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POP Overview

Pelvic organ prolapse (POP) is the descent of one or more pelvic organs (bladder, uterus or vaginal apex, or rectum) into or through the vaginal canal as a result of deficient pelvic floor support.[1][2] Prevalence estimates depend strongly on the population and whether prolapse is defined by symptoms or examination. While many cases are asymptomatic, symptomatic prolapse significantly impacts quality of life across urinary, bowel, and sexual function domains.[1][4]

See also: Female Pelvic Examination, The Vagina, The Uterus, The Bladder, The Female Urethra, The Anal Canal, and The Perineum.

Epidemiology​

Prevalence depends heavily on how prolapse is defined. In an exam-based cohort of 497 women presenting for annual gynecologic care, 477 correctly completed the symptom questionnaire; among those 477, only 18 (4%) had no anatomic prolapse on POP-Q, and the average symptom count increased significantly when the leading edge extended beyond the hymenal remnants, including some stage II and all stage III participants.[23] In the nationally representative 2005–2006 National Health and Nutrition Examination Survey (1,961 nonpregnant women aged 20 years or older), 2.9% reported prolapse symptoms, defined as seeing or feeling a bulge in or outside the vagina.[36] Across the 2005–2010 survey cycles, the weighted prevalence of this symptom was 2.9% among 7,071 women with prolapse data, with no significant change over the period; among 7,924 women with data on at least one pelvic floor disorder, 25.0% reported one, most often moderate-to-severe urinary incontinence (17.1%).[40]

Examination-defined prolapse also changes over time. In a Women's Health Initiative ancillary cohort of 412 postmenopausal women examined annually for 2 to 8 years, 31.8% had prolapse at baseline, and the annual incidence of cystocele, rectocele and uterine prolapse was 9.3, 5.7 and 1.5 cases per 100 women-years. Grade 1 prolapse regressed more often than it progressed (regression 23.5, 22 and 48 versus progression 9.5, 13.5 and 1.9 per 100 women-years for cystocele, rectocele and uterine prolapse).[38]

With the aging US population, the number of women with symptomatic POP is projected to rise 46% from 3.3 to 4.9 million between 2010 and 2050,[24] and the number of women undergoing POP surgery annually is projected to rise from 166,000 in 2010 to 245,970 in 2050 if surgery rates remain unchanged.[25] In a 5% national Medicare sample averaging roughly 22,000 women per year with a prolapse diagnosis (1999–2009), pessary insertion rates were consistently 11–13% and 14–15% underwent surgical repair, with little change in these proportions over the decade studied.[26]

Anatomy and Levels of Support (DeLancey)​

The three-level model of vaginal support, described by DeLancey, remains the foundational framework for understanding POP and guiding repair strategy.[2]

LevelNameStructuresFailure Leads To
IApicalUpper vagina and cervix suspended by the cardinal–uterosacral ligament (CUL) complexUterine descent, vault prolapse, enterocele
IIMid-vaginalLateral attachment to the arcus tendineus fascia pelvis (ATFP/"white line") and superior fascia of levator aniAnterior wall (cystocele), posterior wall (rectocele)
IIIDistalLower vagina fused with perineal membrane, perineal body, and urethraDistal anterior wall descent, perineal deficiency

Assess the apex when evaluating anterior or posterior prolapse: compartments interact, and an isolated wall repair may leave a clinically important apical defect unaddressed.[4][12]

The levator ani sharing this support role is not a single sheet: it has pubovisceral (also called pubococcygeal), puborectal, and iliococcygeal subdivisions, distinguished by their attachments to the perineal body, lateral vaginal wall and tissue beside the anal sphincters (pubovisceral) versus a relatively horizontal sheet from the pelvic sidewall (iliococcygeal). In an in-vivo MRI study of muscle-fiber direction, pubovisceral and puborectal fibers differed by about 60 degrees; both had a horizontal component that closes the levator hiatus, with an additional upward component in the pubovisceral fibers and a slight downward component in the puborectal fibers.[30][31] Birth-associated injury has been localized on MRI specifically to the pubovisceral portion.[30][31]

Classification by Compartment​

Clinical assignment of a central versus paravaginal defect has limited reproducibility; document the measured compartments and plan repair in their overall context.[4]

