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Uterine and Pelvic Organ Prolapse

Deepali Maheshwari, DO, MPH
Lauren Simms, MD

BASICS

DESCRIPTION

Symptomatic descent of one or more of the following: - Anterior vaginal wall (bladder or cystocele) - Posterior vaginal wall (rectum or rectocele) - Uterus and cervix - Vaginal apex (vault) Prolapse above or to the level of the hymen is generally not symptomatic. Associated symptoms: - Pelvic pressure or heaviness - Vaginal bulge - Bowel or bladder symptoms Cost associated with treatment is >$1 billion annually (~200,000 surgeries/year).

EPIDEMIOLOGY

Incidence

  • POP: 1.5–1.8 per 1,000 woman-years, peaking at age 60–69 years
  • ~300,000 surgeries per year in US
  • Lifetime risk of surgery: ~13%

Prevalence

  • ~50% of women will develop prolapse
  • Only 10–20% seek care

ETIOLOGY AND PATHOPHYSIOLOGY

  • Support from pelvic attachments and levator ani muscle complex
  • Multicompartment defects common
  • Begins gradually, often asymptomatic early

RISK FACTORS

  • Vaginal childbirth (each additional increases risk)
  • Age
  • Family history
  • Race: higher in White and Hispanic women
  • Obesity (BMI >30)
  • Chronic straining (constipation, cough, heavy lifting)
  • History of hysterectomy

GENERAL PREVENTION

  • Pelvic floor muscle training
  • Weight loss
  • Treat constipation and other causes of intra-abdominal pressure

COMMONLY ASSOCIATED CONDITIONS

  • Constipation
  • Fecal/urinary incontinence
  • Urgency, frequency, retention

DIAGNOSIS

HISTORY

  • Symptoms: bulge, "something falling out", pressure, splinting, incontinence, urgency
  • Document severity, duration, sexual impact, QoL
  • PMH: parity, constipation, pulmonary disease, pelvic procedures

PHYSICAL EXAM

  • Abdominal + pelvic exam
  • Valsalva in supine + standing
  • Use POP-Q system:
    • Stage 1: ≥1 cm above hymen
    • Stage 2: within ±1 cm of hymen
    • Stage 3: ≥1 cm below hymen
    • Stage 4: complete procidentia
  • Use split speculum to assess compartments

DIFFERENTIAL DIAGNOSIS

  • Rectal prolapse
  • Hemorrhoids
  • Bartholin/vaginal cyst
  • Urethral diverticulum
  • Cervical elongation

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests

  • Urinalysis, Postvoid residual

Follow-Up/Advanced

  • Urodynamics if affecting management
  • Upper tract imaging if obstruction suspected
  • Defecography if symptoms >> findings

TREATMENT

GENERAL MEASURES

  • Guided by patient bother and desire
  • Expectant management:
    • Stage 1/2: observe
    • Stage 3/4: regular follow-up (3–6 months)

PESSARY

  • Offered to all symptomatic women

  • 13 types; common: ring, Gellhorn

  • High satisfaction rate
  • Minor side effects: discharge, odor → treat with vaginal estrogen

MEDICATIONS

  • No proven meds for prevention/treatment
  • Manage constipation aggressively

REFERRAL

  • When pessary or surgery needed

ADDITIONAL THERAPIES

  • Pelvic floor physical therapy

SURGICAL OPTIONS

  • Goals: restore anatomy, relieve symptoms
  • Approaches: vaginal, abdominal, laparoscopic, robotic
  • Native tissue repairs: higher recurrence
  • Mesh/graft: higher success, risk of complications Apical repair options:
  • Sacral colpopexy: best long-term results
  • Often with hysterectomy, but hysteropexy an option Address SUI during prolapse surgery

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Pessary:
    • Recheck in 7–14 days, then individually tailored
    • Clean regularly with soap/water
  • Surgery: follow-up by surgeon

PATIENT EDUCATION

  • Explain anatomy, options with diagrams
  • Emphasize QoL improvement focus
  • Educate on pessary risks and POP symptoms

COMPLICATIONS

  • Recurrence: 3.4%–29.2%
  • Dyspareunia, pelvic pain, mesh erosion
  • Urinary retention, defecatory dysfunction in elderly
  • Vaginal erosion, fistula in neglected pessary cases

REFERENCES

  1. Raju R, Linder BJ. Mayo Clin Proc 2021;96(12):3122-3129.
  2. Dumoulin C, et al. Neurourol Urodyn 2016;35(1):15-20.
  3. Hagen S, Stark D. Cochrane Database Syst Rev 2011;(12):CD003882.

ADDITIONAL READING

  • Baessler K, et al. Cochrane Database Syst Rev 2018;8(8):CD013108.
  • Larouche M, et al. Obstet Gynecol 2021;137(6):1061–1073.

CODES

  • ICD10:
    • N81.9 Female genital prolapse, unspecified
    • N81.10 Cystocele, unspecified
    • N99.3 Vaginal vault prolapse post-hysterectomy

CLINICAL PEARLS

  • Ask about POP—many women don't volunteer symptoms
  • Pessary is a viable option for all symptomatic women
  • Guide treatment by degree of bother and QoL impact