- Ascending infections (e.g., cystitis, pyelonephritis, vaginal and cervical infections, endometritis, salpingitis/adnexitis)
- Sexual dysfunction
- Surgical complications (e.g., recurrence)
We list the most important complications. The selection is not exhaustive.