POP Overview
Pelvic organ prolapse (POP) is the descent of one or more pelvic organs — bladder, uterus/vaginal apex, or rectum — into or through the vaginal canal as a result of deficient pelvic floor support.[1][2] It is among the most common conditions managed by reconstructive urologists, urogynecologists, and pelvic floor surgeons, affecting up to 50% of women on examination over their lifetime. 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.
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]
| Level | Name | Structures | Failure Leads To |
|---|---|---|---|
| I | Apical | Upper vagina and cervix suspended by the cardinal–uterosacral ligament (CUL) complex | Uterine descent, vault prolapse, enterocele |
| II | Mid-vaginal | Lateral attachment to the arcus tendineus fascia pelvis (ATFP/"white line") and superior fascia of levator ani | Anterior wall (cystocele), posterior wall (rectocele) |
| III | Distal | Lower vagina fused with perineal membrane, perineal body, and urethra | Distal anterior wall descent, perineal deficiency |
Level I (apical) support is the most critical determinant of overall vaginal support. Failure to address apical defects at the time of anterior or posterior repair is a leading cause of recurrent prolapse.
Classification by Compartment
| Compartment | Type | Defect / Etiology | Typical Repair |
|---|---|---|---|
| Anterior | Cystocele — central | Loss of central pubocervical fascia | Anterior colporrhaphy |
| Anterior | Cystocele — lateral (paravaginal) | Detachment from ATFP (white line) | Paravaginal repair (vaginal or abdominal) |
| Anterior | Cystocele — transverse | Apical detachment of pubocervical fascia | Apical suspension + anterior repair |
| Posterior | Rectocele | Rectovaginal fascia defect with rectal protrusion | Posterior colporrhaphy |
| Posterior | Enterocele | Small bowel herniation into rectovaginal space | Enterocele repair (peritoneal closure) |
| Posterior | Sigmoidocele | Sigmoid colon descent into rectovaginal space | Enterocele/sigmoidocele repair |
| Apical | Uterine descent | Uterosacral/cardinal ligament attenuation | Hysterectomy + apical suspension OR uterine-sparing suspension |
| Apical | Vault prolapse | Loss of apical support post-hysterectomy | Sacrocolpopexy, 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]
Risk Factor Summary (Pooled Meta-Analysis Data)
| Risk Factor | Odds Ratio | 95% CI / Notes |
|---|---|---|
| Vaginal delivery (first) | 2.65 | 95% CI 1.81–3.88 |
| Forceps delivery | 2.51 | 95% CI 1.24–3.83 |
| Birthweight | 1.04 | Per 100 g increment |
| Age | 1.34 | Per decade increment |
| BMI | 1.75 | Per 5 kg/m² increment |
| Levator ani defect (imaging) | 3.99 | Strongest modifiable anatomical predictor |
| Cesarean delivery | 0.08 | Strongly protective |
| Smoking | 0.59 | Weakly protective |
Data from Schulten et al., Am J Obstet Gynecol 2022.[3]
Genetic and Connective Tissue Factors
Specific genetic polymorphisms are associated with increased POP susceptibility:
| Gene / Locus | Polymorphism | Association |
|---|---|---|
| ESR1 (estrogen receptor alpha) | rs2228480 | POP susceptibility |
| FBLN5 (fibulin-5) | rs12589592 | Connective tissue remodeling |
| PGR (progesterone receptor) | rs1036819 | POP susceptibility |
| COL1A1 (type I collagen) | rs1800215 | Collagen quality/quantity |
Connective tissue disorders, including Marfan syndrome and Ehlers-Danlos syndrome, are associated with early-onset prolapse and increased recurrence risk.
