Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

asymptomatic

1st line – observation ± pelvic floor muscle rehabilitation

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ONGOING
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asymptomatic
1st line – 

observation ± pelvic floor muscle rehabilitation

Asymptomatic patients, or women who have 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] Several studies have demonstrated that PFM training for prolapse is effective in improving prolapse symptoms.[37][39][40]

symptomatic

1st line – pessary

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ONGOING
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symptomatic
1st line – 

pessary

Mechanical supports, such as pessaries, are used to restore the prolapsed organs to their normal position and, thereby, relieve symptoms.[36][37]​​​[42]​​

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 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]

2nd line – reconstructive surgery or native tissue repair

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ONGOING
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symptomatic
2nd line – 

reconstructive surgery or native tissue repair

Reconstructive surgery is often performed with concomitant hysterectomy, if the uterus is present.

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]​​ 

Sacrospinous ligament suspension is generally done unilaterally. The vagina must be long enough to reach the sacrospinous ligament without a suture bridge.

Ureteral injury is the most reported complication following uterosacral suspension.

The uterosacral ligaments are used to resuspend the vaginal apex in uterosacral ligament suspension.

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 sacrocolpopexy.[50][51][52] ​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.

Currently, there are no available Food and Drug Administration (FDA)-approved transvaginal mesh products for the treatment of pelvic organ prolapse (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]

Consider – anterior/posterior vaginal repair

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ONGOING
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symptomatic
Consider – 

anterior/posterior vaginal repair

Treatment recommended for SOME patients in selected patient group

These procedures are used to repair prolapse that is not secondary to primary apical support loss. Concomitant anterior/posterior vaginal repair (for example, with colporrhaphy) should not be routinely considered but based on anatomic defects after repair of the apex.[54][55]​​

Consider – Burch urethropexy or midurethral sling

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ONGOING
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symptomatic
Consider – 

Burch urethropexy or midurethral sling

Treatment recommended for SOME patients in selected patient group

Up to 80% of women with pelvic organ prolapse (POP) have coexisting urinary incontinence.[19][62]​​ If symptoms are bothersome, POP and stress urinary incontinence (SUI) 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 SUI should be informed that the risk of de novo SUI is higher when SUI 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 SUI in women without preoperative incontinence.[63][64][65]​​ [ Cochrane Clinical Answers logo ]

3rd line – colpocleisis

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ONGOING
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symptomatic
3rd line – 

colpocleisis

Obliterative surgery, such as partial (Le Fort) colpocleisis or total colpocleisis, corrects pelvic organ prolapse by moving pelvic viscera back into the pelvis and closing off the vaginal canal either partially or totally.

This surgery 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. One review of colpocleisis reported a success rate of almost 100%.[56]

Consider – Burch urethropexy or midurethral sling

Back
ONGOING
|
symptomatic
Consider – 

Burch urethropexy or midurethral sling

Treatment recommended for SOME patients in selected patient group

Up to 80% of women with pelvic organ prolapse (POP) have coexisting urinary incontinence.[19][62]​​​​ If symptoms are bothersome, POP and stress urinary incontinence (SUI) 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 SUI should be informed that the risk of de novo SUI is higher when SUI 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 post-operative SUI in women without preoperative incontinence.[63][64][65]​​​ [ Cochrane Clinical Answers logo ]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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