Pelvic Organ Prolapse

P RACTICE BULLET IN
clinical management guidelines for obstetrician gynecologists
Number 176, April 2017 (Replaces Committee Opinion Number 513, December 2011)
Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge
and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect qual-
ity of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (1). Although POP
can occur in younger women, the peak incidence of POP symptoms is in women aged 7079 years (2). Given the
aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will
increase by approximately 50% (3). The purpose of this joint document of the American College of Obstetricians
and Gynecologists and the American Urogynecologic Society is to review information on the current understanding
of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available
scientific evidence.
Background toms of POP when the leading edge reaches 0.5 cm distal
to the hymenal ring (5).
Definition
Pelvic organ prolapse is the descent of one or more
Epidemiology
aspects of the vagina and uterus: the anterior vaginal According to the National Health and Nutrition Exam-
wall, posterior vaginal wall, the uterus (cervix), or the ination Survey, approximately 3% of women in the
apex of the vagina (vaginal vault or cuff scar after hys- United States report symptoms of vaginal bulging (3).
terectomy) (4). This allows nearby organs to herniate In one review, the prevalence of POP based on reported
into the vaginal space, which is commonly referred to symptoms was much lower (36%) than the prevalence
as cystocele, rectocele, or enterocele. Mild descent of identified by examination (4150%) (6). This discrep-
the pelvic organs is common and should not be con- ancy likely occurs because many women with POP are
sidered pathologic. Pelvic organ prolapse only should asymptomatic. Pelvic organ prolapse usually is due to
be considered a problem if it is causing prolapse symp- global pelvic floor dysfunction, so most women will
toms (ie, pressure with or without a bulge) or sexual present with POP in multiple compartments (anterior,
dysfunction or if it is disrupting normal lower urinary apical, and posterior vaginal wall) (7).
tract or bowel function. Pelvic organ prolapse can There are few studies of the natural history of POP.
be defined using patient-reported symptoms or physi- In one study that monitored women with symptomatic,
cal examination findings (ie, vaginal bulge protruding untreated POP for an average of 16 months, 78% of
to or beyond the hymen). Most women feel symp- the women had no change in the leading edge of the
Committee on Practice BulletinsGynecology and American Urogynecologic Society. This Practice Bulletin was developed by the Committee on
Practice BulletinsGynecology and the American Urogynecologic Society in collaboration with Paul Tulikangas, MD.
The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be
construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient,
resources, and limitations unique to the institution or type of practice.
prolapse (8). Most of the women had stage IIIV pelvic Older studies reported that women who underwent
organ prolapse (Box 1). In women who do not want primary POP surgery had an approximate 3050%
treatment for their POP, most will have no change or chance of needing a second prolapse surgery (19). More
only a small increase in the size of the POP over the recent studies show a lower reoperation rate of approxi-
next year (9). mately 630%, with most estimates consistent with the
The incidence of POP surgery is 1.51.8 surgeries lower end of this range (1922). This lower reoperation
per 1,000 women years (10, 11). There are approxi- rate may reflect improvement in surgical technique as
mately 300,000 POP surgeries each year in the United well as stratification of urinary incontinence as a sepa-
States (12). rate risk in the outcomes data (19). Pelvic organ prolapse
surgery that includes suspension of the vaginal apex is
Risk Factors associated with a decreased reoperation rate (23). Risk
Risk factors for developing symptomatic POP include factors for recurrent prolapse include age younger than
parity, vaginal delivery, age, obesity, connective tissue 60 years for patients who underwent vaginal surgery
disorders, menopausal status, and chronic constipation for POP, obesity, and preoperative stage III or stage IV
(1317). Modifiable risk factors (obesity and constipa- prolapse (2426).
tion) should be addressed in patients at wellness visits
because improvement in these factors may reduce the
risk of developing POP. Clinical Considerations and
It is not clear if hysterectomy for non-POP conditions
is a risk factor for developing POP. In a subanalysis of
Recommendations
a cohort study from the United Kingdom, patients who What is the recommended initial evaluation
underwent a hysterectomy had a 5% cumulative risk of for a woman with suspected pelvic organ
undergoing prolapse surgery within the next 15 years prolapse?
(13). A more recent study found no increased risk of
POP in women who underwent prior hysterectomy for The recommended initial evaluation for a woman with
non-POP indications (18). suspected POP includes a thorough history, assessment
of symptom severity, physical examination, and goals
for treatment. Symptom assessment is the most impor-
tant part of the evaluation of a woman with POP.
Box 1. Stages of Pelvic Organ Prolapse
History
Stages are based on the maximal extent of prolapse
relative to the hymen, in one or more compartments. In addition to a complete medical, surgical, obstetric,
and gynecologic history, the nature of vaginal bulge
Stage 0: No prolapse; anterior and posterior points
are all 3 cm, and C or D is between TVL and symptoms and the degree of bother associated with
(TVL 2) cm. the bulge should be recorded. Key information to elicit
from the patient includes whether the protrusion is limit-
Stage I: The criteria for stage 0 are not met, and the
most distal prolapse is more than 1 cm above the level ing physical activities or sexual function or becoming
of the hymen (less than 1 cm). progressively worse or bothersome. Many women with
POP on physical examination do not report symptoms of
Stage II: The most distal prolapse is between 1 cm
POP. Treatment is indicated only if prolapse is causing
above and 1 cm below the hymen (at least one point
is 1, 0, or +1). bothersome bulge and pressure symptoms, sexual dys-
function, lower urinary tract dysfunction, or defecatory
Stage III: The most distal prolapse is more than 1 cm
dysfunction (27).
below the hymen but no further than 2 cm less than
TVL. Lower urinary tract function should be assessed.
This includes an evaluation for urine loss and type
Stage IV: Represents complete procidentia or vault (stress or urgency urinary incontinence) and adequacy
eversion; the most distal prolapse protrudes to at least
of bladder emptying. The relationship between urinary
(TVL 2) cm.
symptoms and prolapse can be inferred if voiding
Abbreviations: C, cervix; D, posterior fornix; TVL, total vaginal length. becomes more difficult when the effects of gravity are
Adapted from Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey more pronounced, such as after long periods of stand-
JO, Klarskov P, et al. The standardization of terminology of female
pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet ing (4). In addition, splinting (ie, the need to push on or
Gynecol 1996;175:107. support the bulging tissue) may be required to initiate or
complete voiding.
2 Practice Bulletin No. 176