Modifiable Risk Factors
- Obesity (BMI >30)
- Chronic constipation and straining
- Heavy repetitive lifting (occupational or recreational)
- Chronic obstructive pulmonary disease (chronic cough/raised intra-abdominal pressure)
Risk Factors for Surgical Recurrence
- Age <60 at time of vaginal POP surgery (OR 3.48)
- Preoperative Stage III or IV prolapse (OR 2.68)
- Obesity (BMI >26)
Clinical Presentation
The bulge sensation (feeling or seeing a bulge at the vaginal opening) is the most consistent and specific symptom of prolapse. Symptoms generally emerge when the leading edge of prolapse reaches or passes the hymenal ring (≥0.5 cm distal to the hymen on POP-Q).[4]
| Symptom Category | Specific Symptoms | Notes |
|---|---|---|
| Bulge / Pelvic | Vaginal bulge, heaviness, pelvic pressure | Most specific for POP; worsens with prolonged standing or activity |
| Urinary | Stress urinary incontinence (SUI) | May be masked by outlet obstruction from urethral kinking |
| Urgency / frequency / urgency incontinence | Due to bladder base distortion | |
| Obstructive voiding (hesitancy, weak stream) | Urethral kinking in anterior prolapse; may require manual reduction | |
| Incomplete bladder emptying | PVR elevation with prolapse beyond hymen | |
| Bowel | Constipation, straining | Rectocele / enterocele impairs rectal emptying |
| Incomplete evacuation, feeling of rectal blockage | Posterior compartment defect | |
| Splinting (manual pressure to vagina or perineum to defecate) | Pathognomonic for symptomatic rectocele | |
| Fecal incontinence | Perineal body deficiency; concomitant anal sphincter injury | |
| Sexual | Dyspareunia | May worsen after native tissue posterior repair |
| Coital incontinence | Anterior compartment descent | |
| Body image concerns, sexual avoidance | Patient-centered impact; assess with validated questionnaires |
Staging
POP-Q (Pelvic Organ Prolapse Quantification System)
The POP-Q is the recommended staging system by ACOG and the International Urogynecological Consultation (IUC); it is the only system (along with S-POP) with sufficient reproducibility to support clinical recommendations. The hymen serves as the reference plane (0).[1][4][8]
Six measurement points relative to the hymen (negative = above, positive = below):
| Point | Location |
|---|---|
| Aa | Anterior wall, 3 cm proximal to urethral meatus |
| Ba | Most distal point of anterior wall |
| C | Cervix or vaginal cuff |
| D | Posterior fornix (omit if post-hysterectomy) |
| Ap | Posterior wall, 3 cm proximal to hymen |
| Bp | Most distal point of posterior wall |
Additional measurements: gh (genital hiatus), pb (perineal body), tvl (total vaginal length).
POP-Q Stages:
| Stage | Definition |
|---|---|
| 0 | No prolapse; all points at normal positions |
| I | Leading edge >1 cm above hymen |
| II | Leading edge between −1 cm and +1 cm of hymen |
| III | Leading edge >1 cm below hymen but <2 cm less than TVL |
| IV | Complete eversion; leading edge ≥ (TVL − 2 cm) |
Most women become symptomatic at Stage II–III, when the leading edge is at or below the hymen.
Baden-Walker Halfway System
The Baden-Walker system (Grade 0–4) remains in common clinical use. Grade 2 = descent to halfway to hymen; Grade 4 = maximum eversion. It has lower reproducibility than POP-Q and is not recommended for research or formal treatment planning.
Evaluation
Required Components
A thorough evaluation includes the following elements before any treatment decision:
- 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]
- Symptom assessment: SUI, urgency incontinence, bladder emptying symptoms, bowel symptoms (straining, laxatives, fecal incontinence, incomplete emptying), dyspareunia
- Physical examination:
- Abdominal exam (rule out pelvic mass)
- External genitalia (atrophy, irritation, ulceration from chronic prolapse exposure)
- Split speculum exam with Valsalva and cough (standing exam if prolapse not reproduced supine)
- POP-Q staging: Required before any treatment decision (ACOG; IUC)[1][4]
- Post-void residual (PVR): Obtain if prolapse beyond hymen or voiding symptoms; PVR >100 mL = voiding difficulty threshold
- Urinalysis: Indicated if urgency or LUTS present
Occult SUI Evaluation — All women with significant anterior or apical prolapse should undergo a cough stress test or urodynamic study (UDS) with prolapse reduced prior to surgery. Occult (masked) SUI — incontinence that becomes apparent only when the prolapse is reduced — affects up to 40% of women with advanced prolapse and significantly influences the surgical plan.[1][4]