CompartmentTypeDefect / EtiologyTypical Repair
AnteriorCystocele — centralLoss of central pubocervical fasciaAnterior colporrhaphy
AnteriorSuspected paravaginal cystocelePossible lateral support loss at ATFP (white line)Assess apical and overall support; paravaginal repair is an option in selected cases
AnteriorCystocele — transverseApical detachment of pubocervical fasciaApical suspension + anterior repair
PosteriorRectoceleRectovaginal fascia defect with rectal protrusionPosterior colporrhaphy
PosteriorEnteroceleSmall bowel herniation into rectovaginal spaceEnterocele repair (peritoneal closure)
PosteriorSigmoidoceleSigmoid colon descent into rectovaginal spaceEnterocele/sigmoidocele repair
ApicalUterine descentUterosacral/cardinal ligament attenuationHysterectomy + apical suspension OR uterine-sparing suspension
ApicalVault prolapseLoss of apical support post-hysterectomySacrocolpopexy, USL suspension, SSLF

Pathophysiology and Risk Factors​

POP results from the interaction of anatomical, obstetric, constitutional, and environmental factors leading to failure of the fascial, muscular, and connective tissue support structures of the pelvic floor.[2][3]

Interpreting risk factors​

The 2022 Schulten review combined 27 studies involving 47,429 women. It evaluated anatomic prolapse, including anatomic recurrence after native-tissue repair. Vaginal birth and parity, older age, higher BMI, birthweight and levator defects were associated with primary prolapse; higher preoperative stage and younger age were associated with recurrence after native-tissue surgery.[3]

A Swedish national cohort of 5,236 singleton primiparae, surveyed 20 years after a single delivery, reported symptomatic POP prevalence of 14.6% after vaginal delivery versus 6.3% after cesarean delivery (OR 2.55, 95% CI 1.98–3.28), with no difference between acute and elective cesarean delivery.[32]

In the Mothers' Outcomes After Delivery cohort of 1,011 women examined 5 to 10 years after a first delivery, spontaneous vaginal birth was associated with higher odds of stress incontinence (OR 2.9, 95% CI 1.5–5.5) and of prolapse to or beyond the hymen (OR 5.6, 95% CI 2.2–14.7) than cesarean delivery without labor, and operative vaginal birth carried the highest odds of prolapse (OR 7.5, 95% CI 2.7–20.9). Among women delivered only by cesarean, labor and complete cervical dilation were not associated with any pelvic floor disorder, although the study had limited power for these comparisons.[37]

The IUC pathophysiology review also supports contributions from childbirth, age and inherited susceptibility. Genetic associations inform susceptibility without a routine test or gene-specific treatment pathway.[2]

Discuss weight management, constipation and straining and activities that provoke symptoms. The association between smoking and lower prolapse odds in some observational datasets is not a prevention strategy; continue ordinary smoking-cessation care. Obstetric delivery decisions should not be made from these pooled prolapse associations alone.[3][12]

Clinical Presentation​

The bulge sensation (feeling or seeing a bulge at the vaginal opening) is the most consistent and specific symptom of prolapse. Symptoms are more likely near or beyond the hymen, but there is no single distance at which all patients become symptomatic.[4]

Symptom CategorySpecific SymptomsNotes
Bulge / PelvicVaginal bulge, heaviness, pelvic pressureMost specific for POP; worsens with prolonged standing or activity
UrinaryStress urinary incontinence (SUI)May be masked by outlet obstruction from urethral kinking
Urgency / frequency / urgency incontinenceMay coexist with POP; other causes of OAB remain possible
Obstructive voiding (hesitancy, weak stream)Urethral kinking in anterior prolapse; may require manual reduction
Incomplete bladder emptyingMeasure PVR when clinically indicated
BowelConstipation, strainingMay accompany posterior prolapse; assess stool consistency and functional defecatory disorders
Incomplete evacuation, feeling of rectal blockagePosterior compartment defect
Splinting (manual pressure to vagina or perineum to defecate)Suggests an evacuation problem with several possible causes
Fecal incontinencePerineal body deficiency; concomitant anal sphincter injury
SexualDyspareuniaAssess pain and other contributors separately from prolapse stage
Coital incontinenceAssess the associated urinary problem. Two subtypes: climacturia (leakage at orgasm) and penetration incontinence (leakage with penetration); see below.
Body image concerns, sexual avoidancePatient-centered impact; assess with validated questionnaires

