Approach

Pelvic organ prolapse (POP) is, as a rule, not an emergency, unless it has caused acute urinary retention. In this case, an indwelling Foley catheter should be placed until the prolapse can be addressed. Treatment options should be discussed with the patient and the intervention strategy should be tailored to take into account the patient’s symptoms, pelvic floor anatomy, findings of further investigations if indicated, and the patient’s preference.[28]​ All patients should be offered conservative (nonsurgical) management options; surgical treatment can be offered to women with symptomatic POP who have not responded to or declined nonsurgical approaches.[22][36]

Asymptomatic patients

Asymptomatic patients, or women who have a few minor symptoms but sufficient bladder emptying and normal renal function, may report little or no inconvenience as a result of the disorder. Observation or watchful waiting is appropriate for these women, with education to ensure they understand the possible relationship between prolapse and voiding or defecatory dysfunction.[22]​

Pelvic floor muscle (PFM) training can be offered, despite the lack of quality data supporting its use to prevent progression.[37][38]​​ Cumulative data show PFM training has a significant effect on POP stage and PFM morphology.[37] Several studies have demonstrated that PFM training for prolapse is effective in improving prolapse symptoms.[37][39][40]​ Supervised and more intensive training is more effective than unsupervised training. More high-quality randomized controlled trials are needed to further evaluate the effect of PFM strengthening on POP.[37]​​[38][41]

Conservative management in symptomatic patients

Mechanical supports, such as vaginal pessaries, are used to restore the prolapsed organs to their normal position and, thereby, relieve symptoms.[36][42]​​​​​​​​ A wide range of pessaries are available for prolapse treatment. Pessaries are held in place by the pelvic floor musculature; they are made of medical-grade silicone. This treatment can be offered to women with symptomatic POP who decline surgery, are poor surgical candidates because of medical comorbidities, plan further pregnancies in the future, or need temporary relief of pregnancy-related prolapse or incontinence.

Fitting is by trial and error and affected by clinician experience, whether the woman wants to be sexually active, and which type of pessary is retained, comfortable, and enables the woman to pass urine with the pessary in place. Regular follow-up and adherence to pessary care instructions are important. Pessaries have high satisfaction rates and low complication rates.​​[42]

If vaginal erosion develops in a woman with a pessary, the pessary should be removed and vaginal estrogen cream applied until the erosion is healed. Resolution may occur without local estrogen therapy. The pessary can then be replaced, although a different pessary could be considered.[22]

Surgery

Surgery is indicated if troublesome symptoms persist despite conservative management.[28] Treatment goals must focus on restoration of urinary, defecatory, and sexual function. The surgical approach can be reconstructive versus obliterative, abdominal versus vaginal, or open versus minimally invasive. The type of surgery should be individualized, according to the surgeon’s expertize and patient's preferences, lifestyle, concomitant disease, and age. Several other factors must also be considered when counseling patients about the choice of surgical treatment:

  • Durability

  • Recovery time

  • Immediate and delayed postoperative complications

  • Reoperation rate

  • Concurrent stress urinary incontinence

  • Risk of foreign body: erosions, wound granulation, and dyspareunia may occur after vaginal prolapse repair with graft materials; the incidence of these complications varies widely across studies[43]

  • Desire for future fertility or vaginal intercourse. Most experts prefer to defer POP surgery until childbearing is complete; in the US, the uterus is removed during almost all primary POP procedures.

Perioperative behavioral therapy may be performed, although it does not affect surgical outcomes.[44]​ Other interventions, such as bowel preparation and ureteral stent insertion, have not been shown to reduce operative complications.[45]

Reconstructive versus obliterative surgery

  • Reconstructive procedures to restore the prolapsed uterus and normal anatomy (e.g., sacrocolpopexy, sacrohysteropexy, uterosacral ligament suspension, sacrospinous ligament fixation, and colporrhaphy) are offered to all symptomatic patients and are recommended for those who would like to maintain sexual activity, because obliterative procedures (e.g., colpocleisis or colpectomy) narrow or partially close the vaginal space.