Assessment of bowel function should be undertaken a urinalysis, with culture and microscopy performed if
to determine if there is a history of straining with bowel indicated. Urodynamic testing may help inform patient
movements, laxative use, fecal incontinence, and incom- counseling and may be considered if there is bother-
plete rectal emptying. The symptom of splinting often is some incontinence with stage II or greater prolapse or
correlated with the presence of a posterior compartment voiding dysfunction. If findings on initial assessment
defect (eg, rectocele). Each patient should be assessed do not concur with symptoms, more specific imaging
for symptoms of dyspareunia, coital incontinence (of or referral to a specialist in urogynecologic care may be
urine or stool), and sexual dysfunction that is related to needed.
the prolapse.
Is the pelvic organ prolapse quantification
Physical Examination examination necessary before treatment of
Physical examination should include an abdominal and pelvic organ prolapse?
pelvic examination to rule out pelvic masses. The exter-
A POP-Q examination is recommended before treat-
nal genitalia and vaginal epithelium should be evaluated
ment of POP to objectively evaluate and document the
for vaginal atrophy, skin irritation, or ulceration (27).
extent of prolapse. Evaluation and documentation of
Simply spreading the labia while examining the patient
the extent of the prolapse is important before treatment
in a supine position can be helpful to assess the maxi-
so that the surgeon has a preoperative comparator by
mum descent of the prolapse. A detailed examination of
which to measure postoperative anatomic success. The
the POP should be performed with a split speculum (ie,
POP-Q system is the only validated method for objective
separate a bivalve speculum and use only the posterior
measurement of prolapse in the three pelvic compart-
blade to examine the apex and anterior vaginal wall,
ments: 1) anterior, 2) apical, and 3) posterior (Fig. 1)
then turn the blade over and use it to hold the anterior
(2830). The POP-Q system is recommended by the
wall while examining the postvaginal wall and perineal
major national and international urogynecologic health
body as the patient performs the Valsalva maneuver,
organizations, including the American Urogynecologic
repetitive coughing, or both). Performance of a pelvic
Society, the Society of Gynecologic Surgeons, and
organ prolapse quantification (POP-Q) examination is
the International Continence Society (31). In addition,
recommended before treatment for the objective evalu-
POP-Q is used in most scientific publications on POP
ation and documentation of the extent of prolapse (see
(32). Although the BadenWalker system clinically
Is the pelvic organ prolapse quantification examination
describes prolapse findings, the POP-Q system is more
necessary before treatment for pelvic organ prolapse?)
precise and has been shown to be reproducible.
If a patients prolapse symptoms are not confirmed
The POP-Q system does not use the terms cysto-
by the extent of prolapse observed during supine pel-
cele and rectocele but instead uses terms for each
vic examination, repeating the pelvic examination in
the standing position may reveal the greatest descent prolapsed segment because the exact organ that lies
of POP. behind the prolapsed vaginal epithelium may not be
Pelvic floor muscle tone should be assessed (27). It clear from the clinical examination. It incorporates mea-
should be noted if the pelvic floor muscles can contract surements of the vaginal length, genital hiatus, and peri-
and relax volitionally. The strength of the contraction neal body. The POP-Q measurements can be converted
should be described as absent, weak, normal, or to stages based on the most severely prolapsed vaginal
strong (4). segment (Box 1) (28).
A validated examination allows for consistency
in reporting and facilitates communication between
Is additional testing beyond history and
gynecologic care providers. It is particularly important
physical examination needed to evaluate
if a patient has a recurrent prolapse because it will
women with pelvic organ prolapse?
allow a new gynecologic care provider to understand
In general, no additional testing beyond a complete the patients POP history. Outcomes can be evaluated
gynecologic, urologic, and defecatory history and physi- only if pretreatment POP measurements are recorded
cal examination is needed before treatment. However, accurately.
if the prolapse is beyond the hymen or the patient has For patients desiring expectant management, docu-
voiding symptoms, a postvoid residual urine volume mentation of the prolapse with the POP-Q allows an
should be recorded either with a catheter or ultrasonog- objective, validated, baseline measurement that can be
raphy (27). If there is urinary urgency or other lower referred to if symptoms change over time. Although
urinary tract symptoms, minimum assessment involves recording a POP-Q examination is not necessary for
Practice Bulletin No. 176 3