Coital incontinence has two recognized subtypes. Climacturia (orgasmic urinary incontinence) is leakage at the moment of orgasm, conventionally attributed to detrusor overactivity, though pelvic-muscle spasm during orgasm suggests a stress component may also contribute. Penetration incontinence occurs with vaginal penetration and is conventionally attributed to stress incontinence; urinary leakage during intercourse is reported more often in women with genuine stress incontinence. Assess coexisting stress and urgency symptoms before choosing treatment: for confirmed urgency incontinence, options include behavioral therapy, anticholinergics or beta-3 agonists, chemodenervation and neuromodulation; for confirmed stress incontinence, options include pelvic floor physical therapy, a bulking agent, a midurethral sling or Burch colposuspension. Female ejaculation can involve a small periurethral (Skene's-gland) secretion; squirting can also expel bladder-derived fluid. Ask whether fluid release during sex is experienced as unwanted leakage.[29][44][45][46] Phenazopyridine pad staining indicates urine exposure.[29][44][45][46]

Staging​

POP-Q (Pelvic Organ Prolapse Quantification System)​

Use POP-Q for reproducible description and staging; ACOG and AUGS recommend a POP-Q examination before treatment (Level C).[1] Simplified POP-Q is an accepted alternative when appropriate.[4] The hymen serves as the reference plane (0).[7]

Six measurement points relative to the hymen (negative = above, positive = below):

PointLocation
AaAnterior wall, 3 cm proximal to urethral meatus
BaMost distal point of the upper anterior vaginal wall segment
CCervix or vaginal cuff
DPosterior fornix (omit when the cervix is absent)
ApPosterior wall, 3 cm proximal to hymen
BpMost distal point of the upper posterior vaginal wall segment

Additional measurements: gh (genital hiatus), pb (perineal body), tvl (total vaginal length).

POP-Q landmarks and sign conventionOriginal schematic · v2026-09-11 · Clinical review pending

The six POP-Q points on a schematic midsagittal view, with measured positions in centimeters relative to the hymen: negative above, zero at, positive below. Aa is a defined point 3 cm proximal to the external urethral meatus; Ap is 3 cm proximal to the hymen on the posterior wall. Their measured positions change with prolapse. Ba/Bp are the most dependent points of the upper walls, C is cervix/cuff, and D is the posterior fornix (omitted when the cervix is absent). Stage II spans −1 to +1 cm; stage III/IV extends more than 1 cm beyond the hymen, with their distinction depending on TVL − 2 cm. Stage 0 requires all normal points. Measure on maximal strain except TVL, which is measured with prolapse reduced. Not to scale. (Original WARWIKI schematic; based on standardized POP-Q terminology.)[7]

POP-Q Stages:

StageDefinition
0No prolapse; all points at normal positions
ILeading edge >1 cm above hymen
IILeading edge between −1 cm and +1 cm of hymen
IIILeading edge >+1 cm but <(TVL − 2 cm)
IVComplete eversion; leading edge ≥ (TVL − 2 cm)

Record symptom bother separately from stage; neither a stage label nor a normal-looking examination fully describes bladder, bowel or sexual function.

Simplified POP-Q (S-POP)​

Simplified POP-Q assigns an ordinal stage separately to the anterior wall, posterior wall, apex/cuff and cervix (three segments once the cervix is absent after hysterectomy), based on each segment's leading edge relative to the hymen rather than the nine POP-Q measurements; stage II spans 1 cm above to 1 cm below the hymen. Each segment receives its own stage and the highest becomes the overall stage; unlike POP-Q, S-POP does not use stage 0. A multicenter inter-examiner study of 511 women at 12 centers found almost perfect agreement (weighted kappa 0.87 for overall stage, 0.81–0.89 by segment).[33]

Baden-Walker Halfway System​

The Baden-Walker system is a historical descriptive scale. Use POP-Q or simplified POP-Q for reproducible documentation and comparison; the IUC found insufficient reproducibility to recommend Baden-Walker for this purpose.[4]

Evaluation​

Core assessment​

Tailor the evaluation to symptoms, examination and the contemplated treatment:

