review

Pelvic organ prolapse: A primer for urologists

Michel Bureau, MD; Kevin V. Carlson, MD
Section of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada

Cite as: Can Urol Assoc J 2017;11(6Suppl2):S125-30. http://dx.doi.org/10.5489/cuaj.4634 uterus/cervix or the vaginal cuff and small bowel in post-
hysterectomy patients. Prolapse in an isolated segment can
See related commentary on page S131. occur, but most commonly, more than one compartment
is involved.
Abstract POP is a common condition; however, its true prevalence
is difficult to determine as POP typically remains asymp-
Pelvic organ prolapse (POP) results from weakness or injury of tomatic until it descends to the hymenal ring or beyond. 5
the pelvic floor supports with resulting descent of one or more In questionnaire-based population studies of non-pregnant
vaginal compartments (anterior, apical and/or posterior). Women adult women the prevalence of symptomatic POP ranges
typically become symptomatic from the bulging vaginal wall or from 2.9‒12.1%; 6,7 however, when basing prolapse on
related organ dysfunction once this descent reaches the introitus. examination findings, the prevalence increases to 75‒76%,
POP is a common condition, affecting more than half of adult
with 37‒38% having stage II or higher.7,8 In postmenopausal
women. Many women presenting to an urologist for stress urin-
ary incontinence or overactive bladder will have associated POP;
women enrolled in the Women’s Health Initiative, the preva-
therefore, it is important for urologists who treat these conditions lence of POP was 41% in patients with a uterus and 38%
to be familiar with its diagnosis and management. While POP is in subjects who had had a prior hysterectomy.9
part of the core urology training curriculum in some jurisdictions, Well-established risk factors for POP include age, par-
it is not in Canada.1 This article reviews the diagnosis of POP, ity, and obesity.10 Other risk factors include forceps delivery,
including pertinent symptoms to query in the history, important infant birth weight >4500 g, constipation, smoking, family his-
facets of a systematic pelvic examination, and the appropriate use tory of POP, connective tissue disease, occupation entailing
of ancillary tests. Treatment options are also discussed, including heavy lifting, previous hysterectomy, and ethnic origin.10
conservative measures, pessaries, and various reconstructive and
obliterative techniques.
Evaluation
Symptoms described by patients with POP may be due to
Introduction the prolapse itself or to associated or coexistent dysfunction
of the bladder, bowel, or pelvic floor. Physical symptoms
Pelvic organ prolapse (POP) and stress urinary incontinence commonly reported by patients include sensation of a bulge,
(SUI) are the result of inadequate pelvic floor support, of heaviness or pressure in the vagina, the feeling of “sitting on
which three anatomic levels have been described2,3 (Fig. 1). a ball,” or that “something is falling out.” Functional symp-
The International Continence Society defines pelvic organ toms can provide a clue as to what compartments may be
prolapse (POP) as: “the descent of one or more of: the anter- prolapsed, but correlate poorly with the degree of anatomical
ior vaginal wall, the posterior vaginal wall, and the apex of descent. These include storage and/or voiding lower urin-
the vagina (cervix/uterus) or vault (cuff) after hysterectomy.”4 ary tract symptoms, constipation or sensation of incomplete
Anterior compartment prolapse and SUI are caused by a emptying when passing stools, needing to manually splint the
weakness or injury of the pubocervical fascia with resulting vagina to facilitate emptying of the rectum, fecal or urinary
descent of the bladder (cystocele) and/or bladder neck (SUI). incontinence, and dyspareunia.10,11 Table 1 presents com-
Posterior compartment prolapse is caused by weakness or plaints that may be described by patients with POP. It is
injury of the rectovaginal septum resulting in protrusion of important to keep in mind that none of the symptoms associ-
the rectum (rectocele) and/or the small bowel (enterocele). ated with POP are specific except for the sensation of bulging.
Apical compartment prolapse refers to the decent of the Therefore, the clinician should have an extensive knowledge

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© 2017 Canadian Urological Association
Bureau et al.