Figure. 1. Pelvic organ prolapse quantification system. Nine defined points measured in the midline and relative to the hymen
assessed during maximal Valsalva except for TVL: Aa, 3 cm proximal to the external urethral meatus; Ba, most prolapsed portion of the
anterior vaginal wall; C, leading edge of the cervix or vaginal cuff; gh, middle of the urethral meatus to the midline of the posterior
hymen; pb, middle of the posterior hymen to the middle of the anal opening; tvl, maximum depth of the vagina with prolapse reduced;
Ap, 3 cm proximal to the posterior hymen; Bp, most prolapsed portion of the posterior vaginal wall; D, posterior fornix in a woman
who has a cervix. (Reprinted with permission from Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The
standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:1017.)
these patients, it may be helpful to determine if there is the future. A vaginal pessary is an effective nonsurgi-
an anatomic change over time. cal treatment for women with POP, and up to 92% of
women can be fitted successfully with a pessary (37).
Are effective nonsurgical treatments avail- In one study protocol, a ring pessary was inserted first,
able for women with pelvic organ prolapse? followed by a Gellhorn pessary if the ring did not stay in
For women with asymptomatic prolapse, education and place. Ring pessaries were used more successfully with
reassurance are appropriate. Women may not realize stage II (100%) and stage III (71%) prolapse, and stage
that symptoms of voiding or defecatory dysfunction are IV prolapse more frequently required Gellhorn pes-
related to prolapse, so education about how prolapse saries (64%) (38). If possible, women should be taught
symptoms manifest can be helpful. to change their pessary independently. If a woman
Some symptoms related to pelvic organ prolapse is unable to remove and replace her pessary, regular
may be managed with lifestyle modifications. For follow-up (such as every 34 months) is necessary.
example, defecatory dysfunction may improve with fiber Annual follow-up is recommended for patients who are
supplementation and use of an osmotic laxative (33). able to maintain pessary hygiene on their own.
Sitting with feet elevated may decrease bulge symptoms. Pressure on the vaginal wall from the pessary may
Pelvic muscle exercises, performed either independently result in local devascularization or erosion in 29%
or under professional supervision may improve symp- of patients (39). Therapy should consist of removing
toms or slow the progression of POP (34, 35). the pessary for 24 weeks and local estrogen therapy.
There is limited evidence for the treatment or pre- Resolution may occur without local estrogen therapy.
vention of POP with local or systemic estrogen (36). If the problems persist, more frequent pessary changes
However, some clinicians believe that local estrogen or a different pessary may be required (39). Caregivers
may help with the vaginal irritation associated with POP. to patients with dementia should be made aware of the
Women considering treatment of POP should be regular pessary changes needed to avoid complications.
offered a vaginal pessary as an alternative to surgery. Although rare complications such as fistula can occur,
A pessary should be considered for a woman with pessary use is a low-risk intervention that can be offered
symptomatic POP who wishes to become pregnant in to all women who are considering treatment of POP (40).

When is surgery indicated for the manage- sacrospinous ligaments. Uterosacral and sacrospinous
ment of pelvic organ prolapse, and what are ligament suspension for apical POP with native tissue
the primary approaches? are equally effective surgical treatments of POP, with
comparable anatomic, functional, and adverse outcomes
Surgery is indicated for the treatment of POP in women (21). In the Operations and Pelvic Muscle Training
who are bothered by their POP and have failed or declined in the Management of Apical Support Loss trial, the
nonsurgical treatments. There are various vaginal and 2-year follow-up surgical success rate was 64.5% for
abdominal surgical approaches for the treatment of POP uterosacral ligament suspension compared with 63.1%
(Table 1). Important considerations for deciding the type for sacrospinous ligament fixation (adjusted odds ratio
and route of surgery include the location and severity [OR], 1.1; 95% confidence interval [CI], 0.71.7) (21).
of prolapse, the nature of the symptoms (eg, presence The serious adverse event rate at 2-year follow-up was
of urinary, bowel, or sexual dysfunction), the patients 16.5% for uterosacral ligament suspension compared
general health, patient preference, and the surgeons with 16.7% for sacrospinous ligament fixation (adjusted
expertise (41). OR, 0.9; 95% CI, 0.51.6) (21). Uterosacral ligament
suspension can be performed by attaching the vaginal
Are vaginal surgical approaches effective for apex bilaterally to the ipsilateral uterosacral ligament
the management of pelvic organ prolapse? or by attaching the vaginal apex to uterosacral ligament
complex that is plicated in the midline (42, 43, 45). It
Vaginal hysterectomy and vaginal apex suspension with is important that an adequate segment of uterosacral
vaginal repair of anterior and posterior vaginal wall pro- ligament is secured to the vagina. This often requires
lapse as needed are effective treatments for most women attachment to the midportion of the uterosacral ligament
with uterovaginal and anterior and posterior vaginal wall close to the ischial spine. Alternatively, the sacrospinous
prolapse (21, 22, 42, 43). Vaginal native tissue repairs ligament can be used to support the vaginal apex. A
are performed without the use of synthetic mesh or graft unilateral right sacrospinous ligament fixation usually is
materials. These are relatively low-risk surgeries that used for the attachment point to avoid dissection around
may be considered as surgical options for most women the colon (46).
with primary POP. Anterior colporrhaphy is an effective treatment
If a patient has uterine prolapse, vaginal hyster- for most anterior vaginal wall prolapse (47). Many
ectomy alone is not adequate treatment. Vaginal apex women with anterior vaginal wall prolapse also have
suspension should be performed at the time of hysterec- an apical prolapse (48). In these women, surgery
tomy for uterine prolapse to reduce the risk of recurrent should correct the apical prolapse and the anterior
POP (23, 44). Vaginal apex suspension involves attach- vaginal wall prolapse. Resupport of the vaginal apex
ment of the vaginal apex to the uterosacral ligaments or concurrently with repair of the anterior vaginal wall
Table 1. Types of Pelvic Organ Prolapse Surgery
Surgical Technique Aim Indication

Abdominal sacral colpopexy To correct upper vaginal prolapse Most commonly used in women with recurrent
cystocele, vault, or enterocele
Uterosacral ligament suspension To correct upper vaginal prolapse Performed at the time of hysterectomy or in patients
with posthysterectomy vaginal vault prolapse
Sacrospinous fixation To correct upper vaginal prolapse Performed at the time of hysterectomy or in patients
with posthysterectomy vaginal vault prolapse
Anterior vaginal repair To correct anterior wall prolapse May be used for the treatment of prolapse of the
(anterior colporrhaphy) bladder or urethra (bladder, urethra, or both
herniate downward into the vagina)
Posterior vaginal repair To correct posterior wall prolapse May be used for the treatment of rectocele (rectum
(posterior colporrhaphy) and bulges or herniates forward into the vagina), defects
perineorrhaphy of the perineum, or both
Vaginal repair with synthetic mesh or To correct anterior wall prolapse, Depending on the specific defect, the mesh
biologic graft augmentation apical vaginal prolapse, or both augmentation can either be anterior, apical, or both.
This repair is not routinely recommended.
Adapted from Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Marjoribanks J. Transvaginal mesh or grafts compared with native tissue repair for vaginal
prolapse. Cochrane Database Syst Rev 2016 Feb 9;2:CD012079.

