Pelvic Organ Prolapse | Vaginal Prolapse

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Introduction

Pelvic organ prolapse (POP) is defined as the descent of one or more pelvic organs beyond their normal anatomical confines due to weakening or failure of the supporting structures of the pelvic floor. It may involve the bladder, urethra, uterus, vaginal vault, rectum, or small bowel. POP predominantly affects women following childbirth, during menopause, or with advancing age, and it can markedly impair quality of life.

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Aetiology

POP results from the failure of muscular, fascial, and neural elements of the pelvic floor. Its aetiology is multifactorial, involving mechanical trauma, connective tissue remodelling, hormonal changes, and chronic increases in intra-abdominal pressure.^1-3

Contributing factors include:

• Childbirth: vaginal deliveries, particularly those involving forceps, vacuum extraction, large babies, or prolonged second stage of labour, may cause direct injury or denervation of the pelvic floor
• Ageing: degenerative changes in collagen and elastin reduce tissue elasticity and strength
• Hormonal influences: oestrogen deficiency post-menopause leads to thinning and atrophy of the pelvic tissue
• Congenital factors: abnormal collagen metabolism (e.g. Ehlers-Danlos Syndrome)
• Increased intra-abdominal pressure: chronic coughing (e.g. chronic obstructive pulmonary disease, asthma), constipation, heavy lifting, or obesity contribute to pelvic floor strain
• Iatrogenic factors: pelvic surgery, such as hysterectomy or continence procedures (e.g. Burch colposuspension), may alter pelvic support and predispose to vault prolapse or enterocoele

Anatomy

Pelvic cavity

The pelvic cavity contains the bladder, uterus, rectum, and small bowels. The cavity is supported by muscular and fascial components of the pelvic floor. Their spatial relationships are important to recognise the pathophysiology of pelvic organ prolapse:

• Bladder: lies anteriorly, supported by the anterior vaginal wall and pubocervical fascia
• Uterus: occupies a central position, suspended by the uterosacral, pubocervical, and cardinal ligaments, which provide apical support to the uterus and upper vagina
• Rectum: located posteriorly, supported by the rectovaginal fascia, perineal body, and levator ani muscles
• Small intestine: normally lies superior to the pelvic cavity; loops may herniate into the upper vaginal canal in cases of enterocoele^1-2

Pelvic floor

The pelvic floor consists of muscles and connective tissues that support the pelvic viscera and maintain continence. The uterus and vagina are supported at three key levels:

• Level 1: upper vagina and cervix – supported by the uterosacral and cardinal ligaments
• Level 2: mid-vagina – laterally attached to the pelvic sidewalls via the endopelvic fascia
• Level 3: lower vagina – supported by the levator ani muscles and perineal body (pelvic diaphragm)²

Damage at any of these levels produces distinct types of prolapse.

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Clinical features

History

A thorough gynaecology history should explore the onset, severity, and impact of symptoms. A validated pelvic floor questionnaire can also be used to aid assessment and guide clinical decision-making.

Typical symptoms of POP include:

• Pelvic pressure or heaviness: a persistent feeling of fullness or pressure in the pelvic region, often described as a sensation of ‘dragging’, ‘bearing down’, or ‘lump coming down’
• Vaginal bulging: a visible or palpable bulge in the vaginal canal, which may become more pronounced with standing or physical activity
• Urinary symptoms: urgency, stress incontinence, incomplete emptying, urinary retention or reduced flow
• Bowel symptoms: constipation or difficulty with defecation
• Sexual dysfunction: dyspareunia or reduced sexual satisfaction
• Backache: chronic lower back pain may be associated with altered posture and pelvic biomechanics
• Vaginal bleeding and discharge: in advanced prolapse (stage 3 or 4) due to mucosal ulceration and lichenification^1-3

Symptoms often worsen on prolonged standing and towards the end of the day.

