Continuing Education Activity

Pelvic organ prolapse (POP) is a prevalent condition that affects millions of women worldwide, particularly those with a history of vaginal childbirth, pelvic surgery, pelvic floor trauma, or connective tissue weakening. POP is characterized by the descent of pelvic organs, including the bladder, uterus, rectum, or vaginal apex, into or beyond the vaginal canal due to weakening of the supporting muscles, fascia, and ligaments. While some women remain asymptomatic, others may experience notable symptoms, including pelvic pressure, a sensation of vaginal bulging, urinary or fecal incontinence, and sexual dysfunction. Diagnosis relies on clinical history, pelvic examination, and standardized staging using either the Baden-Walker grading system or the Pelvic Organ Prolapse Quantification (POP-Q) system. Management is individualized based on symptom severity, compartment involvement, and patient goals. Conservative options include pelvic floor muscle training and pessary use, while surgical interventions, such as sacrocolpopexy or colpocleisis, may be indicated in more severe cases. 

This activity provides a comprehensive overview of the etiology, risk factors, diagnostic strategies, and evidence-based management of POP, including conservative treatments such as pelvic floor muscle training and pessary use, as well as surgical interventions such as sacrocolpopexy and colpocleisis. This activity highlights the importance of interprofessional collaboration among healthcare providers and equips them with the knowledge and tools necessary for individualized care planning and effective team-based collaboration, ultimately improving patient outcomes and quality of life.

Objectives:

• Identify key risk factors, clinical manifestations, and anatomical changes associated with pelvic organ prolapse.
• Implement evidence-based diagnostic protocols, including the POP-Q system, to accurately stage and document the severity of prolapse.
• Apply conservative management strategies, such as pelvic floor muscle training and pessary use, tailored to the individual patient's needs.
• Collaborate with the interprofessional healthcare team to manage pelvic organ prolapse, enhance patient satisfaction, support adherence, and ensure continuity of care.

Introduction

Pelvic organ prolapse (POP) is a condition characterized by the descent of pelvic structures, including the anterior or posterior vaginal wall, uterus, cervix, or vaginal apex, into or beyond the vaginal canal due to weakening of the pelvic floor's supportive tissues, including muscles, fascia, and ligaments.[1] This structural weakness allows adjacent organs, such as the bladder, rectum, or small intestine, to herniate into the vaginal space, resulting in clinical manifestations including cystocele, rectocele, enterocele, or uterine prolapse.[2] Mild prolapse may be asymptomatic and fall within physiological limits, but POP becomes clinically significant when it causes symptoms such as pelvic pressure, a sensation or visible bulge in the vagina, difficulty with urination or defecation, urinary or fecal incontinence, or sexual dysfunction.[3]

Initial evaluation should involve a thorough clinical history and a detailed pelvic examination, with particular attention to associated complications such as urinary incontinence, bladder outlet obstruction, and fecal incontinence.[3][4] Pelvic Organ Prolapse Quantification (POP-Q) staging and the Baden-Walker grading system are commonly used to assess the severity and compartmental involvement of the prolapse.[5]

The severity of prolapse, symptom burden, patient preferences, and functional goals guides management strategies. Options range from conservative measures—such as watchful waiting and vaginal pessary use—to definitive surgical correction. Surgical interventions include reconstructive procedures—performed with or without synthetic or biological graft materials—as well as obliterative procedures, which may be appropriate for select non-sexually active individuals.

Etiology

POP is a multifactorial condition primarily driven by pelvic floor injury and connective tissue weakening. Vaginal childbirth remains the most significant risk factor, particularly when associated with high parity, large birthweight, forceps-assisted delivery, or prolonged labor—all of which can result in direct trauma to the pelvic muscles, fascia, and the levator ani complex. Other well-established risk factors include advancing age, obesity (as measured by body mass index [BMI]), genetic predisposition, and connective tissue disorders, each of which can compromise pelvic support and exacerbate descent.