Optional / Selective Testing
| Test | Indication |
|---|---|
| Urodynamics (UDS) | Uncertainty about SUI diagnosis; voiding dysfunction; prior failed surgery |
| Cystoscopy | Suspected bladder pathology; prior mesh implant |
| Defecography / MRI defecography | Complex posterior compartment symptoms; recurrent posterior repair |
| Pelvic MRI (levator morphology) | Research; high recurrence risk; levator avulsion suspected |
| Validated questionnaires (PFDI-20, PFIQ-7) | Quantify symptom bother; assess response to treatment |
Nonsurgical Management
Indications
- Asymptomatic prolapse: reassurance and education; observation appropriate
- Symptomatic prolapse: first-line or preferred by patient; mandatory discussion for women desiring future pregnancy
Lifestyle Interventions
- High-fiber diet and osmotic laxatives (for bowel-related symptoms; see Chronic Constipation)
- Weight loss (targets BMI <25–30)
- Activity modification (reduce high-impact loading)
- Smoking cessation / COPD management
Pelvic Floor Muscle Training (PFMT / Kegel Exercises)
- Improves symptom bother scores and may slow prolapse progression
- Effective adjunct to pessary or as standalone conservative therapy
- Formal pelvic floor physical therapy with biofeedback preferred over self-directed exercises for symptomatic prolapse[6]
Vaginal Pessaries
Pessaries are the principal nonsurgical intervention for symptomatic POP. They should be offered to all women as an alternative to surgery, and are mandatory for women desiring future pregnancy.
Fitting Success by Stage and Pessary Type:
| Pessary Type | Stage II | Stage III | Stage IV |
|---|---|---|---|
| Ring pessary | 100% | 71% | — |
| Gellhorn pessary | — | — | 64% |
| Overall fitting success | — | Up to 92% | — |
Management Principles:
- Patient self-management preferred for hygiene and removal
- If unable to self-manage: follow-up every 3–4 months
- Topical vaginal estrogen (GSM treatment): reduces erosion risk and improves tolerability
- Complications: vaginal erosion/devascularization in 2–9% → remove for 2–4 weeks and apply topical estrogen before refit
PEOPLE Trial (JAMA 2022) — van der Vaart et al. randomized 440 women with symptomatic Stage II+ POP to pessary vs. pelvic floor surgery. At 24 months:
- Subjective improvement: pessary 76.3% vs. surgery 81.5% (risk difference −6.1%)
- Did not meet noninferiority criteria (p = .16 for NI)
- Interpretation limited by 54.1% crossover from pessary → surgery arm
- Adverse events: pessary group — discomfort 42.7%; surgery group — UTI 9%
Clinical takeaway: Surgery achieves modestly higher subjective improvement at 2 years, but pessary is a highly effective and acceptable option for most women; shared decision-making is essential.[5]
Surgical Management
General Indications and Principles
Surgery is indicated when:
- 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 vs. risk profile, prior repairs, and surgeon expertise.
Lifetime reoperation rate: 6–30% (most series consistent with the lower end; improving with standardized technique and apical repair).
Summary of Surgical Options
| Approach | Procedure | Indication | Key Points |
|---|---|---|---|
| Vaginal — Native Tissue | Anterior colporrhaphy | Central cystocele | Plication of pubocervical fascia; low morbidity |
| Paravaginal repair | Lateral (ATFP) cystocele | Can be performed vaginally or abdominally | |
| Posterior colporrhaphy + perineorrhaphy | Rectocele, perineal deficiency | Risk of dyspareunia with over-plication | |
| Enterocele repair | Enterocele / sigmoidocele | Peritoneal purse-string closure | |
| Uterosacral ligament (USL) suspension | Apical prolapse | Incorporates Level I support; ureteral injury risk | |
| Sacrospinous ligament fixation (SSLF) | Apical prolapse | High-uterosacral or anterior-wall lateralization | |
| Abdominal / Robotic | Sacrocolpopexy | Apical prolapse; short vagina; recurrence risk factors | Gold standard; polypropylene mesh; open, laparoscopic, or robotic |
| Obliterative | LeFort colpocleisis (partial) | Advanced prolapse + no intercourse desire | Highest durability; lowest morbidity; first-line for appropriate candidates |
| Total colpocleisis | Same as above (post-hysterectomy) | Preserves perineum; excludes vaginal canal |
Vaginal Native Tissue Repair
Native tissue repairs use the patient's own fascial and connective tissue without synthetic mesh or biologic graft. They carry relatively low operative risk and are appropriate for most women undergoing primary repair.