  1. History: Obstetric, gynecologic, medical, and surgical history; onset and progression of symptoms; degree of bother; impact on physical and sexual function; desire for future vaginal intercourse; future pregnancy plans[1][4][21]
  2. Symptom assessment: SUI, urgency incontinence, bladder emptying symptoms, bowel symptoms (straining, laxatives, fecal incontinence, incomplete emptying), dyspareunia
  3. Physical examination:
    • Abdominal exam (rule out pelvic mass)
    • External genitalia (atrophy, irritation, ulceration from chronic prolapse exposure)
    • Split speculum exam with Valsalva and cough, with an empty bladder for prolapse staging; repeat upright if the examination does not reproduce the reported bulge[21]
  4. POP-Q staging: Document the compartments and apical support[1]; simplified POP-Q is an alternative where appropriate[4]
  5. Post-void residual (PVR): Obtain for voiding symptoms, recurrent UTI or concern about incomplete emptying; PVR >100 mL is a commonly used research threshold, not a diagnostic cutoff for all patients; interpret repeated measurements with symptoms and voided volume[4]
  6. Urinalysis: Indicated if urgency or LUTS present

Continence planning: when testing for SUI before repair, reduce the prolapse and use adequate bladder filling (the IUC describes at least 200 mL).[4] This is separate from staging the prolapse with an empty bladder. For a preoperative cough stress test, prolapse may be reduced with a pessary or speculum; the method affects occult-SUI detection. Reduction may reveal pre-existing stress incontinence masked by prolapse, whereas postoperative SUI can still occur after a negative preoperative test.[4] A fitted home pessary trial over at least one week is a separate assessment described in a small study.[28] Posterior prolapse can have a similar effect: in a prospective urodynamic study of 90 women without severe anterior or apical defects, retracting a grade 3 posterior wall with a split speculum lowered maximum urethral closure pressure and functional urethral length, increased cough leakage, and revealed potential stress incontinence in four women.[35] A positive reduction test increases concern for postoperative SUI; a negative test lowers risk. Invasive urodynamics is selective, particularly when incontinence and voiding dysfunction coexist.[4]

Counseling on postoperative voiding after repair: in a retrospective cohort of 266 women with preoperative urodynamics before anterior or apical prolapse repair, 239 had postoperative PVR data. Among those 239, a large preoperative bladder capacity (>600 mL, a data-derived cutpoint) was associated with a two- to three-fold higher risk of PVR >200 mL at each woman's longest available follow-up (14.3–20.3% versus 4.1–7.0% with capacity ≤600 mL), although voiding efficiency after surgery was similar regardless of preoperative capacity.[34]

Optional / Selective Testing​

TestIndication
Urodynamics (UDS)Uncertainty about SUI diagnosis; voiding dysfunction; prior failed surgery
CystoscopySuspected bladder/urethral pathology or mesh-related complication; distinguish this from intraoperative cystoscopy
Defecography / MRI defecographyComplex posterior compartment symptoms; recurrent posterior repair
Pelvic MRI (levator morphology)Selected complex questions or research; not routine prolapse staging
Validated questionnaires (PFDI-20, PFIQ-7)Quantify symptom bother; assess response to treatment

A demonstrable prolapse does not routinely require pelvic imaging, cystoscopy or urodynamics before nonsurgical treatment. Investigate unexplained bleeding, a mass, retention or other concerning findings on their own merits.[1][4]

Nonsurgical Management​

Indications​

  • Asymptomatic prolapse: reassurance and education; observation appropriate
  • Symptomatic prolapse: discuss no treatment, nonsurgical treatment and surgery according to patient preference and desire for future childbearing; NICE calls for regional MDT review if surgery is considered and the woman may wish to have children in the future.[12]

In a 4-year Women's Health Initiative ancillary study of 259 postmenopausal women with a uterus who completed at least two annual POP-Q examinations (73 had four, 128 three and 58 two), maximal vaginal descent was estimated to increase by 2 cm or more in 11.0% of women over 3 years and decrease by 2 cm or more in 2.7%.[27] This supports observation as a reasonable choice for asymptomatic prolapse without predicting an individual patient's trajectory.

Lifestyle measures and pelvic floor muscle training​

Address constipation and consider weight reduction when BMI exceeds 30; discuss reducing heavy lifting that aggravates symptoms. For symptomatic stage I–II prolapse, NICE advises considering a supervised pelvic floor muscle training program of at least 16 weeks as the first option, continued if helpful.[12]

Offer referral to pelvic floor physical therapy. An August 2026 trial randomized 220 primiparous women with early postpartum prolapse; all had stage II prolapse at baseline, and 183 completed 24-month follow-up. Adding electrical stimulation with biofeedback did not establish better anatomic improvement or quality of life than supervised training alone, although muscle strength improved.[6][8]