Chronic increases in intra-abdominal pressure—due to factors such as persistent coughing, constipation, or heavy lifting—place additional stress on weakened tissues, accelerating the development of prolapse. A history of pelvic surgery or hysterectomy also contributes to POP by disrupting native support structures.[4] These risk factors interact dynamically throughout a woman’s lifespan, resulting in degenerative changes and symptomatic POP in susceptible individuals.[6]

Epidemiology

POP is a common condition, though its true prevalence is often underestimated due to discrepancies between symptom reporting and clinical examination findings. National surveys indicate that approximately 3% of women in the United States report symptoms of vaginal bulging, whereas physical examination reveals that 41% to 50% have some degree of prolapse.[7] POP primarily affects older women, with prevalence increasing with age and peaking at around 5% among those aged 60 to 69. Longitudinal studies show that among symptomatic women who defer treatment, approximately 78% experience no significant anatomical progression over an average follow-up of 16 months. However, about 29% of symptomatic women progress to clinically significant prolapse—defined as POP-Q descent beyond the hymen—within a year, particularly older individuals or those with more advanced baseline prolapse.[8] The incidence of POP is expected to rise by 46%, reaching an estimated 4.9 million affected women by 2050.[9]

Pathophysiology

Although the exact mechanisms are heterogeneous and respective for patients with POP, current understanding regarding the pathophysiology of POP indicates that DNA polymorphisms rs2228480 at the ESR1 gene, rs12589592 at the FBLN5 gene, rs1036819 at the PGR gene, and rs1800215 at the COL1A1 gene are significantly associated with POP.[10] POP specifically related to pregnancy and labor & delivery, there is a strong etiologic link between vaginal birth and symptoms of POP, with the first vaginal delivery and forceps delivery being the main determinants. Regarding age and menopause, age is consistently identified as a risk factor for POP, whereas postmenopausal status in isolation is not directly associated with POP.[11] 

Histopathology

Investigations of changes in the vaginal tissue that occur in women with POP remain limited.[12] Several studies have analyzed collagen content or changes in collagen subtypes in the vagina of patients with prolapse compared with controls and produced contrary results. These conflicting results can be attributed to the different methods of collagen quantification employed in these reports.[13] The biopsy site may vary from one study to another, and specimens are often not well-defined by histology, making it impossible to precisely determine which layer of the vaginal wall is being analyzed. Consequently, recent studies conclude that it is difficult to make comparisons between existing studies. Moreover, in some studies, the histological sections are interpreted subjectively by pathologists or measured on randomly selected fields, which can lead to bias.

Several studies suggest that changes in the morphometry of the vagina, particularly at the muscularis layer, may affect the function of the tissue and contribute to the development of POP.[14][15] Although these changes are often observed, the mechanism underlying this transformation remains unclear. Yet, other authors have also found normal vaginal tissue in patients with POP, suggesting that the pathophysiology of POP cannot be explained only by an alteration of the quality of the vagina.[16]

Toxicokinetics

Although conclusive relationships between toxicokinetic pathways remain uncertain, recent studies have identified a potential target in the treatment and toxicokinetics of POP in Frizzled class receptor 3 (FZD3) expression.[17] Li et al reported that FZD3 was downregulated in POP.[18]  Vaginal wall fibroblasts (VWF) from POP exhibited lower cell viability, increased extracellular matrix (ECM) degradation, and higher rates of apoptosis. Knockdown of FZD3 inhibited cell viability, ECM degradation, and promoted apoptosis in VWFs, whereas overexpression of FZD3 had the opposite effect. Moreover, IWP-4 (a Wingless-type [Wnt] pathway inhibitor) reversed the effect of FZD3 overexpression on biological behaviors. Taken together, FZD3 facilitates VWFs viability, ECM degradation, and inhibits apoptosis via the Wnt pathway in POP. The findings provide a potential target for the treatment of POP.[19]

History and Physical

A comprehensive evaluation for POP begins with a thorough medical, surgical, obstetric, and gynecological history. Particular attention should be given to symptoms of vaginal bulging and the extent to which these symptoms interfere with daily activities, sexual function, or show signs of progression over time, as many women with clinically apparent POP may be asymptomatic.[20] Evaluation should also include a detailed review of urinary function, with screening for stress or urgency incontinence, voiding difficulties, and compensatory behaviors such as manual splinting. Likewise, bowel habits should be evaluated for indications of posterior compartment involvement, including straining, incomplete evacuation, reliance on laxatives, or fecal incontinence. 