  • Simple hysterectomy, without reconstruction of the support abnormalities in the vaginal apex, is insufficient for symptom resolution. Vaginal apex suspension should be performed at the same time as hysterectomy, to reduce the risk of recurrent prolapse.[22]​​

  • Sacrospinous ligament fixation procedures, including sacrospinous hysteropexy, and uterosacral ligament suspension, with or without hysterectomy, have the same advantages for treatment of vaginal apical prolapse.[22][46][47][48]​​​ Native tissue repair is performed vaginally. If minimizing adverse events or reoperation is the priority, a vaginal approach with native tissue repair is recommended.[49]

  • Sacrocolpopexy, to treat vaginal vault prolapse, can be performed through an open abdominal or minimally invasive laparoscopic approach, with or without robotic assistance.[50][51]​​[52]

  • Robot-assisted sacrocolpopexy shows a cure rate ranging from 84% to 100%; surgery-related outcomes improve with increased experience.[52] One trial that assessed the cost-effectiveness and rehospitalization (within 6 weeks) of laparoscopic sacrocolpopexy compared with robotic sacrocolpopexy found similar outcomes and complication rates in both groups.[53]

  • Sacrocolpopexy may be performed with a synthetic mesh or a biologic graft.

  • Sacrohysteropexy (abdominal or laparoscopic), with synthetic mesh, is an alternative treatment for women who do not wish to have hysterectomy.

  • Concomitant anterior and/or posterior vaginal surgery (for example, with colporrhaphy) should not be routinely considered but based on anatomic defects after repair of the apex.[54][55]

  • Obliterative surgery, such as partial (Le Fort) colpocleisis and total colpectomy, can be offered to patients who are at high risk of complications (e.g., those with severe systemic disease or older patients who are not sexually active and prefer to avoid more aggressive surgery) and/or do not wish to maintain vaginal patency. A review of colpocleisis reported a success rate of almost 100%.[56]

Complications

  • Possible complications of POP surgery include intraoperative hemorrhage, bladder injury, rectal or small bowel injury, and severe gluteal pain radiating down the posterior leg due to sciatic nerve entrapment.

  • Presacral bleeding, although uncommon, is the most concerning intraoperative complication associated with both laparoscopic and open types of sacrocolpopexy and can have life-threatening consequences. Complications associated with open sacrocolpopexy include cystotomy (3.1%), enterotomy (1.6%), incisional problems (4.6%), ileus (3.6%), thromboembolic event (3.3%), and transfusion (4.4%).[57][58]​​[59]

  • Currently, there are no available Food and Drug Administration (FDA)-approved transvaginal mesh products for the treatment of POP. The FDA has received thousands of reports of complications involving the use of mesh for transvaginal repair of POP, including infection, bleeding, pelvic pain, pain during intercourse, organ perforation, and urinary problems from mesh eroding into the surrounding tissues. In 2019, the FDA called for withdrawal of vaginal mesh for POP repair from practice and ordered manufacturers of all remaining transvaginal mesh kits for repair of POP to stop selling and distributing their products in the US immediately.[60]​ The UK National Institute for Health and Care Excellence no longer recommends vaginal mesh for POP repair.[28][61]

  • Ureteral injury is the most often reported complication following uterosacral ligament suspension and was more common compared with sacrospinous fixation.[59]

  • Approximately 40% of women with apical or anterior prolapse who do not have incontinence develop postoperative urinary incontinence and further treatment may be needed.[19][28]

Concomitant incontinence surgery

  • Up to 80% of women with POP have coexisting urinary incontinence.[19][62]​​​​ If symptoms are bothersome, POP and stress urinary incontinence can be treated concurrently to reduce persistent or worsening stress incontinence after prolapse surgery.[22]​ The route of access for prolapse repair determines the type of continence procedure.[19][63]

  • Patients with POP who do not have stress urinary incontinence should be informed that the risk of de novo stress urinary incontinence is higher if a continence procedure is not performed but the risk of adverse effects is increased with an additional procedure.[19]​ Both Burch colposuspension concurrent with abdominal sacrocolpopexy and retropubic midurethral sling concurrent with vaginal surgery for POP repair reduce the risk of postoperative stress urinary incontinence in women without preoperative incontinence.[63][64][65]​​​ [ Cochrane Clinical Answers logo ] ​​ In most available studies, data is insufficient to state whether a concomitant continence procedure effects the rates of recurrent POP, need for further surgery, or postoperative overactive bladder.[63]

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