Vaginal Pessaries​

Pessaries are the principal nonsurgical intervention for symptomatic POP, including for women who wish to defer surgery, for example for future pregnancy.[12] NICE advises considering a pessary for symptomatic prolapse, alone or with supervised pelvic floor muscle training.[12]

Fitting and follow-up: more than one size or type may be needed. Choose a device that provides symptom relief, stays in position, permits voiding and fits the patient's sexual and self-care goals. Before fitting, discuss discharge, bleeding, difficulty removing the pessary, expulsion and the effect on intercourse, and consider vaginal estrogen if menopausal genitourinary symptoms are present. Teach self-management when feasible and arrange clinic care when it is not.[12] Do not fit a pessary when neither regular clinic follow-up nor self-management is feasible. Defer fitting for active vaginal or pelvic infection or inflammation, and evaluate unexplained bleeding before fitting.[47]

NICE advises telling women that the pessary should be removed at least once every 6 months to prevent serious complications, and offers a pessary-clinic appointment every 6 months to women at risk of complications, for example because a physical or cognitive impairment makes self-care difficult. Earlier or more frequent review may be appropriate after fitting or with symptoms. Bleeding, pain, ulceration or difficulty voiding should prompt assessment rather than waiting for a scheduled review.[12]

Consider vaginal estrogen for associated GSM. In a 2025 placebo-controlled trial of 420 postmenopausal ring-pessary users, estrogen did not improve 12-month continuation with satisfaction (87.0% versus 86.7% among 411 analyzed); erosion or ulcer, bleeding and discharge were less frequent secondary outcomes. Estrogen is not required for every pessary user.[15]

PEOPLE trial (JAMA 2022): 440 women with symptomatic stage II or greater prolapse were randomized to initial pessary treatment (218) or surgery (222); one ineligible participant was excluded. At 24 months, improvement was reported by 132/173 (76.3%) assigned initially to pessary treatment and 132/162 (81.5%) assigned to surgery. Pessary treatment did not meet the prespecified 10-percentage-point noninferiority margin (one-sided lower confidence bound −12.7%; P=.16 for noninferiority).[5]

118/218 (54.1%) assigned to pessary treatment crossed to surgery. Patients with previous prolapse or incontinence surgery or pessary use were excluded, and surgery did not include a concomitant SUI procedure. Discuss an initial pessary trial and the possibility of later surgery according to the patient's preferences.[5]

Surgical Management​

For step-by-step operative technique and comparative outcomes for each repair below, see the Prolapse Repair atlas.

General Indications and Principles​

Prolapse-associated urinary retention or hydronephrosis warrants assessment even without bothersome bulge symptoms; pessary reduction or surgery may be appropriate according to the findings.[41][42][43]

For elective symptom relief, offer surgery when both conditions below are met:[12]

  • The patient is bothered by prolapse symptoms AND
  • Nonsurgical management has failed or has been declined

Pre-surgical planning must account for: compartments involved, severity of prolapse, patient comorbidities, desire for future vaginal intercourse, durability requirements versus. risk profile, prior repairs, and surgeon expertise.

Discuss outcomes using a defined procedure, endpoint and follow-up interval. Anatomic recurrence, recurrent bothersome bulge and repeat surgery are different outcomes.

Perioperative vaginal estrogen — EVA 2026​

EVA randomized 311 postmenopausal women scheduled for primary native-tissue prolapse repair; 293 underwent surgery and started the study cream. The 12-month primary patient-reported outcome was available for 210 women: improvement occurred in 97/106 (91.5%) with estriol versus 83/104 (79.8%) with placebo. Although statistically significant, the 11.7-percentage-point difference was below the trial's prespecified 15-point threshold for clinical relevance. Anatomy, composite success and reintervention did not differ significantly. A more durable repair was not demonstrated. See the perioperative hormone evidence.[18]