The physical examination should begin with inspection of the external genitalia and vaginal mucosa for signs of atrophy, irritation, or ulceration. A focused pelvic examination is then performed using a split-speculum technique during a Valsalva maneuver or coughing to elicit maximum prolapse, with careful evaluation of all 3 compartments—anterior, apical, and posterior. Standardized prolapse grading systems, such as the POP-Q system or the Baden-Walker Halfway Scoring System, provide objective staging and facilitate consistent documentation of prolapse.[21][22] 

If prolapse is not fully appreciated in the supine position, examination should be repeated with the patient upright.[23] A single-blade Sims speculum may be used to improve visualization of the vaginal apex and to sequentially inspect the anterior and posterior vaginal walls for evidence of cystocele or rectocele, respectively. Additionally, pelvic floor muscle strength should be assessed and documented as absent, weak, normal, or strong, as this evaluation is crucial for guiding an individualized management plan.[20]

Evaluation

Evaluation of POP integrates patient-reported symptoms with a standardized physical examination to accurately determine the type and severity of pelvic support defects. The assessment begins with a thorough history, including symptoms such as pelvic pressure or a sensation of vaginal bulge, urinary or fecal incontinence, voiding or defecatory dysfunction, and sexual discomfort.[4] 

The physical assessment utilizes the POP-Q system or Baden-Walker Halfway Scoring System, as mentioned, which objectively measures the descent of the anterior, apical, and posterior vaginal compartments relative to the hymen during a Valsalva maneuver, providing reliable staging from 0 to 4.[24] Although imaging studies, such as dynamic magnetic resonance imaging and defecography, may assist in complex or multicompartment prolapse, the clinical pelvic examination remains the cornerstone of evaluation.

Adjunctive tests, such as post-void residual measurement, urodynamic studies, or stress-cough testing with and without prolapse reduction, are appropriate for assessing coexisting urinary dysfunction.[23] Importantly, both the patient's symptomatic presentation and the POP-Q stage/Baden-Walker Halfway Scoring System guide management decisions, allowing treatment to be tailored to the severity of prolapse and its impact on urinary, bowel, and sexual function.[5][25]

Treatment / Management

Both conservative and surgical management may be appropriate depending on the patient’s age, desire for future fertility and sexual function, symptom severity, and comorbid conditions. The affected compartment also influences treatment choice. Management goals include symptom relief, preservation or improvement of sexual function, prevention of new support defects and incontinence, and restoration of adequate pelvic support.[26]

Observation and close follow-up are appropriate for women with mild, asymptomatic cases. Most women do not experience symptoms until the bulge protrudes beyond the vaginal opening. Pelvic floor muscle training (Kegel exercises) allows a systematic contraction of the levator ani muscles, strengthening the pelvic floor. Kegel exercises have been proven to improve symptoms of stress, urge, and mixed urinary incontinence and can be useful in women with mild POP.[27]

Two-thirds of patients with symptomatic POP opt for pessary management, and up to 77% continue use after 1 year.[28] Pessaries are devices that are typically made of medical-grade silicone and inserted into the vagina to restore normal pelvic anatomy. Suitable for all stages of prolapse, they can prevent progression and delay the need for surgery. Approximately 85% of patients are successfully fitted for a pessary.[29] However, fitting may be challenging in patients with a short vaginal length, wide vaginal opening, or history of hysterectomy. The initial choice is usually a ring pessary, folded for insertion and positioned between the pubic symphysis and posterior vaginal fornix. A proper fit remains at least one fingerbreadth above the introitus when the patient bears down. After fitting, patients should sit, walk, and void to ensure comfort and avoid urinary retention. They must be instructed on regular removal and cleaning—ranging from nightly to monthly—based on individual needs. 

When considering surgical intervention for POP, it is important to assess and discuss the patient’s goals regarding future fertility and sexual function. A range of abdominal and vaginal procedures is available to restore pelvic floor support and relieve symptoms. Colpocleisis—an obliterative procedure involving closure or shortening of the vaginal cuff—offers an anatomic success rate of 98% and a subjective success rate of 93%.[30] However, before performing this procedure, it is essential to counsel the patient that coital function will no longer be possible. For individuals who wish to preserve sexual function, a range of reconstructive surgical options should be explored.

Adequate support of the vaginal apex has been recognized as a critical component of successful surgical repair for advanced POP. Although some techniques rely on a woman's native tissues and ligaments for suspension, many incorporate biological grafts or mesh to support the uterus. Transvaginal approaches offer shorter operative and recovery times, whereas abdominal approaches tend to provide more durable outcomes and lower recurrence rates.[31]

One of the most widely performed transvaginal suspension procedures is sacrospinous fixation, which involves attaching the vaginal apex to the sacrospinous ligament of the coccygeus muscle. Advantages include avoiding the morbidity of an abdominal incision, preserving vaginal function, and enabling simultaneous repair of anterior and posterior compartment defects through a single surgical site.[32] However, this technique shifts the vaginal axis posteriorly, which may contribute to the development of new anterior compartment defects.[33] Associated complications that have been reported include intraoperative hemorrhage due to laceration of the pudendal artery, vaginal shortening, sexual dysfunction, and injury to the pudendal nerve.[34]