Level I cially if the POP described by the

Uterosacral/cardinal patient is not initially appreciat-
ligament complex
ed.14 Furthermore, as the degree of
To arcus prolapse may be impacted by the
tendineus
fasciae pelvis
menstrual cycle and/or fatigue of
the pelvic floor muscles (PFMs), the
Level II
exam may need to be scheduled at
a time when prolapse is most likely
to be demonstrated. The external
To arcus genitalia are first inspected, then
tendineus
rectovaginalis
the vestibule and urethra are exam-
ined. Estrogenization of the tissues
Level III
and the presence of scarring from
prior surgery or obstetrical trauma
Obturator
should be noted. A Sims speculum
foramen or the posterior blade of a bivalve
speculum is used to depress the
External anal
sphincter posterior wall of the vagina to
Arcus tendineus Arcus tendineus Perineal better assess the anterior wall, and
rectovaginalis levator ani membrane
Perineal vice versa to assess the posterior
Vagina Urethra Superficial transverse
membrane perineal muscle wall. The cervix or vaginal cuff
Arcus tendineus
fasciae pelvis Perineal
External anal sphincter
can be examined using a complete
body
bivalve speculum. Subsequently, a
Fig. 1. Integrated levels of support: Illustration of the normal vaginal axis and the three levels of support of the bimanual exam should be done to
vagina and uterus from the perspective of a standing woman. In level I, the endopelvic fascia suspends the upper rule out other gynecological con-
vagina and cervix from the lateral pelvic walls. Fibers of level I extend both vertically and posteriorly toward the ditions. Finally, rectal and rectov-
sacrum. In level II, the vagina is attached to the arcus tendineus fasciae pelvis and superior fascia of the levator ani
aginal exams are performed to
muscles. In level III, the distal vagina is supported by the perineal membrane muscles. The insets show transverse
sections made through the vagina perpendicular to the normal axis at each level. Reproduced from: Barber MD. evaluate posterior POP and the
Contemporary views on female pelvic anatomy. Cleve Clin J Med 2005;72:S3-11. With permission from Cleveland perineal body.
Clinic Foundation. ©2005 Cleveland Clinic Foundation. All rights reserved.
Table 1. Symptoms commonly reported by patients with
of the differential diagnosis of pelvic complaints and use cau- POP10,11
tion when counselling a patient regarding the expectations of Vaginal:
a treatment for their POP. Finally, the psychological impacts -- Bulging sensation
-- Visualization of the prolapsed vagina
of POP should not be underestimated. Urinary and lower -- Bleeding from eroded vaginal mucosa
gastrointestinal tract dysfunction can be a significant source
Urinary:
of embarrassment in women and may contribute to social -- Incontinence
isolation, and discomfort or pain caused by the prolapsed -- Frequency and urgency
vagina may lead to restriction of activities and/or intimacy. -- Sensation of incomplete emptying
When evaluating a patient with POP, it is important to -- Weak stream
-- Intermittency
question all aspects of pelvic floor dysfunction. The clin-
-- Straining or need to change position to empty the bladder
ician should gather information regarding symptoms directly -- Manual reduction of POP to empty the bladder
caused by the prolapse and inquire about urinary, digest- Gastrointestinal:
ive and sexual symptoms. Past medical history should be -- Constipation
reviewed, as it may have an impact on the treatment options. -- Incontinence
In addition, a complete gynecological and obstetric history -- Sensation of incomplete emptying
-- Manual reduction of POP or pressure on the perineum to
should be taken. It is critical to determine if a patient is
empty the rectal ampulla (vaginal splinting)
sexually active or desires to be, as this may also factor into
Sexual:
treatment decisions. A variety of validated questionnaires -- Dyspareunia
exist to help in the assessment of the patient’s condition and -- Coital incontinence
its impact on her quality of life.12,13 Other:
Physical examination of women with POP is tradition- -- Pelvic discomfort, pain, or heaviness
ally performed in the dorsal lithotomy position. Ideally, the -- Lower back pain
exam should also be done in the standing position espe- POP: pelvic organ prolapse.

