Patient information: See related handout on pelvic organ prolapse , written by the authors of this article.

Pelvic organ prolapse, or genital prolapse, is the descent of one or more of the pelvic structures (bladder, uterus, vagina) from the normal anatomic location toward or through the vaginal opening. Women of all ages may be affected, although pelvic organ prolapse is more common in older women. The cause is a loss of pelvic support from multiple factors, including direct injury to the levator ani, as well as neurologic injury from stretching of the pudendal nerves that may occur with vaginal childbirth. Previous hysterectomy for pelvic organ prolapse; ethnicity; and an increase in intra-abdominal pressure from chronic coughing, straining with constipation, or repeated heavy lifting may contribute. Most patients with pelvic organ prolapse are asymptomatic. A sense of bulging or protrusion in the vagina is the most specific symptom. Evaluation includes a systematic pelvic examination. Management options for women with symptomatic prolapse include observation, pelvic floor muscle training, mechanical support (pessaries), and surgery. Pessary use should be considered before surgery in women who have symptomatic prolapse. Most women can be fitted with a pessary regardless of the stage or site of predominant prolapse. Surgical procedures are obliterative or reconstructive.

Pelvic organ prolapse is the descent of one or more of the pelvic structures (bladder, uterus, vagina) from the normal anatomic location toward or through the vaginal opening.1 Pelvic organ prolapse may be associated with urinary incontinence or defecatory dysfunction.

Epidemiology Jump to section + Abstract

Epidemiology

Etiology

Clinical Presentation

Treatment

References The prevalence of pelvic organ prolapse varies widely across studies, depending on the population studied and entry criteria. Women of all ages may be affected, although it is more common in older women. In the Women's Health Initiative study, investigators found a 41.1 percent prevalence of pelvic organ prolapse at a standard physical assessment in postmenopausal women older than 60 years who had not had a hysterectomy.2 View/Print Table SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Women should be asked about symptoms of pelvic organ prolapse because they may not volunteer the information. C 6, 16 Lifestyle interventions such as weight loss may help improve or prevent symptoms of pelvic organ prolapse, although the evidence is conflicting. B 21, 40 Pessaries can be used for the nonsurgical treatment of pelvic organ prolapse in appropriate patients. B 33, 34, 37 SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating References Women should be asked about symptoms of pelvic organ prolapse because they may not volunteer the information. C 6, 16 Lifestyle interventions such as weight loss may help improve or prevent symptoms of pelvic organ prolapse, although the evidence is conflicting. B 21, 40 Pessaries can be used for the nonsurgical treatment of pelvic organ prolapse in appropriate patients. B 33, 34, 37

Etiology Jump to section + Abstract

Epidemiology

Etiology

Clinical Presentation

Treatment

References The cause of pelvic organ prolapse is multi-factorial, resulting from loss of the support maintained by a complex interaction among the levator ani, the vagina, and the connective tissue, as well as neurologic injury from stretching of the pudendal nerves that may occur during childbirth. In a healthy woman in whom the levator ani has normal tone and the vagina has adequate depth, the upper vagina lies nearly horizontal when she is upright. The result is a “flap valve” in which the upper vagina presses against the levator plate when there is an increase in intra-abdominal pressure. When the levator ani loses tone, it moves from a horizontal to a semi-vertical position, creating a widened genital hiatus (i.e., the distance between the external urethral meatus and the posterior midline hymen) that forces the pelvic structures to rely on connective tissue for support. When the connective tissue support also fails, as a result of possible collagen decrease and tearing, prolapse may occur.3,4 Table 1 lists risk factors associated with pelvic organ prolapse.2,5–12 View/Print Table Table 1. Risk Factors for Pelvic Organ Prolapse Category Risk factors Ethnicity Hispanic adults2 General Advancing age, increasing body mass index, menopause,5,6 low socioeconomic status7 Increased intra-abdominal pressure Chronic cough caused by smoking, chronic lung disease,8 straining with chronic constipation or repeated heavy lifting7,9 Obstetric Current pregnancy, previous prolonged labor, instrumental delivery, episiotomy,10 increasing parity, weight of babies5* Previous surgery Hysterectomy,11 previous prolapse surgery Table 1. Risk Factors for Pelvic Organ Prolapse Category Risk factors Ethnicity Hispanic adults2 General Advancing age, increasing body mass index, menopause,5,6 low socioeconomic status7 Increased intra-abdominal pressure Chronic cough caused by smoking, chronic lung disease,8 straining with chronic constipation or repeated heavy lifting7,9 Obstetric Current pregnancy, previous prolonged labor, instrumental delivery, episiotomy,10 increasing parity, weight of babies5* Previous surgery Hysterectomy,11 previous prolapse surgery