defect reduces the risk of recurrent POP surgery (23). cine dermal xenograft used in this study is no longer
Paravaginal defects are lateral detachments of the vagi- available (60). In a study that evaluated the 5-year
nal wall from the fascial condensations over the leva- surgical outcomes of abdominal sacrocolpopexy among
tor ani muscles (49, 50). Diagnosis of paravaginal patients randomized to receive polypropylene mesh or
defects by physical examination is unreliable (51, 52). cadaveric fascia lata, use of synthetic mesh resulted in
Moreover, if a paravaginal defect is suspected, there better anatomic cure than use of cadaveric fascia lata
usually is apical loss of support (50). Apical support grafts (93% [27 out of 29] versus 62% [18 out of 29],
procedures may address most anterior vaginal wall P=.02) (61).
defects, including paravaginal defects (53). Abdominal sacrocolpopexy with synthetic mesh has
Posterior vaginal wall repair traditionally has been a lower risk of recurrent POP but is associated with more
performed through a midline plication of the posterior complications than vaginal apex repair with native tis-
vaginal wall fibromuscular connective tissue (54). The sue. Data from randomized controlled trials also show a
repair should be performed without placing tension significantly greater likelihood of anatomic success with
on the levator ani muscles because this may lead to mesh abdominal sacrocolpopexy compared with vaginal
dyspareunia (55). Perineorrhaphy that results in reat- apex repair with native tissue (pooled OR, 2.04; 95% CI,
tachment of the perineal muscles to the rectovaginal 1.123.72) (62). Surgical complications that are more
septum can be performed as needed if a perineal defect common after abdominal sacrocolpopexy with mesh
is present. An alternative technique for performing pos- include ileus or small-bowel obstruction (2.7% versus
terior vaginal wall repair is site-specific repair, which 0.2%, P<.01), thromboembolic phenomena (0.6% versus
involves dissection of the vaginal epithelium off the 0.1%, P=.03), and mesh or suture complications (4.2%
underlying fibromuscular connective tissue and repair versus 0.04%, P<.01) (62). In addition, sacrocolpopexy
of localized tissue defects with sutures. A finger often is with mesh is associated with a significant reoperation
placed in the rectum and directed anteriorly to identify rate due to mesh-related complications. Long-term (ie,
various tissue defects of the posterior vaginal wall (56). 7-year) follow-up of participants of the Colpopexy and
Although a retrospective comparison of site-specific Urinary Reduction Efforts (CARE) trial found that the
repair and midline colporrhaphy found that site-specific estimated rate of mesh complications (erosion into the
repair was associated with a higher rate of recurrence of vagina, visceral erosions, and sacral osteitis) was 10.5%
a symptomatic bulge (11% versus 4%, P=.02) (57), a (95% CI, 6.816.1), with a significant number of reop-
prospective study showed comparable outcomes for the erations (20). Many of the CARE trial sacrocolpopex-
two techniques (58). ies, however, were performed with non-type 1 mesh,
which may have increased the mesh complication rate.
When is abdominal sacrocolpopexy indicated Because of complications attributed to multifilament and
for the management of pelvic organ prolapse? small-pore-size synthetic mesh, type 1 synthetic meshes
(monofilament with large pore size) currently are used
Abdominal sacrocolpopexy is a proven and effective sur- in the United States.
gery for the treatment of POP (20, 59). This procedure
involves placement of a synthetic mesh or biologic graft Do patients benefit from a minimally invasive
from the apex of the vagina to the anterior longitudinal approach to pelvic organ prolapse surgery?
ligament of the sacrum. Women who may be candidates
for abdominal sacrocolpopexy include those who have Sacrocolpopexy with or without supracervical hys-
a shortened vaginal length, intra-abdominal pathology, terectomy or total hysterectomy can be performed
or risk factors for recurrent POP (eg, age younger than laparoscopically with or without robotic assistance (63).
60 years, stage 3 or 4 prolapse, and body mass index Although open abdominal sacrocolpopexy is associ-
greater than 26) (2426). In women who are at increased ated with shorter operative times (222 minutes versus
risk of synthetic mesh-related complications (eg, chronic 296 minutes; P<.02), minimally invasive sacrocolpo-
steroid use, current smoker), sacrocolpopexy with a bio- pexy is associated with less blood loss (122 146 mL
logic graft or alternatives to a sacrocolpopexy could be versus 187 142 mL; P<.01) and shorter hospitalization
considered. (1.3 1 days versus 2.9 1.6 days; P< .01) (64). Similar
Studies evaluating abdominal sacrocolpopexy with results were seen in a randomized controlled trial that
biologic grafts show conflicting results. Abdominal compared open abdominal sacrocolpopexy with laparo-
sacrocolpopexy with porcine dermis xenograft had scopic sacrocolpopexy, in which mean blood loss was
efficacy similar to that of abdominal sacrocolpopexy significantly greater in the open arm (mean difference
with synthetic polypropylene mesh. However, the por- [MD] 184 mL; 95% CI, 96272), and there were fewer

