Pelvic Organ Prolapse
Pelvic organ prolapse is descent of pelvic organs (bladder, uterus, rectum, vaginal vault) through weakened support — managed by severity and symptoms with conservative options (pelvic floor training, pessary) first and surgery for symptomatic/refractory cases, remembering that prolapse and incontinence often coexist.
The big picture
Pelvic organ prolapse is herniation of pelvic organs into/through the vagina due to weakened pelvic floor support (childbirth, ageing, raised intra-abdominal pressure, connective tissue factors). Compartments include anterior (cystocele — bladder), apical (uterine/vault), and posterior (rectocele). Symptoms include a vaginal bulge/pressure, voiding or defecatory dysfunction, and it commonly coexists with urinary incontinence.
Stage by compartment and treat by symptoms: reassure mild/asymptomatic, offer pelvic floor training and a pessary first, and reserve surgery for symptomatic/refractory cases — and always consider coexisting/occult stress incontinence.
Symptom sorter
The common presentation.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Treatment ladder
Match treatment to symptoms and stage; conservative first, surgery for symptomatic/refractory prolapse, with continence managed alongside.
Procedure chooser
- Compartment-specific repair (native-tissue), apical suspension (e.g. sacrocolpopexy); obliterative procedures (colpocleisis) in selected non-sexually-active patients; address stress incontinence as indicated
Complications
- Voiding/defecatory dysfunction, retention, ulceration; quality-of-life impact
- Pessary: erosion/discharge/ulceration if not maintained
- Surgery: recurrence, de novo incontinence, mesh-related complications, dyspareunia
- Treat symptomatic cases; maintain pessaries; assess continence before surgery
- Adjust/maintain pessary; surgical repair; manage incontinence/complications
Follow-up
- Symptom relief and prolapse recurrence
- Pessary complications (erosion, discharge) — regular review
- Continence and voiding after repair
- Regular pessary checks; postoperative review
- Symptom relief with maintained support and continence
- Recurrence, pessary complications, de novo/persistent incontinence
- Severe prolapse with obstruction; complications
- Recurrence; mesh-related issues (where used); ongoing continence management
If treatment fails
If prolapse symptoms persist/recur, ask: is conservative management optimised (pessary fit), which compartment is involved, and has coexisting/occult incontinence been addressed?
Red flags
Reducing a large prolapse can unmask stress incontinence — assess and plan continence management with repair.
Mild/asymptomatic prolapse usually needs only reassurance — conservative first.
Relieve obstruction and assess the upper tracts; plan definitive repair.
Summary tables
Pelvic organ prolapse essentials
| Item | Detail |
|---|---|
| Compartments | Anterior (cystocele), apical (uterine/vault), posterior (rectocele) |
| Assess | Symptoms + stage by compartment/degree; continence (occult SUI) |
| Mild/asymptomatic | Reassurance |
| Conservative | Pelvic floor training + vaginal pessary |
| Surgery | Symptomatic/refractory (compartment-specific/apical); manage incontinence |
Memory hooks
Prolapse = pelvic organ descent (anterior/apical/posterior).
Mild/asymptomatic → reassure.
Conservative first: pelvic floor training + pessary.
Surgery for symptomatic/refractory.
Watch for coexisting/occult stress incontinence.
Board traps
Conservative (PFMT/pessary) first.
Occult stress incontinence can be unmasked by prolapse reduction.
Treat by symptoms/compartment, not by appearance alone.
Clinical cases
A 62-year-old woman has a symptomatic vaginal bulge and a cystocele on examination. She wishes to avoid surgery initially.
What conservative options are appropriate, and what continence issue must be assessed?