Clinical examination

An abdominal examination should be performed initially to exclude a pelvic mass.

A vaginal and speculum examination can confirm the diagnosis, identify the compartment(s) involved, and assess severity, including assessment of vaginal wall descent at rest and during the Valsalva manoeuvre.

A digital rectal examination may be performed to assess anal sphincter tone and the presence of rectal prolapse if bowel symptoms are present.

Additional specialist assessments may be warranted in specific cases:

• Pelvic floor muscle assessment: evaluates tone and strength to determine suitability for physiotherapy
• Assessment of vaginal atrophy: particularly in post-menopausal women^1-4

Re-examination and further testing should be considered in the presence of significant urinary symptoms, obstructed defaecation, faecal incontinence, or unexplained pelvic pain.

Classification of prolapse

POP is classified based on the compartment or organ involved:

• Cystocele: prolapse of the bladder into the anterior wall of the vagina
• Urethrocele: prolapse of the lower anterior vaginal wall involving the urethra alone
• Uterine (apical): prolapse of the uterus, cervix, and upper vagina. If the uterus has been removed, the vault or top of the vagina, where the uterus used to be, can still experience prolapse (known as vault prolapse).
• Enterocele: prolapse of the upper posterior wall of the vagina, with the resulting pouch usually containing loops of small bowel
• Rectocele: prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum^1-4

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Differential diagnoses

Conditions that may present with similar symptoms to POP include:

• Uterine fibroids: noncancerous growths in the uterus that may cause pelvic pressure and abnormal bleeding
• Endometriosis: presence of endometrial tissue outside the uterus, which can cause pelvic pain
• Gynaecological malignancies: such as cervical or uterine cancer, which can present with pelvic masses, abnormal bleeding, or discomfort
• Vaginal cysts: fluid-filled sacs that may cause a bulge or discomfort in the vaginal area

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Investigations

A structured approach to investigation ensures accurate diagnosis, exclusion of alternative causes, and appropriate management planning.^1-6

Bedside investigations

Relevant bedside investigations include:

• Urinalysis: to detect urinary tract infection or haematuria, both of which may exacerbate lower urinary tract symptoms
• Microbiological testing: if recurrent urinary tract infections or discharge are present
• Post-void residual volume: if symptoms of voiding dysfunction are present, preferably assessed using a bladder scan rather than catherisation

Laboratory investigations

Laboratory testing is not routinely required but may assist in preoperative evaluation or in excluding systemic disease.

Relevant laboratory investigations include:

Imaging

Imaging is generally unnecessary when the diagnosis is confirmed on physical examination. However, it may be indicated when symptoms persist without a clear explanation or when secondary pathology is suspected.

Relevant imaging includes:

• Pelvic ultrasound: to evaluate the uterus, adnexa, and pelvic or abdominal masses
• Ultrasound of the kidneys, ureters, and bladder: to assess for obstructive uropathy secondary to pelvic floor prolapse
• MRI pelvis: for complex or recurrent cases to delineate soft tissue defects and guide surgical planning

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Management

The management of POP should be individualised based on symptom severity, prolapse stage, patient comorbidities, and reproductive intentions.^{1-4, 7}

For women planning future pregnancies, a multidisciplinary team should be involved, including specialists in urogynaecology and pelvic floor physiotherapy.

Conservative management

Conservative management may include:

• Lifestyle modifications: encourage weight reduction (if BMI ≥30 kg/m²), smoking cessation, management of constipation, and avoidance of heavy lifting
• Pelvic floor muscle training: a supervised 16-week programme is recommended first-line for symptomatic POP-Q stage 1 or 2 prolapse
• Intravaginal devices (pessaries): provide mechanical support and symptom relief; regular review is required to prevent complications such as ulceration or infection. Used in those who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated

Medical management

Medical management may include:

• Topical oestrogen therapy: may be beneficial in post-menopausal women with genitourinary symptoms or vaginal atrophy to enhance tissue integrity

Surgical management

Surgery is indicated in symptomatic patients refractory to conservative measures or in those seeking definitive repair, with the technique dependent on the type of prolapse.