inpatient days in the laparoscopic group (MD, 0.9 days; such as cardiac disease, chronic obstructive pulmonary
95% CI, 0.11.7) (65). disease, or thromboembolic disease. In addition, oblit-
Although robotic assistance shortens the learning erative procedures for the treatment of POP are associ-
curve for performing laparoscopic sacrocolpopexy and ated with low rates of complications, intensive care unit
improves surgeon ergonomics (6668), it has not been admissions, and mortality (6.8%, 2.8%, and 0.15%,
shown to improve short-term outcomes for patients respectively) (82). Patients undergoing obliterative pro-
(6972). In two randomized controlled trials that com- cedures must be committed to no longer having vaginal
pared robot-assisted sacrocolpopexy with laparoscopic sexual intercourse. In a multisite prospective study
sacrocolpopexy, operating time, postoperative pain, and of older women (mean age 79 years) who underwent
cost were found to be significantly greater in the obliterative repair of POP, 95% of patients (125 out of
robot-assisted group (69, 72). The groups had similar 132) reported being satisfied or very satisfied with the
anatomic and functional outcomes 6 months to 1 year results of the procedure 1 year after surgery (79). Patient
after surgery, although the robotic experience of the regret also has been reported to be low. Among women
surgeons was low at the start of the study, which may interviewed more than 1 year after obliterative prolapse
have affected the results (73). Overall, the current litera- repair, only 9% (3 out of 32) reported they regretted hav-
ture is too scant to adequately indicate which minimally ing the procedure (81).
invasive approach should be recommended. Further Common types of obliterative surgical repair of POP
comparative studies that assess long-term anatomic and include a Le Fort-style partial colpocleisis and total col-
functional outcomes and patient safety and that identify pectomy. Le Fort partial colpocleisis is performed when
subgroups of patients who would benefit from a robotic the uterus is preserved at the time of prolapse repair.
approach are warranted (74). This procedure involves denuding a strip of epithelium
from the anterior and posterior vaginal walls and then
Is posterior vaginal wall prolapse repair suturing them together (83). This leaves lateral canals to
more effective with a transanal or transvagi- drain the secretions from the cervix. Because the uterus
nal incision? is difficult to access postoperatively, normal results from
cervical cytology and human papillomavirus testing
Posterior vaginal wall prolapse repair is more effective
when performed through a transvaginal incision than and an endometrial evaluation usually are documented
a transanal incision. Systematic review findings show before surgery. For posthysterectomy vaginal prolapse, a
that, compared with transanal incision, posterior vaginal colpectomy or tight anterior and posterior colporrhaphy
repair results in fewer recurrent prolapse symptoms (rel- creating a constricted vagina is a surgical option if a
ative risk [RR], 0.4; 95% CI, 0.21.0), lower recurrence patient is amenable to an obliterative procedure. In total
on clinical examination (RR, 0.2; 95% CI, 0.10.6), colpectomy procedures, the entire vaginal epithelium is
and a smaller mean depth of rectocele on postoperative denuded and sutures are used to invert the vagina (83).
defecography (MD, 1.2 cm; 95% CI, 2.0 to 0.3) (75). With any obliterative procedure, a suburethral plication
or midurethral sling and a perineorrhaphy often are rec-
Are surgical approaches available to treat ommended to decrease the risk of postoperative stress
pelvic organ prolapse in women with medical urinary incontinence and recurrent posterior vaginal wall
comorbidities? prolapse (80).
Obliterative procedureswhich narrow, shorten, or com- What can be recommended regarding cur-
pletely close the vaginaare effective for the treatment rently available synthetic mesh and biologic
of POP and should be considered a first-line surgical graft materials for use in vaginal pelvic
treatment for women with significant medical comor- organ prolapse surgery?
bidities who do not desire future vaginal intercourse or
vaginal preservation (7679). Obliterative procedures The use of synthetic mesh or biologic grafts in POP
have high reported rates of objective and subjective surgery is associated with unique complications not seen
improvement of POP (98% and 90%, respectively) (80) in POP repair with native tissue. A systematic review of
and are associated with a low risk of recurrent POP (76, seven randomized controlled trials that compared native
80, 81). Because obliterative surgical procedures can be tissue repair with synthetic mesh vaginal prolapse repair
performed under local or regional anesthesia, these pro- found that more women in the mesh group required
cedures may be especially beneficial for the treatment of repeat surgery for the combined outcome of prolapse,
POP in women with significant medical comorbidities stress incontinence, or mesh exposure (RR, 2.40;
that preclude general anesthesia or prolonged surgery, 95% CI, 1.513.81) (41). The rate of mesh exposure