The iliococcygeus suspension is another transvaginal approach that provides excellent apical support by attaching the vaginal apex to the fascia of the iliococcygeus muscle.[35] As this technique preserves the vaginal axis, anterior compartment prolapse is rare. However, vaginal shortening can occur due to the ischial spines being positioned inferiorly relative to the standard vaginal apex. An alternative transvaginal approach is uterosacral suspension, which involves plicating the uterosacral ligaments at the midline and attaching them to the vaginal cuff. A notable disadvantage of this method is the close proximity of the uterosacral ligaments to the ureters.[31]

In recent years, abdominal sacrocolpopexy has emerged as the preferred procedure for POP and can be performed via laparotomy, laparoscopy, or robotic-assisted techniques. Since Lane first described the procedure in 1962, numerous refinements have been made. Birnbaum later proposed anchoring the suspensory mesh to the sacrum, although this approach carries a significant risk of hemorrhage due to potential laceration of the presacral vessels.[36] Various suspensory materials have been used in abdominal sacrocolpopexy, including mesh, non-absorbable sutures, fascia, and dura mater. Currently, mesh-based sacrocolpopexy is considered the gold standard, offering long-term symptom relief and effective restoration of vaginal function.[37] This procedure should be considered for women who wish to preserve vaginal function or who have experienced failure with prior surgical repairs for uterine or vaginal vault prolapse.

An increasing number of women desire to preserve the uterus and, therefore, reproductive function; thus, hysterectomy may not align with patient goals for management of POP.[38] Specific surgical methods that preserve the uterus, such as Manchester surgery, ischia spinous fascia fixation, uterosacral ligament suspension, and transvaginal mesh, have already been widely applied in clinical practice. The current practice in the Netherlands for all stages of uterine prolapse is uterus-sparing surgery, and 60% of gynecologists prefer sacrospinous hysteropexy over the Manchester procedure as the first choice for the primary treatment of uterine descent.[39] However, the use of vaginal mesh for POP remains controversial, as mesh exposure increases the risk for potential complications, and other novel treatment options are being studied.[40] These results are based on prospective, nonrandomized, and retrospective cohort studies; thus, the differences between sacrospinous hysteropexy and other hysteropreservation techniques may be over-or underestimated. Several RCTs compared the efficacy and safety of sacrospinous hysteropexy and other preservation techniques in women with POP; however, inconsistent results have been obtained.

Differential Diagnosis

POP shares overlapping symptoms with several other pelvic conditions, making differential diagnosis essential. Conditions such as urethral diverticulum, Gartner duct cysts, Bartholin gland cysts or abscesses, and vaginal neoplasms may mimic POP by presenting as vaginal or perineal masses. Additionally, anatomic variants such as cystocele, rectocele, enterocele, and prolapsed ureteroceles can resemble or coexist with POP.

Staging

The American Urogynecologic Society and the Society of Gynecologic Surgeons agreed upon a consensus document for staging POP at the 1996 International Continence Society.[41] The result was the development of the POP-Q system—a standardized and widely adopted method for assessing and staging POP in both clinical and research settings.[42] The technique measures prolapse in each compartment relative to the hymenal ring, using centimeters as the unit of measurement. Prolapse points located above (proximal to) the hymen are assigned negative values, whereas those protruding beyond the hymen receive positive values. 

A total of 6 points are delineated, including 2 on the anterior vaginal wall (Aa and Ba), 2 on the vaginal apex (C and D), and 2 on the posterior vaginal wall (Ap and Bp). Additional measurements include GH (genital hiatus), PB (perineal body), and TVL (total vaginal length).[43] Prolapse is staged from 0 (no prolapse) to 4 (complete eversion). The POP-Q system provides objective and reproducible measurements that aid in diagnosis, treatment planning, and the comparison of clinical outcomes.