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 POP for urologists

The need for additional testing depends principally on degree of bother and impact on quality of life, desire for
the patient’s symptoms and clinician’s findings. To further sexual function, and patient preferences and expectations.
assess the patient’s bladder function a voiding diary, patient- Furthermore, available expertise and resources may play a
reported outcomes (PROs), measurement of post-void resid- role in treatment decisions. While broad treatment recom-
ual volume, or a urodynamic study (UDS) may be useful. In mendations can be made, each patient must be managed
postmenopausal women with vaginal bleeding, especially in in a highly individualized fashion.
the absence of ulceration of the vagina or cervix, the endo- In all cases, treatment begins with education about nor-
metrium should be evaluated with an ultrasound and/or a mal anatomy and function. Excessive stress on the pelvic
biopsy.15 In patients presenting with advanced prolapse, the floor from heavy lifting, chronic constipation, or cough
ureters may be obstructed; therefore, imaging of the upper should be corrected, and weight loss and smoking cessa-
urinary tract to rule out hydronephrosis may be prudent. tion are recommended when appropriate.21 Symptomatic
Several grading systems have been developed to describe urogenital atrophy should be treated with topical estrogen
POP. The Pelvic Organ Prolapse Quantification (POP-Q) replacement if there are no contraindications.22 Management
scale is one of the most commonly used and was designed options include continued observation, non-surgical inter-
to standardize assessment of POP.16 The system uses the ventions, and surgery.
position of six defined points measured in cm above or For asymptomatic women and those mildly bothered by
below a fixed point (the hymenal ring) while the patient is their condition, observation is often recommended; however,
straining. Three other parameters (total vaginal length, gen- if adverse sequelae of untreated prolapse — such as urinary
ital hiatus, and perineal body) are also measured with the retention, severe bowel dysfunction, or hydronephrosis — are
patient relaxed. The stage of prolapse can then be described present, treatment should be offered. Patients with advanced
based on the POP-Q score as shown in Table 2. POP choosing observation should be reassessed regularly to
Diagnostic imaging to characterize a patient’s POP is an ensure they do not develop any such complications.
emerging field of study, but in clinical practice is generally not Pelvic floor muscle training (PFMT), either self-directed or
necessary. In fact, there is often a discrepancy between radio- under the guidance of a therapist with specialty training, is typ-
logical and surgical findings, and there is a lack of standard- ically suggested as an initial non-surgical modality for stages
ized criteria for the radiological diagnosis of POP. Therefore, 1‒3 POP. Recent evidence indicates that PFMT under the guid-
imaging studies are mainly used in research settings.17 ance of a therapist provides superior results, with significant
Urinary incontinence is a frequent condition associat- numbers demonstrating an improvement in symptoms and
ed with POP. Interestingly, up to 44% of patients without by one stage on POP-Q examination.23-25 These observations
incontinence will develop stress urinary incontinence (SUI) have led the 5th International Consultation on Incontinence
once the prolapse is surgically reduced.18 This so-called latent, to upgrade its recommendation for this modality.26
or occult, SUI occurs when obstruction of the outlet caused In patients significantly bothered by their POP but who
by the prolapse is corrected, thus unmasking SUI. Latent SUI do not want surgery, and in those who are not medically
should be sought by the clinician during physical examination fit or planning to become pregnant again, a pessary can be
or UDS with the prolapse manually reduced (e.g., pessary), tried. These devices, usually made of silicone, come in a
as it may impact the treatment plan and outcomes. variety of shapes and sizes and are inserted in the vagina
It is also notable that 22‒88% of patients presenting with to reduce the prolapse by supporting the pelvic organs.
POP have coexistent overactive bladder (OAB) symptoms
that may need to be addressed.19 The pathophysiology most
Table 2. Stages of pelvic organ prolapse based on the
likely to explain this relationship is bladder outlet obstruc- POP-Q score
tion, although other factors, such as activation of urothelial Stage Description
stretch receptors or bladder neck funnelling to allow urine 0 No prolapse. Points Aa, Ba, Ap, Bp are all -3, and
to pool in the proximal urethra, may play a role. Following either C or D is within 2 cm of TVL
POP surgery, the impact on OAB is difficult to predict, and I Some prolapse is present, but the distal most
there is no reliable data to guide patient counselling in this point is >1 cm above the hymen
regard; however, it clearly does resolve in many cases,19 II The furthest distal point is within 1 cm of either
particularly with higher-stage prolapse.20 side of the hymen
III The distal most point is >1 cm but <(TVL-2) cm
beyond the hymen
Management IV Complete eversion of the vagina, usually with
the leading point being the cervix or vaginal cuff.
A patient-centred approach is taken in the management The distal point is at least (TVL-2) cm beyond the
of POP, taking into consideration the anatomic defect(s) hymen
present, effect on organ function, severity of symptoms, POP-Q: Pelvic Organ Prolapse Quantification; TVL: total vaginal length.

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Bureau et al.