A decision aid should be used to discuss surgical options, their benefits, risks, potential changes in urinary, bowel, and sexual function, recurrence risk, and other details.

Uterine prolapse

Surgical options include:

• Vaginal sacrospinous hysteropexy: cervix is attached to a pelvic ligament
• Vaginal hysterectomy: with or without sacrospinous fixation, suitable for women not requiring uterine preservation
• Sacro-hysteropexy: mesh is used to attach the uterus to the sacrum to restore apical support
• Manchester repair: the neck of the cervix is shortened to support the uterus in its natural position (rare)

Vault prolapse

Surgical options include:

• Vaginal sacrospinous fixation: the cervix is stitched to the sacrospinous ligaments in the pelvis
• Sacrocolpopexy: the vagina is attached to the sacrum using a plastic mesh
• Colpocleisis: the vaginal canal is sutured closed; considered for women who do not intend to have penetrative vaginal sex or those who are at increased risk of operative and postoperative complications

Anterior prolapse

Surgical options include:

• Anterior colporrhaphy: reinforcement of the anterior vaginal wall with stitches

Posterior prolapse

Surgical options include:

• Posterior colpoperineorrhaphy: reinforcement of the posterior vaginal wall and perineum with stitches

Follow-up and prevention

Postoperative review, typically at six months, should assess anatomical correction, mesh integrity (if applicable), and symptom resolution.

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Complications

While most women experience symptom improvement following treatment, both conservative and surgical approaches carry potential risks.

Complications may arise from the underlying condition, therapeutic intervention, or postoperative healing, including:

• Recurrent prolapse: occurs in approximately 1/3 of cases following surgical repair
• Urinary tract infections: may result from altered urinary flow or incomplete bladder emptying
• Sexual dysfunction: dyspareunia or reduced sexual satisfaction can occur after prolapse or corrective surgery
• Pelvic pain: persistent discomfort may reflect scarring, mesh-related issues, or altered pelvic floor dynamics
• Mesh-related symptoms: pain or sensory changes in the back, abdomen, pelvis, vagina, leg, groin, or perineum; vaginal symptoms such as discharge, bleeding, or dyspareunia; urinary symptoms including incontinence, retention, or dysuria; and bowel symptoms such as dyschezia or faecal incontinence^1-4

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Reviewer

Dr Qiu Ju Ng

Gynaecological Oncology Subspecialty Trainee

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Editor

Dr Jamie Scriven

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References

1. Collins S, Arulkumaran S, Hayes K, et al. Oxford Handbook of Obstetrics and Gynaecology. United Kingdom: Oxford University Press. 2013.
2. Rogers R, Fashokun T. Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management. UpToDate. 2024. Available from: [LINK].
3. Jelovsek, J. Pelvic organ prolapse in women: Choosing a primary surgical procedure. UpToDate. 2024. Available from: [LINK].
4. NICE NG123. Urinary incontinence and pelvic organ prolapse in women: management. 2019. Available from: [LINK].
5. Persu C, Chapple CR, Cauni V, et al. Pelvic Organ Prolapse Quantification System (POP-Q) – a new era in pelvic prolapse staging. Journal of Medicine and Life. 2011. Available from: [LINK].
6. Fashokun T, Rogers R. Pelvic organ prolapse in females: Diagnostic evaluation. UpToDate. 2024. Available from: [LINK].
7. Tan KT, Ng QJ, and Tan TC. Practical Obstetrics and Gynaecology Handbook for O&G Clinicians and General Practitioners. 3rd ed. World Scientific Publishing Company. 2024. Available from: [LINK].

Image references

• Figure 2. Openstax. Muscles of the female perineum. Licence: [CC BY 3.0]. Available from: [LINK].

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