was 12%, and 8% of women required repeat surgery for between the groups (RR, 1.09; 95% CI, 0.452.62) (58,
mesh exposure up to 3 years after the initial surgery (41). 75, 87). There was no difference in the rate of postop-
Systematic review findings show that vaginal repair of erative dyspareunia between the groups (RR, 1.26; 95%
prolapse with biologic grafts (tissue from human cadaver CI, 0.592.68). Another trial that compared posterior
or other species) results in similar rates of awareness of biologic graft repair with traditional repair noted worse
prolapse and reoperation for prolapse compared with anatomic outcomes with posterior biologic graft repair
repairs using native tissue (41). However, it is difficult than with traditional repair (46% versus 14%; P=0.02)
to make an overall recommendation about the use of (19, 58). Thus, synthetic mesh or biologic grafts should
biologic grafts for vaginal prolapse repair because the not be placed routinely through posterior vaginal wall
available evidence is of low quality, and most of the incisions to correct POP for primary repair of posterior
biologic grafts that were used in studies to date are no vaginal wall prolapse.
longer available.
Synthetic mesh placed through a transvaginal inci- Anterior Vaginal Repair
sion to correct POP has been studied extensively, Polypropylene mesh augmentation of anterior vaginal
although there are few long-term (greater than 3 years) wall prolapse repair improves anatomic and some sub-
studies regarding the effectiveness of procedures cur- jective outcomes but does not affect reoperation rates
rently being performed, as many transvaginal mesh for recurrent prolapse and is associated with a higher
products were removed from the market following rate of complications compared with native tissue
the 2011 U.S. Food and Drug Administration (FDA) vaginal prolapse repair (41). Polypropylene mesh grafts
announcement that identified serious safety and effec- placed through anterior vaginal wall incisions improve
tiveness concerns over the use of transvaginal mesh to subjective outcomes and the anatomic success rates for
treat POP (84). In January 2016, the FDA issued two repair of anterior vaginal wall defects compared with
final orders regarding surgical mesh that is used to repair native tissue repair (88, 89). However, vaginally placed
POP transvaginally (85): polypropylene mesh is associated with longer operating
1. The FDA reclassified this surgical meshfrom times and greater blood loss compared with native tis-
class II, which generally includes moderate-risk sue anterior repair (88, 90). The use of vaginally placed
devices, to class III, which generally includes high- polypropylene mesh does not decrease the chance of
risk devices. having a repeat surgery for POP and may lead to surger-
2. The FDA required manufacturers to submit a pre- ies to correct mesh-related complications.
market approval application to support the safety Pelvic organ prolapse vaginal mesh repair should be
and effectiveness of surgical mesh for the transvagi- limited to high-risk individuals in whom the benefit of
nal repair of POP. mesh placement may justify the risk, such as individuals
with recurrent prolapse (particularly of the anterior or
Subsequently, in January 2017, the FDA reclassified all apical compartments) or with medical comorbidities that
urogynecologic surgical mesh instrumentation (whether preclude more invasive and lengthier open and endo-
used for transvaginal POP repair or other urogynecologic scopic procedures. Before placement of synthetic mesh
surgical mesh procedures) from class I (low risk) exempt grafts in the anterior vaginal wall, patients should pro-
from premarket notification to class II (moderate risk) vide their informed consent after reviewing the benefits
and subject to premarket notification (86). and risks of the procedure and discussing alternative
repairs. For more information, see Committee Opinion
Posterior Vaginal Repair
No. 694, Management of Mesh and Graft Complications
The use of synthetic mesh or biologic grafts in trans- in Gynecologic Surgery.
vaginal repair of posterior vaginal wall prolapse does not
improve outcomes (41). In addition, there are increased Is special training required to perform pelvic
complications (eg, mesh exposure) associated with organ prolapse procedures that use mesh or
placement of mesh through a posterior vaginal wall inci- biologic grafts?
sion (54). In two randomized trials that compared native
tissue with biologic graft material for the repair of poste- Surgeons who perform POP surgery with biologic
rior prolapse, the objective failure rate was significantly grafts or synthetic mesh grafts should have training
lower at the 1-year follow up in the native tissue group specifically for these procedures and should be able
(10% [10 out of 98]) as compared with the biologic to counsel patients regarding the riskbenefit ratio for
graft group (21% [20 out of 93]) (RR, 0.47; 95% CI, the use of mesh compared with native tissue repair.
0.240.94), and the subjective failure rate was similar There are unique risks and complications associated

with the use of mesh in surgeries to treat POP. Special incision also can be performed. A 2016 cohort study that
training regarding patient selection, anatomy, surgical compared laparoscopic sacral hysteropexy with vaginal
technique, postoperative care, and management of com- mesh hysteropexy found that, at 1-year follow-up, the
plications is necessary for physicians who perform POP two procedures had similar efficacy and no significant
surgery using mesh or biologic grafts (84, 90, 91). The differences in the rate of complications, blood loss, or
American Urogynecologic Society has published guide- length of hospitalization (101).
lines for training and privileging for the performance of Benefits of hysteropexy compared with total hys-
abdominal sacrocolpopexy and vaginal mesh prolapse terectomy include shorter operative time and a lower
surgery (92, 93). incidence of mesh erosion if mesh augmentation is used.
In comparison, women with uterine prolapse who choose
Is it necessary to perform intraoperative hysterectomy will have a lower risk of uterine and cervi-
cystoscopy during pelvic organ prolapse cal cancer or any procedures that involve abnormalities
surgery? of the cervix or uterus (eg, endometrial biopsy). They
will not become pregnant and will not have uterine bleed-
Routine intraoperative cystoscopy during POP surgery is
ing or pain.
recommended when the surgical procedure performed is
Outcome data comparing hysterectomy with hys-
associated with a significant risk of injury to the bladder
teropexy are not clear. In one study, vaginal hysterec-
or ureter. These procedures include suspension of the
tomy for the treatment of stage II or greater POP was
vaginal apex to the uterosacral ligaments, sacrocolpo-
associated with a lower risk of recurrent prolapse than
pexy, and anterior colporrhaphy and the placement of
hysteropexy (100). However, in a randomized trial
mesh in the anterior and apical compartments (94, 95).
that compared sacrospinous hysteropexy with vaginal
Intraoperative cystoscopy is performed after com-
hysterectomy and uterosacral ligament vaginal vault
pletion of POP repair while the patient is still under
suspension for stage 2 or greater POP, sacrospinous
anesthesia and should include a complete survey of the
hysteropexy was found to be noninferior to vaginal hys-
bladder and assessment of efflux of urine from the ure-
terectomy (for anatomic recurrence of the apical com-
teral orifices. Identified issues such as no flow or reduced
partment with bothersome bulge symptoms or repeat
flow from the ureter or an injury to the bladder should surgery for recurrent apical prolapse): sacrospinous hys-
be addressed intraoperatively. Delay in recognition of a teropexy 0% (n=0) versus vaginal hysterectomy 4.0%
urinary tract injury may lead to increased morbidity (96). (n=4), a difference of 3.9% (95% CI, 8.6%0.7%)
over 12 months (102). Longer-term follow-up on this
Are there effective pelvic organ prolapse cohort of women is needed. Another study that com-
surgical treatment methods available for pared postoperative sexual function in women who
women who prefer to avoid hysterectomy? underwent hysteropexy with women who underwent
Women who desire surgical treatment of POP may hysterectomy found no significant difference between
choose to avoid hysterectomy for a variety of reasons, the two groups (98). There is little information regarding
including preservation of fertility, maintenance of body pregnancy after uterine suspension (103).
image, and beliefs about adverse effects on sexual func-
tion (9799). Alternatives to hysterectomy for the surgi- Le Fort Colpocleisis
cal treatment of POP include hysteropexy (ie, uterine In women with POP who want to avoid hysterectomy or
suspension) and Le Fort colpocleisis. who have significant comorbidities and no longer desire
vaginal coital function, a Le Fort colpocleisis is a thera-
Hysteropexy peutic option. This is an effective treatment for POP
Hysteropexy is a viable alternative to hysterectomy in with a high success rate and high patient satisfaction.
women with uterine prolapse, although there is less However, patients should be counseled that this surgery
available evidence on safety and efficacy compared is irreversible (77). For more information, see Are surgi-
with hysterectomy (99). Hysteropexy may be performed cal approaches available to treat pelvic organ prolapse
through a vaginal incision by attaching the cervix to the in women with medical comorbidities?)
sacrospinous ligament with sutures (100) or mesh (101).
Hysteropexy also may be performed abdominally or lap- Can the occurrence of stress urinary inconti-
aroscopically by placing a mesh or biologic graft from nence after surgery for pelvic organ prolapse
the cervix to the anterior longitudinal ligament (99). be anticipated and avoided?
Shortening the uterosacral ligaments laparoscopically All women with significant apical prolapse, anterior
with or without robotic assistance or by an abdominal prolapse, or both should have a preoperative evaluation