Summary of Surgical Options​

ApproachProcedureIndicationKey Points
Vaginal — Native TissueAnterior colporrhaphyCentral cystocelePlication of pubocervical fascia; low morbidity
Paravaginal repairLateral (ATFP) cystoceleCan be performed vaginally or abdominally
Posterior colporrhaphy + perineorrhaphyRectocele, perineal deficiencyRisk of dyspareunia with over-plication
Enterocele repairEnterocele / sigmoidocelePeritoneal purse-string closure
Uterosacral ligament (USL) suspensionApical prolapseIncorporates Level I support; ureteral injury risk
Sacrospinous ligament fixation (SSLF)Apical prolapseVaginal apex attached to the sacrospinous ligament; counsel on buttock pain and neurovascular risk
Abdominal / RoboticSacrocolpopexySelected symptomatic apical prolapseAbdominal mesh attachment; open, laparoscopic or robotic
ObliterativeLeFort colpocleisis (partial)Advanced prolapse when future penetrative vaginal intercourse is not desiredDiscuss the permanent loss of vaginal penetrative function
Total colpocleisisVault prolapse when vaginal penetration is no longer desiredObliterative repair; discuss permanence and urinary function

Vaginal Native Tissue Repair​

Native-tissue repairs avoid an implanted mesh or graft. The appropriate vaginal suspension depends on the defect, risks and the patient's goals.

In E-OPTIMAL, five-year estimated composite failure was 61.5% after uterosacral suspension versus 70.3% after sacrospinous fixation (adjusted difference −8.8 percentage points; 95% CI −24.2 to 6.6). The original trial enrolled women undergoing surgery for both apical prolapse and SUI, all but three with a midurethral sling; 285 of 374 randomized women entered the extension, and 244 completed it. No significant difference between suspensions was detected, and symptoms remained improved despite many women meeting the trial's strict first-failure definition.[19]

When hysterectomy is performed for uterine prolapse, document how apical support will be restored; see the prolapse-repair principles and vaginal hysterectomy pages.

Abdominal Sacrocolpopexy​

Sacrocolpopexy attaches the vaginal apex to the anterior longitudinal ligament over the sacrum using mesh. It can be performed open, laparoscopically or robotically. See Sacrocolpopexy for operative principles, the ASPIRe trial and the limitations of platform comparisons.

Choosing sacrocolpopexy: discuss it alongside vaginal native-tissue suspension using the patient's compartment defects, prior repairs, sexual goals, comorbidities and preferences. For post-hysterectomy vault prolapse, the 2023 Cochrane review found less prolapse awareness, recurrence and repeat surgery after sacral colpopexy than vaginal procedures. Evidence for superiority across all uterine-preserving comparisons was inconclusive. In the ASPIRe trial of post-hysterectomy vault prolapse, adjusted 36-month composite failure was 28% after sacrocolpopexy, 29% after transvaginal mesh and 43% after native-tissue repair; only sacrocolpopexy was statistically superior to native tissue, and mesh exposure was 3% versus 5% for the two mesh arms.[12][16][20]

Counsel about mesh exposure, bowel and vascular complications, and operative burden.

Colpocleisis (Obliterative Procedures)​

Colpocleisis closes the vaginal canal and is an effective option for selected patients who do not want future vaginal penetration, especially when comorbidity increases the burden of reconstructive surgery. NICE does not rank colpocleisis above reconstructive operations.[12]

  • LeFort colpocleisis (partial): appropriate for women with uterus in situ
  • Total colpocleisis: performed in post-hysterectomy vault prolapse

Selection and counseling:

  • Symptomatic uterine or vault prolapse, including advanced Stage III–IV disease[12]
  • No desire for future vaginal intercourse (must be confirmed and documented)
  • Significant comorbidities that make longer procedures higher risk

Preoperative counseling must explicitly address the permanent loss of vaginal penetrative function. Explore expectations, decisional certainty and possible future changes in sexual goals.

Mesh and Grafts​

Abdominal Polypropylene Mesh (Sacrocolpopexy)​

  • Established role in apical repair, with mesh-specific risks requiring explicit counseling
  • Macroporous, monofilament type 1 polypropylene is the standard
  • Comparative benefit is clearest for post-hysterectomy vault prolapse
  • Exposure risk depends on mesh, concomitant hysterectomy and follow-up. A longitudinal total-hysterectomy/sacrocolpopexy cohort reported cumulative mesh or permanent-suture exposure of 18/182 (9.9%) at a mean 5.3 years, including prior events; only 82 of the original 200 participants entered the second extension, and 56 had an examination.[17]

Native-tissue uterine preservation: 10-year SAVE-U update​

AUGS (2025) advises offering uterine-preserving surgery to suitable patients without uterine or cervical pathology, after an individualized benefit-risk discussion with the patient; see Apical Prolapse for counseling points and management of cervical elongation.[22]