Apical Suspension — OPTIMAL Trial Findings:
The OPTIMAL trial (multicenter RCT) compared uterosacral ligament (USL) suspension vs. sacrospinous ligament fixation (SSLF) for vaginal apical support:
- Success at 2 years: USL suspension 64.5% vs. SSLF 63.1% — statistically comparable
- Conclusion: Both procedures are equally effective for apical support (ACOG)
- Choice is guided by anatomy, surgeon expertise, and concomitant compartment defects
Vaginal apex suspension should be performed at the time of hysterectomy for uterine prolapse. Failure to address the apex at the time of uterine prolapse repair is associated with significantly higher rates of recurrent vault prolapse.
Abdominal Sacrocolpopexy
Sacrocolpopexy is the gold standard for apical prolapse repair, attaching the vaginal apex to the sacral promontory via a Y-shaped polypropylene mesh bridge. It can be performed open, laparoscopically, or robotically (comparable outcomes in experienced hands).
Candidates for sacrocolpopexy (preferred over vaginal native tissue):
| Indication | Rationale |
|---|---|
| Shortened vaginal length | Mesh bridge restores length without tension |
| Intra-abdominal pathology requiring concurrent procedure | Efficient combined approach |
| Age <60 at primary surgery | High recurrence risk; durability favored |
| Preoperative Stage III/IV | Higher recurrence risk with native tissue alone |
| BMI >26 | Increased stress on repair; abdominal access preferred |
| Prior failed vaginal repair | Mesh support necessary for durability |
Lower anatomic recurrence compared to vaginal native tissue repairs, but associated with higher rate of complications (mesh-related, bowel, bleeding). Bowel prep and cystoscopy at time of repair are standard.[1][7]
Colpocleisis (Obliterative Procedures)
Colpocleisis closes the vaginal canal and is the most durable surgical option with the lowest perioperative morbidity of all POP repairs.
- LeFort colpocleisis (partial): appropriate for women with uterus in situ
- Total colpocleisis: performed in post-hysterectomy vault prolapse
Indications (ACOG: first-line surgical option for appropriate candidates):
- Advanced-stage prolapse (Stage III–IV)
- 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. Approximately 2–10% of patients later express regret; careful patient selection is essential.
Mesh and Grafts
Abdominal Polypropylene Mesh (Sacrocolpopexy)
- Well-established safety profile when placed via abdominal route
- Macroporous, monofilament type 1 polypropylene is the standard
- Lower recurrence rates compared to native tissue for apical compartment
- Mesh exposure rate: ~3–5% at 5 years; most managed conservatively or with minor office procedures
Transvaginal Mesh — FDA Actions and Current Status
| Year | FDA Action |
|---|---|
| 2008 | Public health notification — serious complications reported with transvaginal mesh for POP |
| 2011 | Safety communication — reclassified as Class III device; complications not rare |
| 2019 | Ordered halt of sales of transvaginal mesh products for POP in the United States |
Transvaginal mesh for POP is largely abandoned due to high rates of mesh erosion into the vagina, chronic pelvic pain, dyspareunia, and need for reoperation. Transvaginal anterior mesh improves anatomic outcomes compared to native tissue but with significantly increased morbidity. Transvaginal mesh does not improve posterior wall outcomes compared to native tissue repair.
Current indications where transvaginal mesh may still be considered (limited):
- Recurrent prolapse, especially anterior or apical compartment, where native tissue has failed
- Medical comorbidities precluding more invasive abdominal approaches
- Surgeon with specific expertise and dedicated informed consent process
Biologic Grafts
- Porcine dermis (e.g., Pelvicol) and autologous fascia lata are alternatives to synthetic mesh in high-risk cases
- Lower erosion risk than polypropylene mesh transvaginally
- Less durable than synthetic mesh; mixed data on long-term anatomic outcomes
- May be preferred in patients with mesh contraindications (infection risk, tissue quality concerns, connective tissue disorders)
Concomitant Anti-Incontinence Surgery
All women with significant anterior or apical prolapse should undergo pre-operative occult SUI evaluation (cough stress test or urodynamic study with prolapse reduced). See Stress Urinary Incontinence (Female), Mixed Urinary Incontinence, and the Female SUI treatment database for procedure selection.