Clinical Presentation Jump to section + Abstract

Epidemiology

Etiology

Clinical Presentation

Treatment

References TERMINOLOGY Older terms describing pelvic organ prolapse (e.g., cystocele, urethrocele, rectocele) have been replaced because they imply an unrealistic certainty about the structures on the other side of the vaginal bulge, particularly in women who have had previous pelvic organ prolapse surgery. The current practice is to divide the pelvis into anterior, posterior, and middle or apical compartments.13 Following hysterectomy, prolapse of the vaginal apex with or without prolapse of the anterior and/or posterior vaginal wall is referred to as vault prolapse.13 HISTORY Most patients with pelvic organ prolapse are asymptomatic.1 Seeing or feeling a bulge of tissue that protrudes to or past the vaginal opening is the most specific symptom.1,14 During a well-woman examination, screening questions (e.g., “Do you see or feel a bulge in your vagina?”) with a thorough pelvic examination are important.1 This is true of patients who are older, obese, or otherwise at risk.14,15 The report of a bulge has an 81 percent positive predictive value and a 76 percent negative predictive value for pelvic organ prolapse.16 The uterus and surrounding pelvic support tend to be dynamic in prolapse, resulting in a variation of symptoms depending on the position of the uterus and pressure of the surrounding structures.1 Consequently, as the day progresses, bulging and discomfort may increase.1 Extensive standing, lifting, coughing, and physical exertion may increase patient awareness of discomfort in the pelvis, vagina, abdomen, and low back. Vaginal discharge may be present in patients with complete uterine prolapse (i.e., procidentia) who have a decubitus ulcer of the cervix or vagina. Pelvic organ prolapse may progress with increasing body mass index.17 Weight loss does not reverse the prolapse.18 Patients may have difficulty urinating—stress incontinence affects 40 percent of patients with pelvic organ prolapse—or defecating19; therefore, they should be asked about these symptoms because they may not volunteer such information.6,16 Urinary outlet obstruction may occur because of pressure on the urethra in anterior vaginal prolapse and sometimes in large posterior vaginal prolapse. Symptoms may not correlate with the location or severity of the prolapsed compartment.1,20,21 Patients with posterior vaginal prolapse sometimes use manual pressure on the perineum or posterior vagina to help with defecation. These maneuvers are called “splinting.” Sexual activity, body image, and quality of life may be affected.22–24 EXAMINATION If prolapse is visible at the vaginal introitus or a bulge is noted during the Valsalva maneuver, a systematic examination should be performed. With the patient in a supine position and the head of the examination table elevated to 45 degrees, an appropriately sized vaginal speculum is placed in the vagina to view the cervix or vaginal cuff. While the patient is performing the Valsalva maneuver, the speculum is slowly removed. The extent to which the cervix or the vaginal vault follows the speculum through and out of the vagina is noted. The speculum is disassembled and the posterior or fixed blade is used for examination. To examine the anterior vaginal wall, the posterior vaginal wall is retracted with the fixed blade and the extent of any anterior vaginal prolapse during the Valsalva maneuver is noted. To examine the posterior vaginal wall, the fixed blade is inverted, the anterior vaginal wall is retracted, and the patient is instructed to repeat the Valsalva maneuver. Any resulting prolapse is noted. Decubitus ulcers are inspected and palpated. Bimanual and rectovaginal examinations help identify any coexisting pelvic abnormalities, including those of the perineal body. If pelvic organ prolapse is not evident, especially in a woman feeling a bulge, the patient should be examined in the standing position while she performs the Valsalva maneuver.1 STAGING The Baden-Walker (grades 0 through 4) and pelvic organ prolapse–quantification (pelvic organ prolapse-Q; stages 0 through IV) are the two main systems for staging the degree of pelvic organ prolapse. Both systems measure the most distal portion of the prolapse during straining/Valsalva maneuver (Table 2).1,13,25 The Baden-Walker system is a reasonable clinical method to evaluate the three pelvic compartments.1,26 The pelvic organ prolapse-Q, an international system that involves taking several measurements, is more complex but highly reliable and is used in clinical assessment and research.1,13,27 View/Print Table Table 2. Evaluation/Staging of Pelvic Organ Prolapse Baden-Walker system Pelvic organ prolapse–quantification system Grade Description Stage Description 0 Normal position for each respective site, no prolapse 0 No prolapse 1 Descent halfway to the hymen I > 1 cm above the hymen 2 Descent to the hymen II ≤ 1 cm proximal or distal to the plane of the hymen 3 Descent halfway past the hymen III > 1 cm below the plane of the hymen, but protrudes no farther than 2 cm less than the total vaginal length 4 Maximal possible descent for each site IV Eversion of the lower genital tract is complete Table 2. Evaluation/Staging of Pelvic Organ Prolapse Baden-Walker system Pelvic organ prolapse–quantification system Grade Description Stage Description 0 Normal position for each respective site, no prolapse 0 No prolapse 1 Descent halfway to the hymen I > 1 cm above the hymen 2 Descent to the hymen II ≤ 1 cm proximal or distal to the plane of the hymen 3 Descent halfway past the hymen III > 1 cm below the plane of the hymen, but protrudes no farther than 2 cm less than the total vaginal length 4 Maximal possible descent for each site IV Eversion of the lower genital tract is complete FURTHER EVALUATION Further studies depend on the symptoms, stage of pro-lapse, and treatment plan. If needed for definitive treatment planning, multichannel urodynamic studies can help identify those patients with urinary symptoms who are most likely to benefit from surgery.28–30 Patients with defecatory symptoms and/or fecal incontinence may need anal manometry, dynamic defecography, and endoanal ultrasonography.31