The August 2026 follow-up found apical surgical failure in 3/44 women after sacrospinous hysteropexy versus 7/49 after vaginal hysterectomy with uterosacral suspension (difference −6.6 percentage points; 95% CI −19.9 to 6.7). Only 93 of the original 208 randomized women contributed that primary endpoint. Posterior-compartment failure was less frequent after hysteropexy (11.6% versus 52.2%), while obstructive voiding scores were worse (both medians 0).[14]

Transvaginal Mesh — FDA Actions and Current Status​

YearFDA Action
2008Public health notification — serious complications reported with transvaginal mesh for POP
2011Safety communication emphasizing serious complications
2016Transvaginal POP mesh reclassified as Class III
2019Ordered halt of sales of transvaginal mesh products for POP in the United States

Transvaginal POP mesh has a different benefit–harm profile and regulatory status from abdominal sacrocolpopexy mesh. Historical trial products are unavailable for transvaginal POP repair in the US.[11]

US regulatory distinction: the 2019 order stopped sales and distribution of mesh products intended for transvaginal POP repair. It does not apply to abdominal sacrocolpopexy mesh or SUI slings. Historical and international transvaginal POP mesh uses are not currently available treatment options in the US.[11]

Ten-year SUPeR results (2026). Vaginal mesh sacrospinous hysteropexy had fewer composite failures than vaginal hysterectomy with uterosacral suspension: 40% versus 53% among 175 analyzed participants (adjusted HR 0.64, 95% CI 0.41–1.00). Only 64% entered extended follow-up; patient-reported outcomes did not differ, and the durability advantage did not increase in years 6–10.[10]

Biologic Grafts​

NICE NG123 recommends anterior and posterior vaginal repairs without mesh, and cross-refers to NICE interventional procedures guidance 599, which limits transvaginal mesh repair of anterior or posterior wall prolapse to research.[12]

Concomitant Anti-Incontinence Surgery​

2026 Cochrane update: 22 RCTs involving 3,095 women support discussing a concomitant midurethral sling for symptomatic or occult SUI; it probably reduces postoperative SUI, while adverse-effect estimates remain uncertain. A staged continence procedure is also reasonable.[9] Evidence in women with neither overt nor occult SUI is less certain.[9]

Before prolapse surgery, assess baseline continence and discuss de novo SUI. A prolapse-reduction stress test may help counselling; routine invasive urodynamics is not required solely because prolapse is present.[4][12] See Stress Urinary Incontinence (Female), Mixed Urinary Incontinence, and the Female SUI treatment database for procedure selection.

In the CARE trial, 12 of 313 stress-continent women leaked on urodynamics before sacrocolpopexy without prolapse reduction. With reduction at 300 mL, detection varied by method, from 6% with a pessary to 30% with a speculum.[39] Women who leaked with reduction more often reported stress incontinence 3 months after surgery, both without a Burch colposuspension (58% vs 38%, p = 0.04) and with one (32% vs 21%, p = 0.19).[39] After the 2016 correction of a stress-test coding error, the primary CARE report gives postoperative stress incontinence in women without leakage on reduction testing as 47.9% without a Burch versus 22.9% with one (p < 0.001); the uncorrected primary report gave 38.2% and 20.8%.[49]

Decision Framework:

Pre-op SUI StatusRecommendation
Overt SUI (present with prolapse unreduced)Discuss concomitant anti-incontinence procedure (midurethral sling); counsel on added risks vs. persistent SUI
Occult SUI (present only with prolapse reduced)Discuss the increased risk of postoperative SUI, benefits/harms of a concomitant procedure and a staged option
No SUI (overt or occult)Counsel about de novo SUI. NICE advises against surgery solely to prevent incontinence; EAU strongly recommends against a concomitant anti-incontinence operation with abdominal prolapse surgery.[12][48]

In OPUS, adding a retropubic midurethral sling to vaginal prolapse repair increased bladder perforation, UTI and incomplete-emptying events while reducing postoperative incontinence. Discuss simultaneous versus staged treatment using baseline symptoms, testing, patient preference and the operation planned.[13]

Outcomes and Complications​

Recurrence and retreatment​

Record both symptoms and examination findings after treatment. Duration of follow-up, the compartments repaired and the trial's failure definition explain much of the variation between published rates.[14][19]

Procedure-specific harms​

Counsel about infection, voiding dysfunction, new urinary or bowel symptoms, pain or dyspareunia, organ injury and repeat treatment. Uterosacral suspension carries ureteral risk; sacrospinous fixation carries buttock and nerve and vascular risks. Abdominal mesh repair adds potential mesh exposure, bowel and adhesion complications and rare sacral infection.[12][17][19]

Arrange follow-up to assess healing, bladder emptying and symptoms; NICE recommends a 6-month review with vaginal examination and a mesh-exposure check when mesh was used.[12] Persistent bleeding or discharge, fever, severe or new pain, or inability to void warrants assessment; delayed mesh problems may first appear years after surgery.[12][17]

Selected evidence​

OPUS · 2012[13]; SAVE-U · 10 years[14]; SUPeR · 10 years[10].