Decision Framework:
| Pre-op SUI Status | Recommendation |
|---|---|
| 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) | Counsel that postoperative SUI is likely after prolapse repair; offer concomitant procedure with shared decision-making |
| No SUI (overt or occult) | Counsel that de novo SUI may develop post-repair; concomitant procedure not routinely recommended but may be discussed |
Adding a concomitant anti-incontinence procedure increases the risk of voiding dysfunction, UTI, and operative time. The decision to proceed with concomitant sling placement must be individualized based on severity of occult SUI, patient preference, anatomy, and comorbidities. Shared decision-making is mandatory.
Outcomes and Complications
Reoperation Rates and Recurrence
- Overall lifetime reoperation rate: 6–30% (most series 10–15%)
- Risk factors for surgical failure (Schulten et al., 2022):
- Preoperative Stage III/IV: OR 2.68
- Age <60 at vaginal POP surgery: OR 3.48
- Obesity
- Levator ani avulsion
Complications of Native Tissue Repair
| Complication | Frequency | Notes |
|---|---|---|
| UTI | Common (5–15%) | Particularly with concomitant sling |
| Voiding dysfunction | Common; usually transient | Catheterization may be required short-term |
| Dyspareunia | ~16% at 24 months | Most common after posterior colporrhaphy; risk of over-plication |
| Ureteral injury | Uncommon (<2%) | Risk highest with USL suspension; intraoperative cystoscopy recommended |
| Rectovaginal fistula | Rare | Risk with posterior colporrhaphy and concurrent rectal injury |
| Vesicovaginal fistula | Rare | Risk with anterior repair and concurrent bladder injury |
| Foreshortened / restricted vagina | Uncommon | Over-resection of vaginal wall; consider in sexually active patients |
Complications of Sacrocolpopexy
- Mesh exposure: ~3–5% at 5 years
- Bowel obstruction or adhesions (abdominal approach)
- Sacral osteomyelitis (rare but serious)
- Dyspareunia: similar to or lower than vaginal native tissue
See Also
- Female Pelvic Examination
- Stress Urinary Incontinence (Female)
- Mixed Urinary Incontinence
- Urgency Incontinence & OAB
- Fecal Incontinence
- Chronic Constipation
- Genitourinary Syndrome of Menopause
- Pelvic Floor Physical Therapy
- Female SUI Treatment Database
- Urodynamics
- History of Prolapse & Urogynecology
- Guidelines & White Papers
References
1. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519
2. Deprest JA, Cartwright R, Dietz HP, et al. "International Urogynecological Consultation (IUC): Pathophysiology of POP." Int Urogynecol J. 2022;33(7):1699-1710. doi:10.1007/s00192-022-05081-0
3. Schulten SFM, Claas-Quax MJ, Weemhoff M, et al. "Risk Factors for Primary POP and Prolapse Recurrence." Am J Obstet Gynecol. 2022;227(2):192-208. doi:10.1016/j.ajog.2022.04.046
4. Barbier H, Carberry CL, Karjalainen PK, et al. "IUC Chapter 2 Committee 3: Clinical Evaluation of POP." Int Urogynecol J. 2023;34(11):2657-2688. doi:10.1007/s00192-023-05629-8
5. van der Vaart LR, Vollebregt A, Milani AL, et al. "Effect of Pessary vs Surgery on Patient-Reported Improvement: PEOPLE Trial." JAMA. 2022;328(23):2312-2323. doi:10.1001/jama.2022.22385
6. Sung VW, Jeppson P, Madsen A. "Nonoperative Management of POP." Obstet Gynecol. 2023;141(4):724-736. doi:10.1097/AOG.0000000000005121
7. Raju R, Linder BJ. "Evaluation and Management of POP." Mayo Clin Proc. 2021;96(12):3122-3129. doi:10.1016/j.mayocp.2021.09.005
8. Bump RC, Mattiasson A, Bo K, et al. "The Standardization of Terminology of Female Pelvic Organ Prolapse and Pelvic Floor Dysfunction." Am J Obstet Gynecol. 1996;175(1):10-17. PMID:8694033