for occult stress urinary incontinence, with cough stress For more information, see Practice Bulletin No. 155,
testing or urodynamic testing with the prolapse reduced Urinary Incontinence in Women (104).
(104). Some women will have a positive cough stress
test result only when their POP is in the reduced posi- What are the complications of pelvic organ
tion. Prolapse may obstruct the urethra or the urethra prolapse surgery, and how are they managed?
might kink from an anterior vaginal wall prolapse. This
Complications after native tissue POP surgery include
could mask stress urinary incontinence, which then may
bleeding, infection (typically urinary tract) and voiding
present after surgery. In women with bothersome POP
dysfunction (which usually is transient). Less common
and current stress urinary incontinence symptoms, it is
complications include rectovaginal or vesicovaginal
prudent to correct both disorders to reduce persistent
fistula, ureteral injury, foreshortened vagina, or a restric-
or worsening stress incontinence after surgery. Because
tion of the vaginal caliber (21, 75). In the Operations and
there is no single procedure that adequately treats POP
Pelvic Muscle Training in the Management of Apical
and urinary incontinence, two procedures are done con-
Support Loss trial, dyspareunia was noted in 16% of
comitantly. Thus, women with bothersome stress urinary
women 24 months after native tissue POP surgery (107).
incontinence who are undergoing POP surgery should
Changes in vaginal anatomy may lead to pelvic pain and
consider having concomitant treatment for both disor-
pain with intercourse. Fistula and ureteral injury require
ders. The type of continence procedure often is selected
prompt referral to specialists with expertise in managing
based on the route of access for the prolapse repair (104).
these conditions. A short vagina or vaginal constriction
Patients with POP but without stress urinary incon-
after POP surgery often can be managed with vaginal
tinence who are undergoing either abdominal or vaginal
estrogen and progressive dilators (108). If these manage-
prolapse repair should be counseled that postoperative
ment methods are not successful, referral to a specialist
stress urinary incontinence is more likely without a
who is experienced with surgical correction of postop-
concomitant continence procedure but that the risk of
erative POP complications is recommended.
adverse effects is increased with an additional procedure
There are unique complications associated with syn-
(104). Burch colposuspension at the time of abdominal
thetic mesh when they are used in POP surgery. These
sacrocolpopexy and retropubic midurethral sling at the
include mesh contracture and erosion into the vagina,
time of vaginal surgery for POP repair decrease the
urethra, bladder, and rectum. The rate of mesh erosion is
risk of postoperative stress urinary incontinence in
approximately 12% after vaginal mesh prolapse surgery
women without preoperative stress urinary inconti-
(41). When mesh is used for anterior vaginal wall pro-
nence (104106). In the CARE trial, women with no
lapse repair, there is a 10% risk of mesh extrusion, with
reported preoperative stress urinary incontinence who
6% of these cases requiring surgical correction (88). The
were undergoing open abdominal sacrocolpopexy for
rate of dyspareunia is approximately 9% after vaginal
prolapse repair were randomized to receive concomi-
mesh prolapse surgery (109). Multiple procedures often
tant Burch colposuspension or no continence procedure
are required to manage mesh-related complications
(105). Fewer women who underwent concomitant Burch
(110). Referral to an obstetriciangynecologist with
colposuspension had postoperative stress incontinence
appropriate training and experience, such as a female
compared with those who underwent sacrocolpopexy
pelvic medicine and reconstructive surgery specialist, is
alone (34% versus 57%, P<.001). Similar results were
recommended for surgical treatment of prolapse mesh
found in the outcomes after the Vaginal Prolapse Repair
complications. For more information, see Committee
and Midurethral Sling trial, which evaluated placement
Opinion No. 694, Management of Mesh and Graft
of a prophylactic midurethral sling at the time of vaginal
Complications in Gynecologic Surgery.
prolapse surgery (106). Among the women who under-
went prophylactic midurethral sling placement at the
How should recurrent pelvic organ prolapse
time of vaginal surgery, 24% developed stress urinary
be managed?
incontinence after surgery, compared with 49% in those
who underwent only POP surgery. Recurrence of POP is possible after any POP surgery.
In women undergoing vaginal POP surgery, the Recurrence rates between 6% and 30% have been
risks of complications from the stress urinary incon- reported (19). Women should be counseled about the
tinence surgery should be weighed against the risk of risk of recurrence before undergoing POP surgery.
postoperative stress urinary incontinence. Some prac- Women who present with recurrent POP should
titioners favor a staged approach in which women undergo counseling similar to that for women who pres-
undergo stress urinary incontinence surgery after POP ent with primary POP. It is helpful to review the preop-
surgery only if they develop stress urinary incontinence. erative examination results and prior surgical reports.

