Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer.

banner image

amboss

Trusted medical answers—in seconds.

Get access to 1,000+ medical articles with instant search
and clinical tools.

Try free for 5 days

Pelvic organ prolapse

Last updated: January 25, 2021

Summarytoggle arrow icon

Pelvic organ prolapse (POP or female genital prolapse) is the protrusion of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault due to decreased pelvic floor support. It is commonly seen in women of advanced age. Other risk factors include multiparity (particularly vaginal births), prior pelvic surgery, connective tissue disorders, and increased intra-abdominal pressure secondary to obesity or chronic constipation. Patients present with a sensation of vaginal pressure, discomfort, and/or pain. The protruded pelvic organ is visualized and assessed during inspection. Low-grade prolapse can be managed conservatively with pelvic floor (Kegel) exercises or a vaginal pessary to support the pelvic floor. Pelvic floor repair surgery is indicated for women with symptomatic prolapse who do not respond to or decline conservative management. Complications include urinary or fecal retention or incontinence, abdominal/pelvic pain, and avoidance of sexual activity because of embarrassment or discomfort.

  • Anatomical overview: The pelvic floor is supported by a continuous endopelvic fascia, which consists of:
  • Definition: herniation into or descent of pelvic organs to or beyond the vaginal walls
    • Partial/subtotal prolapse: pelvic organs are only partially outside the vaginal opening.
    • Total prolapse: pelvic organs are everted and located outside of the vaginal opening.
  • Specific sites
    • Anterior vaginal wall prolapse: herniated anterior vaginal wall, which is often associated with a cystocele (descent of the bladder) or urethrocele (descent of the urethra); can be due to weakness of the pubocervical fascia
    • Posterior vaginal wall prolapse: herniated posterior vaginal wall; , which is associated with a rectocele ; (descent of the rectum) or enterocele ; (herniated section of the intestines); can be due to weakness of the rectovaginal fascia
    • Uterine prolapse: descent of the uterus
    • Vaginal vault prolapse: descent of the apex of the vagina
    • Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus

References:[1]

  • POP is a common disorder in older women.

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Risk factors

POP is due to an insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina , which may be caused by:

References:[1][2]

  • Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)
  • Lower back and pelvic pain (may become worse with prolonged standing or walking)
  • Rectal fullness, constipation, incomplete rectal emptying
  • Prolapse of the anterior (in cystocele/urethrocele); or the posterior (in enterocele/rectocele) vaginal wall, possibly with excessive vaginal discharge on inspection; , bimanual examination, and speculum examination of the patient in lithotomy position; occurs at rest and with increased abdominal pressure
  • Weakened pelvic floor muscle and anal sphincter tone

Patients with POP may present with concurrent complications!

References:[1][2]

  • Usually a clinical diagnosis relying on the Pelvic Organ Prolapse Quantitation system (POP-Q)
    • Stage 0: no prolapse
    • Stage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen.
    • Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.
    • Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.
    • Stage 4: The vagina is completely everted or uterine procidentia has occurred.

References:[3][4]

Elongation of the cervix

  • An elongated cervix can be mistaken for a prolapse.
  • Evaluated during pelvic examination

Urethral diverticulum [5]

The differential diagnoses listed here are not exhaustive.

Conservative treatment

First-line treatment for all cases of POP. May be definitive treatment for patients with manageable symptoms (low-grade POP) who would like to avoid complications of surgery or patients at high risk of surgical complications.

  • Insertion of a vaginal pessary to support the pelvic organs
    • A silicone or latex device that is inserted into the vagina
    • Pessary insertion is not a long-term treatment!
  • Reduction of modifiable risk factors (e.g., avoid smoking to prevent a chronic cough, weight loss, prevent constipation)
  • Kegel exercises: pelvic floor muscle training (also as a preventive measure)

Surgery

Indicated for symptomatic prolapse if conservative treatment fails or the patient declines it.

References:[2][6]

References:[7]

We list the most important complications. The selection is not exhaustive.

  1. Rogers RG, Fashokun TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-epidemiology-risk-factors-clinical-manifestations-and-management.Last updated: March 30, 2017. Accessed: April 28, 2017.
  2. Lazarou G. Pelvic Organ Prolapse. Pelvic Organ Prolapse. New York, NY: WebMD. http://emedicine.medscape.com/article/276259-overview. Updated: June 20, 2016. Accessed: April 28, 2017.
  3. Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP–Q) – a new era in pelvic prolapse staging. J Med Life. 2011; 4 (1): p.75-81.
  4. Fashokun TB, Rogers RG. Pelvic Organ Prolapse in Women: Diagnostic Evaluation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pelvic-organ-prolapse-in-women-diagnostic-evaluation.Last updated: June 21, 2017. Accessed: December 18, 2017.
  5. Quiroz LH AND Gutman RE. Urethral diverticulum in women. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/urethral-diverticulum-in-women?search=Urethral%20diverticulum&source=search_result&selectedTitle=1~26&usage_type=default&display_rank=1#H708034.Last updated: June 4, 2020. Accessed: August 20, 2020.
  6. Surgery for Pelvic Organ Prolapse. https://www.acog.org/Patients/FAQs/Surgery-for-Pelvic-Organ-Prolapse#pelvic. Updated: December 1, 2013. Accessed: November 5, 2017.
  7. Jundt K, Wagner S, von Bodungen V, Friese K, Peschers U. Occult incontinence in women with pelvic organ prolapse - does it matter?. Eur J Med Res. 2010; 15 (3): p.112. doi: 10.1186/2047-783x-15-3-112 . | Open in Read by QxMD
  8. Archer R, Blackman J, Stott M, Barrington J. Urethral diverticulum. The Obstetrician & Gynaecologist. 2015; 17 (2): p.125-129. doi: 10.1111/tog.12192 . | Open in Read by QxMD