Pelvic organ prolapse — key study comparisons
Study and populationComparison and resultsUse and limitations
OPUS · 2012

Women without symptomatic SUI, with anterior prolapse stage ≥2, undergoing vaginal prolapse repair.

Randomized n=337

Source and methods: OPUS · 2012
Source
Wei JT et al. A Midurethral Sling to Reduce Incontinence after Vaginal Prolapse Repair (2012). DOI: 10.1056/NEJMoa1111967
Design
Multicentre randomized sham-controlled trial
Denominators
327 (97%) completed 1-year follow-up.
Follow-up
12 months
Concomitant midurethral sling vs sham incisions

Urinary incontinence, allowing subsequent treatment · 12 months

27.3% with sling vs 43.0% without sling; number needed to treat 6.3.

Adjusted odds ratio 0.48; 95% CI 0.30–0.77.

Counsel about staged versus concomitant continence surgery using both prevention benefit and procedure-related harms.

  • Sling increased bladder perforation (6.7% vs 0%), UTI (31.0% vs 18.3%) and incomplete emptying at 6 weeks (3.7% vs 0%).
  • Vaginal-repair population.
SAVE-U · 10 years

Women with uterine descent stage ≥2; native-tissue sacrospinous hysteropexy.

Randomized n=208

Source and methods: SAVE-U · 10 years
Source
Oegema K et al. Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Uterine Prolapse: 10-year Follow-up of a Randomised Controlled Trial (2026). DOI: 10.1007/s00192-026-06822-1
Design
Long-term follow-up of a randomized trial
Denominators
Primary 10-year outcome available in 93 women: 44 hysteropexy and 49 hysterectomy; 89 underwent examination. Earlier failures were incorporated.
Follow-up
10 years; published online August 13, 2026
Native-tissue sacrospinous hysteropexy vs vaginal hysterectomy with uterosacral suspension

Apical stage ≥2 plus bothersome bulge or repeat apical surgery · 10 years

3/44 (7%) vs 7/49 (14%).

Difference −6.6 percentage points; 95% CI −19.9 to 6.7; no statistically significant difference.

Native-tissue uterine-preservation counselling.

  • Fewer than half of the original randomized participants contributed the 10-year primary endpoint.
SUPeR · 10 years

Postmenopausal women with symptomatic uterovaginal prolapse at 9 US centres.

Randomized n=183

Source and methods: SUPeR · 10 years
Source
Nager CW et al. Sacrospinous Hysteropexy With Mesh vs Vaginal Hysterectomy for Treatment of Uterovaginal Prolapse: 10-Year Results of a Randomized Clinical Trial (2026). DOI: 10.1001/jamasurg.2026.2263
Design
Extended follow-up of a randomized trial
Denominators
175 eligible for intention-to-treat analysis (88 vs 87); 112 (64%) entered years 6–10 follow-up.
Follow-up
10 years; first online June 24, 2026 (August issue date)
Sacrospinous hysteropexy with vaginal mesh vs vaginal hysterectomy with uterosacral suspension

Composite prolapse beyond hymen, symptoms or retreatment · Through 10 years

Failure 40% (35/88) vs 53% (46/87).

Adjusted hazard ratio 0.64; 95% CI 0.41–1.00; P=.05.

Historical mesh-assisted comparison.

  • Substantial attrition and loss of masking in years 6–10; no patient-reported outcome difference.
  • The vaginal mesh product is not currently marketed in the US.

See Also​

Podcasts​

Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse
BackTable OBGYN, Ep. 32 (2023) · Olivia Chang, Suzette Sutherland
backtable.com

Videos​

Surgical Treatment of Pelvic Organ Prolapse
UAB Medicine
Native Tissue Approaches for Pelvic Organ Prolapse
Grand Rounds in Urology (2024)

References​

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