Pelvic organ prolapse

She is 58, three vaginal births, postmenopausal, and tells you, in the consulting room, that "something is falling out down below". You examine her with the Sims speculum in semi-lithotomy, ask her to strain, and watch the anterior vaginal wall bulge to the introitus. You then record nine measurement points against the hymen and call it Stage II. The exam answer and the conversation diverge from there: Stage II is your clinical currency, but what she wants to know is whether she can keep her uterus, whether the pessary will work, what surgery would do to her sex life, and how likely the prolapse is to come back. This topic is for both ends of that conversation.^[1][4]

Overview and definition

POP is a clinical diagnosis: one or more of the anterior vaginal wall, the cervix or uterus (or, after hysterectomy, the vaginal vault), and the posterior vaginal wall descends from its normal position and is documented using the standardised POP-Q system agreed by the International Continence Society, the American Urogynecologic Society and the Society of Gynecologic Surgeons in 1996.^[1]

The 1996 Bump paper is the canonical source for the POP-Q because the same document that defines the classification defines the staging — Stages 0 to IV measured against the hymen as the fixed reference point at zero. Reproducing that staging is the difference between a competent answer and a fellowship-grade one at the oral.^[1]

^{[2] [3] [5]}

References16ShowHide

1. [1]Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL, Smith AR The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction Am J Obstet Gynecol, 1996.PMID 8694033
2. [2]Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence Obstet Gynecol, 1997.PMID 9083302
3. [3]Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, Markland AD Prevalence and trends of symptomatic pelvic floor disorders in U.S. women Obstet Gynecol, 2014.PMID 24463674
4. [4]DeLancey JO Anatomic aspects of vaginal eversion after hysterectomy Am J Obstet Gynecol, 1992.PMID 1615980
5. [5]Atan IK, Lin S, Dietz HP, Herbison P, Wilson PD Levator Avulsion Is Associated With Pelvic Organ Prolapse 23 Years After the First Childbirth J Ultrasound Med, 2018.PMID 29675869
6. [6]Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population Int Urogynecol J Pelvic Floor Dysfunct, 2009.PMID 19444368
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8. [8]Dumoulin C, Cacciari LP, Hay-Smith EJC Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women Cochrane Database Syst Rev, 2018.PMID 30288727
9. [9]Maher C, Yeung E, Haya N, Christmann-Schmid C, Mowat A, Chen Z, Baessler K Surgery for women with apical vaginal prolapse Cochrane Database Syst Rev, 2023.PMID 37493538
10. [10]Yeung E, Baessler K, Christmann-Schmid C, Haya N, Chen Z, Wallace SA, Mowat A, Maher C Transvaginal mesh or grafts or native tissue repair for vaginal prolapse Cochrane Database Syst Rev, 2024.PMID 38477494
11. [11]Haylen BT, Freeman RM, Swift SE, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) & grafts in female pelvic floor surgery Int Urogynecol J, 2011.PMID 21140130
12. [12]Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, Kenton K, Amundsen CL, Schaffer J, Meikle SF, Spino C A midurethral sling to reduce incontinence after vaginal prolapse repair N Engl J Med, 2012.PMID 22716974
13. [13]Jelovsek JE, Chagin K, Gyhagen M, et al. Predicting risk of pelvic floor disorders 12 and 20 years after delivery Am J Obstet Gynecol, 2018.PMID 29056536
14. [14]Bø K, Anglès-Acedo S, Batra A, et al. International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training Int Urogynecol J, 2022.PMID 35980443
15. [15]Winkelman WD, Modest AM, Richardson ML U.S. Food and Drug Administration Statements About Transvaginal Mesh and Changes in Apical Prolapse Surgery Obstet Gynecol, 2019.PMID 31503162
16. [16]Bugge C, Kearney R, Best C, et al. Four Year Clinical and Cost Effectiveness of Vaginal Pessary Self-Management Versus Clinic-Based Care for Pelvic Organ Prolapse (TOPSY): Long Term Follow-Up of a Randomised Controlled Superiority Trial BJOG, 2025.PMID 40832737