Many patients may choose not to undergo a repeat sur- more complications than vaginal apex repair with
gery. They may choose instead to monitor the prolapse native tissue.
or to use a pessary.
Obliterative procedureswhich narrow, shorten, or
If a patient chooses to undergo surgery for recur- completely close the vaginaare effective for the
rent vaginal apex prolapse, abdominal sacrocolpopexy, treatment of POP and should be considered a first-
vaginal colpopexy with possible mesh or graft augmen- line surgical treatment for women with significant
tation, or colpocleisis may be considered if the patient medical comorbidities who do not desire future
has failed a vaginal native tissue apical suspension.
vaginal intercourse or vaginal preservation.
If the surgeon is not comfortable performing these pro-
cedures, referral of the patient to a surgeon who sub- The use of synthetic mesh or biologic grafts in POP
specializes in pelvic reconstructive surgery and can offer surgery is associated with unique complications not
these procedures is recommended. seen in POP repair with native tissue.
Hysteropexy is a viable alternative to hysterectomy
Summary of in women with uterine prolapse, although there is
less available evidence on safety and efficacy com-
Recommendations and pared with hysterectomy.
Conclusions The following recommendations are based primar-
The following recommendations and conclusions ily on consensus and expert opinion (Level C):
are based on good and consistent scientific evi-
dence (Level A): A POP-Q examination is recommended before
treatment for the objective evaluation and documen-
Uterosacral and sacrospinous ligament suspension tation of the extent of prolapse.
for apical POP with native tissue are equally effec-
tive surgical treatments of POP, with comparable A pessary should be considered for a woman with
anatomic, functional, and adverse outcomes. symptomatic POP who wishes to become pregnant
in the future.
The use of synthetic mesh or biologic grafts in trans-
vaginal repair of posterior vaginal wall prolapse Pelvic organ prolapse vaginal mesh repair should be
does not improve outcomes. limited to high-risk individuals in whom the benefit
of mesh placement may justify the risk, such as
Polypropylene mesh augmentation of anterior vagi- individuals with recurrent prolapse (particularly of
nal wall prolapse repair improves anatomic and
the anterior or apical compartments) or with medi-
some subjective outcomes but does not affect reop-
cal comorbidities that preclude more invasive and
eration rates for recurrent prolapse and is associated
lengthier open and endoscopic procedures. Before
with a higher rate of complications compared with
placement of synthetic mesh grafts in the anterior
native tissue vaginal prolapse repair.
vaginal wall, patients should provide their informed
The following recommendations and conclusions consent after reviewing the benefits and risks of the
are based on limited or inconsistent scientific evi- procedure and discussing alternative repairs.
dence (Level B): Surgeons who perform POP surgery with biologic
grafts or synthetic mesh grafts should have training
Many women with POP on physical examination do specifically for these procedures and should be able
not report symptoms of POP. Treatment is indicated to counsel patients regarding the riskbenefit ratio
only if prolapse is causing bothersome bulge and
for the use of mesh compared with native tissue
pressure symptoms, sexual dysfunction, lower uri-
repair.
nary tract dysfunction, or defecatory dysfunction.
Routine intraoperative cystoscopy during POP sur-
Women considering treatment of POP should be gery is recommended when the surgical procedure
offered a vaginal pessary as an alternative to surgery.
performed is associated with a significant risk of
Vaginal apex suspension should be performed at the injury to the bladder or ureter. These procedures
time of hysterectomy for uterine prolapse to reduce include suspension of the vaginal apex to the utero-
the risk of recurrent POP. sacral ligaments, sacrocolpopexy, and anterior col-
Abdominal sacrocolpopexy with synthetic mesh has porrhaphy and the placement of mesh in the anterior
a lower risk of recurrent POP but is associated with and apical compartments.

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Full-text document published concurrently in the April 2017
The MEDLINE database, the Cochrane Library, and issue of Female Pelvic Medicine & Reconstructive Surgery.
ACOGs own internal resources and documents were used
to conduct a literature search to locate relevant articles pub Copyright April 2017 by the American College of Obstetri
lished between January 2000 and October 2016. The search cians and Gynecologists. All rights reserved. No part of this
was restricted to articles published in the English language. publication may be reproduced, stored in a retrieval system,
Priority was given to articles reporting results of original posted on the Internet, or transmitted, in any form or by any
research, although review articles and commentaries also means, electronic, mechanical, photocopying, recording, or
were consulted. Abstracts of research presented at sympo otherwise, without prior written permission from the publisher.
sia and scientific conferences were not considered adequate Requests for authorization to make photocopies should be
for inclusion in this document. Guidelines published by directed to Copyright Clearance Center, 222 Rosewood Drive,
organizations or institutions such as the National Institutes Danvers, MA 01923, (978) 750-8400.
of Health and the American College of Obstetricians and
ISSN 1099-3630
Gynecologists were reviewed, and additional studies were
located by reviewing bibliographies of identified articles. The American College of Obstetricians and Gynecologists
When reliable research was not available, expert opinions 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
from obstetriciangynecologists were used. Pelvic organ prolapse. Practice Bulletin No. 176. American College of
Studies were reviewed and evaluated for quality according Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e5672.
to the method outlined by the U.S. Preventive Services
Task Force:
I Evidence obtained from at least one prop er
ly
designed randomized controlled trial.
II-1 Evidence obtained from well-designed con trolled
trials without randomization.
II-2 Evidence obtained from well-designed co hort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and con
sistent scientific evidence.
Level BRecommendations are based on limited or incon
sistent scientific evidence.
Level CRecommendations are based primarily on con
sensus and expert opinion.

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P RACTICE BULLET IN

clinical management guidelines for obstetrician gynecologists

Pelvic Organ Prolapse

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Table 1. Types of Pelvic Organ Prolapse Surgery

Surgical Technique Aim Indication

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