An alternative to the POP-Q system is the previously used Baden-Walker Halfway Scoring System for grading POP.[21] The Baden-Walker Halfway System is a 4-grade staging system for POP, where prolapse is described by its descent relative to the hymen. The grades are: Grade 0 for no prolapse, Grade 1 for descent halfway to the hymen, Grade 2 for descent to the hymen, Grade 3 for descent halfway past the hymen, and Grade 4 for maximum descent. This system utilizes the hymenal ring as a reference point and is a simpler alternative to the more detailed POP-Q system.[44]

Prognosis

Although POP can significantly affect quality of life, it is not life-threatening. Most patients are initially asymptomatic. Among those with bulge symptoms, many experience substantial relief with pessary use and other noninvasive treatments. Surgical intervention has a success rate of approximately 95%, with studies demonstrating marked improvement in bulge symptoms and high patient satisfaction at 2- and 5-year follow-ups, accompanied by minimal new morbidity.[45]

Complications

Concomitant urinary symptoms can be exacerbated by POP. Therefore, during evaluation, it is essential to retract the bulge and assess for signs of urinary incontinence that may be masked by prolapse.[46] Additionally, POP can lead to fecal incontinence and bowel obstruction, which can be a significant complication of POP. Many patients can describe splinting in which a finger in the vagina is required to aid in defecation.[47]

Although pessary use is highly effective, patients should be counseled about potential complications before the pessary is placed. Follow-up symptoms such as vaginal discharge, irritation, ulceration, bleeding, pain, odor, vaginal wall ulceration, fistula formation, or bowel herniation may indicate pessary-related complications.[48] Infections with anaerobic organisms—particularly bacterial vaginosis—are more common in women who change their pessaries less than once per week.[49] Vaginal ulceration and bleeding are also more frequently observed in postmenopausal women and in those who remove their pessaries infrequently. 

Several complications have been associated with mesh use in the surgical treatment of POP. The application of transvaginal mesh and biological graft materials remains controversial, prompting ongoing scrutiny regarding their safety and effectiveness. In response to safety concerns, the US Food and Drug Administration (FDA) has discontinued the use of large transvaginal mesh grafts for POP repair, limiting vaginal surgeries to native tissue or biological grafts only.[50] Notable mesh-related complications include infection and dyspareunia. Meshes with pore sizes smaller than 10 μm permit bacterial infiltration while preventing macrophage access, thereby increasing the risk of infection.[51]

Postoperative and Rehabilitation Care

Effective postoperative care and rehabilitation are crucial for achieving optimal recovery and ensuring the long-term durability of surgical repair in POP. Early mobilization—including ambulation and stair climbing—is safe and may enhance patient satisfaction without increasing the risk of recurrence, compared to restrictive activity guidelines. Enhanced recovery protocols offer additional benefits, such as reduced opioid use, shorter hospital stays, and improved patient-reported outcomes.[52]

Pelvic floor physical therapy (PFPT) after surgery strengthens pelvic musculature and enhances quality-of-life outcomes, although randomized trials show mixed effects on objective anatomical recurrence at 6 months. One randomized controlled trial found that both the PFPT and control groups experienced improved pelvic floor distress scores between 3 and 6 months postoperatively, with no significant difference between the groups.[53] Despite this, supervised PFPT remains guideline-recommended, particularly for patients with persistent incontinence or pelvic floor muscle weakness.[54]

Deterrence and Patient Education

Educating patients about the high prevalence of POP can help reduce stigma and address psychosocial barriers that may delay diagnosis. The International Urogynecological Association (IUGA) and the American Urogynecological Society (AUGS) provide educational pamphlets and printable resources that outline common symptoms, diagnostic evaluations, and treatment options. Additionally, pamphlets on pessary care and home maintenance have been shown to significantly decrease complications and boost patient confidence in managing their treatment.[55]

Enhancing Healthcare Team Outcomes

Effective management of POP often begins with a general obstetrician or gynecologist, who can manage low-grade cases. However, more advanced or complicated presentations, especially those involving comorbid conditions such as stress urinary incontinence, fecal incontinence, defecatory dysfunction, or other lower urinary tract abnormalities, may require referral to a urogynecologist and the involvement of a broader interprofessional healthcare team.

As outlined by the National Institute for Health and Clinical Excellence (NICE), the healthcare team may include a urogynecologist, urologist, specialist nurse, physical therapist, and colorectal surgeon. A collaborative, patient-centered approach that also incorporates advanced practitioners, pharmacists, and other healthcare professionals ensures comprehensive and coordinated care. Each healthcare team member plays a vital role, contributing to diagnosis, treatment planning, patient education, emotional support, and medication management, while upholding ethical responsibilities such as informed consent and destigmatization. Strong interprofessional communication and clearly defined care pathways are essential for optimizing patient safety, outcomes, and overall team effectiveness.

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Disclosure: Chu-Hsuan Kuo declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Martingano declares no relevant financial relationships with ineligible companies.

Disclosure: Beverly Mikes declares no relevant financial relationships with ineligible companies.