Pelvic Organ Prolapse (POP)
Summary
Pelvic Organ Prolapse is the herniation of the pelvic organs (Uterus, Bladder, Rectum) into or beyond the vaginal walls due to failure of the ligamentous and muscular support of the pelvic floor. It affects 50% of parous women over 50. It is not life-threatening but significantly impacts Quality of Life. Management ranges from "do nothing" to physiotherapy, pessaries, or surgery. [1,2]
Clinical Pearls
The "Dragging" Sensation: The classic description is "feeling like something is coming down" or "sitting on a ball". Symptoms are gravity-dependent - better in the morning, worse at the end of the day after standing.
Renal Failure Risk: In severe Procidentia (total prolapse), the bladder drags the ureters down with it, kinking them at the urethra. This causes silent Hydronephrosis and Renal Failure. Always check renal function in Grade 4 prolapse.
Occult Stress Incontinence: The prolapse might be kinking the urethra and preventing leakage. When you fix the prolapse (surgically or with a pessary), you "unkink" the hose and the patient becomes incontinent! Warn them.
Risk Factors
- Childbirth: Validated risk factor. Vaginal delivery > Caesarean. Forceps > Spontaneous.
- Age: Estrogen loss causes collagen weakness.
- Obesity: Chronic intra-abdominal pressure.
- Connective Tissue: Ehlers-Danlos / Marfan's.
- Chronic Straining: Constipation, COPD (Coughing), Heavy lifting.
Anatomy of Defect
- Anterior Compartment: Bladder herniates -> Cystocele (Most common).
- Posterior Compartment: Rectum herniates -> Rectocele. (Or Small Bowel -> Enterocele).
- Apical Compartment: Uterus herniates -> Uterine Prolapse. Or Vaginal Vault (after hysterectomy).
| Condition | Features |
|---|---|
| Prolapse | Reduces on lying down. Increases on straining (Valsalva). |
| Polyp | Cervical or Endometrial polyp. Soft, fleshy, bleeds. |
| Fibroid | Pedunculated fibroid prolapsing through cervix. Firm. |
| Cyst | Gartner's duct or Bartholin's cyst. |
| Inverted Uterus | Obstetric emergency (post-partum). |
Symptoms
Examination
Grading (Baden-Walker / POP-Q)
Bedside
- Urinalysis: Infection?
- Bladder Scan: Post-void residual (Retention?).
Specialist
- Urodynamics: Only if incontinence symptoms present or prior to surgery (to rule out occult stress incontinence).
- Renal Ultrasound: If severe prolapse (rule out hydronephrosis).
Management Algorithm
SYMPTOMATIC PROLAPSE
↓
CONSERVATIVE MEASURES
- Weight Loss
- Treat Constipation / Cough
- Pelvic Floor Muscle Training (PFMT)
(Physio >3 months)
↓
IMPROVEMENT? -> Continue
NO IMPROVEMENT
↓
┌───────────┴───────────┐
PESSARY SURGERY
(Non-invasive) (Definitive)
↓ ↓
- Ring Pessary - Anterior Repair
- Shelf/Gellhorn - Posterior Repair
- Change q6 months - Vaginal Hysterectomy
- Sacrocolpopexy
1. Conservative
- PFMT: First line. Can improve grade 1-2 prolapse symptoms.
- Estrogen: Vaginal estrogen (cream/pessary) improves mucosal thickness/comfort, though doesn't fix the hernia.
2. Vaginal Pessaries
- Mechanical device inserted into vagina to prop up organs.
- Ring: Most common. Easy to change.
- Shelf/Gellhorn: For severe prolapse where ring falls out. suction effect. Patient cannot have sex with these in.
- Maintenance: Change every 6 months to prevent erosion/fistula (The "forgotten pessary" is a classic cause of nasty discharge/bleeding).
3. Surgical (Native Tissue Repair)
- Anterior Colporrhaphy: Plicating the fascia to fix Cystocele.
- Posterior Colporrhaphy: Fixing Rectocele.
- Vaginal Hysterectomy: Removing the heavy uterus.
- Sacrospinous Fixation: Hitching the vault to the ligament.
4. Mesh Debate
- Vaginal Mesh: Banned/Restricted in many countries due to complications (erosion/pain).
- Abdominal Mesh (Sacrocolpopexy): Still gold standard for apical prolapse, done laparoscopically. Lower erosion risk than vaginal mesh.
- Ulceration: Bleeding from exposed mucosa rubbing on underwear.
- Renal Failure: Obstruction.
- Incarceration: Irreducible prolapse (Emerency).
- Recurrence after surgery is common (up to 30%).
- Pessaries can be used indefinitely if managed well.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Prolapse | NICE NG123 (2019) | Offer PFMT first. Discuss mesh risks extensively. |
| Pessaries | RCOG / BSUG | Standards for pessary changes (q6mo). |
Landmark Evidence
1. PROSPECT Study (Lancet)
- Compared native tissue repair vs mesh. found NO benefit to using mesh for primary repairs, but higher complications. Sealed the fate of vaginal mesh.
What is a Prolapse?
It's a hernia. The muscles and ligaments holding your womb, bladder, and bowel up act like a hammock. If the hammock tears or stretches (from childbirth/aging), these organs drop down and bulge into the vagina.
Is it dangerous?
No, it is not cancer and it isn't life-threatening. Ideally we treat it only if it bothers you.
What are my options?
- Do nothing: If it doesn't annoy you, leave it.
- Physio: Strengthen the hammock muscles.
- Pessary: A silicone ring sitting inside to hold everything up (like a prop). Safe and removable.
- Surgery: Stitching the tissues back together.
Will surgery fix it forever?
Maybe. But about 3 in 10 women need surgery again later because the tissues are naturally weak.
Primary Sources
- NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). 2019.
- Glazener CM, et al. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT). Lancet. 2017.
Common Exam Questions
- Symptoms: "Digitation?"
- Answer: Splinting the perineum to poo -> Rectocele.
- Examination: "Speculum method?"
- Answer: Sims speculum, lateral insertion.
- Complication: "Bleeding with pessary?"
- Answer: Vaginal erosion/ulceration. Remove and treat with estrogen.
- Complication: "Silent renal failure?"
- Answer: Ureteric kinking (Hydronephrosis).
Viva Points
- Mesh Scandal: Be aware of the pause on vaginal mesh due to erosion/pain. Abdominal mesh (sacrocolpopexy) is distinct and still used.
- Occult SUI: Why do urodynamics before prolapse surgery? To unmask stress incontinence that the prolapse is currently hiding (kinking the urethra).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.