Pessaries, when properly fitted by a trained clinician, usu- of the arcus tendineus fascia pelvis (ATFP) were corrected
ally improve or resolve symptoms associated with POP and by re-approximating the pubocervical fascia to the ATFP.
can also help with urinary and bowel symptoms. In women Understanding that many failures of anterior vaginal repairs
successfully fitted with a pessary, 40‒60% will continue were due to associated weakness of vaginal apical supports
use for more than 6‒12 months.27 Potential complications (DeLancey level I), contemporary anterior repair includes
of these devices are vaginal discharge, bleeding, erosion, re-approximation of pubocervical fascia to the vaginal apex
pain, constipation, and incontinence (including unmasking with or without associated vaginal vault suspension.
SUI).28 In the absence of contraindications, the concomitant Posterior vaginal repairs may address an enterocele,
use of topical estrogens is usually recommended. rectocele, and/or perineal body defect. Enteroceles may
Surgery for POP is indicated for women experiencing be addressed transvaginally via intra- or extraperitoneal
significant bother and wishing a definitive treatment. Surgery approaches. Most commonly, transvaginal native tissue
should only be done after childbearing is complete and, site-specific repairs are performed once the enterocele sac
depending on the case, after a proper trial of conservative is reduced, again with or without concomitant vaginal vault
measures. Numerous procedures have been described and suspension. More distally, posterior colporraphy restores the
their detailed review is beyond the scope of this article. support to the posterior wall of the vagina by correcting
General concepts regarding the correction of POP are pre- defects in the rectovaginal fascia over the rectum; however,
sented below. a site-specific approach obviating the need for plication may
POP repair procedures can be broadly divided into recon- again be chosen where appropriate. Finally, perineorrhaphy
structive and obliterative surgeries. Reconstructive proced- is commonly performed at the time of these repairs, using
ures aim at restoring normal anatomy and function of the sutures to reconstruct the perineal body.
vaginal canal, whereas obliterative surgeries will result in Apical compartment prolapse must be addressed when
the permanent and irreversible closure of the vagina. present to minimize the likelihood of recurrence. This may
Pelvic floor reconstructive surgery can be accomplished be accomplished vaginally with uterocervical suspension to
via transvaginal or transabdominal approaches, or a combin- the sacrospinous ligament or with a hysterectomy followed
ation of both. The procedure should aim to restore each level by a high suspension to the uterosacral ligaments, or to one
of pelvic floor support that is felt to be defective: reconstruc- or both sacrospinous ligaments. It can also be corrected
tion of multiple compartments is often necessary. Surgery abdominally (open, laparoscopic, or robotic-assisted) with
should aim to preserve vaginal length and axis in sexually sacrocolpopexy or sacrohysteropexy, which suspends the
active women. Surgical risks must be carefully discussed vaginal apex or uterus to the longitudinal sacral ligament
and expectations aligned. The surgery chosen should bal- using a Y-shaped graft of synthetic mesh. The abdominal
ance surgical risks with the goals of achieving a durable approach is considered the gold standard in women wishing
repair that meets the above criteria. Surgeons undertaking to preserve sexual function with high-grade post-hysterec-
these operations should be skilled in vaginal dissection, tomy vault prolapse, and those requiring secondary repairs
have a thorough understanding of the pelvic anatomy via following a failed vaginal technique.31,32
transvaginal and transabdominal approaches, have a broad In the early 2000s, transvaginal implantation of synthetic
repertoire of techniques available to tailor to the individual mesh became very popular for the repair of POP to address
patient, and have the skills and resources to diagnose and what was felt to be a very high recurrence rate following
manage potential complications. Even in the best of hands, native tissue repairs; however, their use has fallen dramatic-
and regardless of technique chosen, organ injury, neuro- ally owing to warnings about serious complications issued
pathic pain, and functional derangements are potential risks. by the US Food and Drug Administration (FDA), along
Importantly, the need for reoperation for recurrent prolapse with evidence that refutes their benefit in reducing risk of
is high, owing to the nature of the tissues being reconstructed recurrence.33 In 2010, Health Canada released a Notice to
and the constant demands placed on the pelvic floor. This is Hospitals to inform healthcare professionals of the potential
particularly true with a history of higher-stage (3 or 4) POP, risks associated with transvaginal placement of synthetic
preoperative prolapse in more than two vaginal compart- mesh for POP and SUI. This was updated in 2014.34 These
ments, prior pelvic floor surgery for POP or SUI, and the advisories highlight the observation that transvaginal use of
presence of sexual activity.29,30 mesh may carry a higher risk of certain complications when
Anterior compartment prolapse was classically treated compared to transabdominal mesh placement or native tis-
by anterior colporrhaphy, which corrects defects in the sue repair. They also point out that complications may not
pubocervical fascia to provide support to the anterior vaginal be completely correctable with additional surgeries and that
wall and thus correct a so-called central defect cystocele. the surgeon should be familiar with the device techniques
Lateral defect cystoceles, caused by attenuation or tearing and warning, as well as have proper training to implant

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 POP for urologists

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them. More recently, the Canadian Urological Association symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int
issued a consensus statement discouraging the routine use Urogynecol J Pelvic Floor Dysfunct 2009;20:1037-45. https://doi.org/10.1007/s00192-009-0902-1
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Competing interests: The authors report no competing personal or financial interests.
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S130 CUAJ • June 2017 • Volume 11, Issue 6(Suppl2)