Pelvic Organ Prolapse


  • Abnormal descent/herniation of one or more of the pelvic organs as a result of failure of ligamentous and fascial supports, resulting in the protrusion of the organ beyond its normal anatomical confines
  • Can occur
    • Anteriorly (urethrocele, cystocele, cystourethrocele)
    • Middle/Apically (uterine, vaginal vault (post-hysterectomy), enterocele)
    • Posteriorly (rectocele)
  • Can also be classed by severity
    • Stage 0- no prolapse
    • Stage 1- more than 1cm above the hymen
    • Stage 2- within 1cm of the hymen
    • Stage 3- more than 1cm below the hymen but less than 2cm away from the introitus
    • Stage 4- protrusion out of the introitus
      • Alternatively
    • 1st degree- prolapse contained within the vagina
    • 2nd degree- prolapse through the introitus
    • 3rd degree- entire uterus outside the introitus
  • Common: mild prolapse can be found in up to 50% of parous women (many asymptomatic)

Risk factors

  • Multiparity and vaginal child birth
  • Age
  • High BMI
  • Others include family history, intrapartum complications e.g. macrosomia, prolonged labour, assisted labour; young pregnancy; constipation;


  • General sensation of pressure, fullness, heaviness (‘something coming down’)
    • Bulge/protrusion may be felt/seen
    • Difficulty with tampons
    • Spotting
  • It is important to ask about urinary symptoms e.g. frequency, incontinence, urgency, incomplete emptying; weak flow;
    • Rarely, some need to manually reduce the prolapse prior to urination.  More commonly, some women need to change positions to empty the bladder
  • Ask also about sexual difficulty including dyspareunia; loss of sensations
  • Ask about any bowel symptoms e.g. constipation, urgency, incontinence, incomplete evacuation/straining, change of position etc
  • On examination
    • Ideally examine standing and lying (flat and left lateral)
    • Use a Sims speculum (if available) to look at the walls of the vagina and/or a bivalve to look at the cervix/uterus
    • Ask the patient to strain/cough to exacerbate any findings
    • Ulceration may be seen on the prolapsing part


  • Usually a clinical diagnosis but some investigations may be warranted e.g.
    • in the case of urinary sx (e.g. urinalysis, residual volume scan, urodynamics etc)
    • bowel symptoms may warrant anal manometry/USS


  1. Watchful waiting, with observation for development of any new symptoms/complications
    1. for stage 1 or asymptomatic patients
  2. Conservative management
    1. Lifestyle
      1. e.g. weight loss, treat constipation, reduce heavy lifting
    2. Physiotherapy (pelvic floor)
      1. Useful for stage 1/2 symptomatic patients
    3. Local oestrogen creams may be trialled in conjunction with physiotherapy, particularly in post-menopausal women
  3. Pessaries
    1. Considered effective in most women if tolerated and suitably fitting
      1. (many different sizes/shapes)- ring pessary often very effective although accurate fitting is recommended
      2. Usually replaced every 3-6 months
  4. Surgery
    1. NB The evidence for classical prolapse surgeries e.g. tapes/colposuspension/fixation, is lacking and these are becoming less routine
    2. Only considered if there is failure of management with pessary; prolapse is symptomatic i.e. incontinence, difficulty with voiding/defecating etc; and where patient preference is a strong factor

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: