Principles of Pelvic Organ Prolapse Repair
Prolapse treatment should address the patient's symptoms and functional goals while accounting for anatomy, health, previous surgery and preferences about uterine preservation, vaginal intercourse and mesh.[1][13] For individual operations, see the prolapse repair atlas.
Assessment and Treatment Selection
- Document bulge symptoms, urinary emptying and leakage, bowel function, sexual function and the patient's priorities. Examine all compartments using POP-Q, assess pelvic floor contraction and vaginal tissue, and exclude other pathology. Investigate pain, obstructed defecation or symptoms that do not match the examination. Measure postvoid residual when voiding dysfunction or recurrent UTI is present.[1]
- Discuss observation, pelvic floor therapy, pessary and surgery. Observation is reasonable for uncomplicated prolapse that is not bothersome; urinary dysfunction or other complications still need assessment. A pessary trial is an option, not a prerequisite for surgery. NICE recommends offering surgery when symptoms persist with nonsurgical management or the patient declines it.[1]
- Agree on what success means: relief of bulge and functional symptoms, acceptable recovery and sexual function, and avoidance of further treatment. Anatomic recurrence, bothersome recurrence and reoperation are different outcomes; trial percentages must be interpreted with their definition and follow-up interval.[2][9] For research, the International Urogynecological Consultation recommends defining surgical success primarily as absence of bothersome bulge symptoms or retreatment for prolapse, with at least 12 months of follow-up; anatomic measures and related pelvic floor symptoms are secondary outcomes that should not define success or failure. For clinical practice, it defines success primarily as absence of bothersome bulge symptoms.[15]
Nonsurgical Management
Pessaries provide a reversible treatment option, either alone or with pelvic floor muscle training. Fitting may require several sizes or types; anatomy, comfort, retention, self-management and intercourse preferences guide selection. In TOPSY, 340 women who had retained a pessary for at least two weeks were randomized to taught self-management or clinic-based care; at 18 months, observed PFIQ-7 means among 139 self-management and 152 clinic-care respondents were 32.3 and 32.5, respectively, and the adjusted trial difference was not statistically significant (−0.03, 95% CI −9.32 to 9.25).[18] At 18 months, the mean proportion of applicable pessary complication types reported per participant was lower among 142 self-management respondents than among 152 clinic-care respondents (16.7% versus 22.0%).[18] At four years, 186/340 randomized women responded, and the adjusted clinic-care minus self-management difference in this measure was 3.01 percentage points (95% CI −0.58 to 6.61).[22] Shelf, Gellhorn and cube pessaries and women with limited manual dexterity or cognitive impairment were excluded.[18] Successful initial fitting is different from long-term use or symptom improvement. Explain discharge, bleeding, expulsion and removal difficulties, and establish a removal and follow-up plan.[1] NICE advises pessary removal at least once every 6 months and a pessary-clinic appointment every 6 months for patients at increased risk of complications because physical or cognitive impairment limits ongoing care.[1]
In the PEOPLE randomized trial, 440 women with symptomatic stage 2 or greater prolapse were assigned to initial pessary treatment or surgery. At 24 months, 132/173 respondents assigned to pessary (76.3%) and 132/162 assigned to surgery (81.5%) reported substantial improvement; the assigned-pessary group included women who crossed over to surgery. Pessary treatment did not meet the prespecified noninferiority criterion of 10 percentage points; 118/218 women assigned to pessary crossed over to surgery.[8]
Supervised pelvic floor muscle training for at least 16 weeks is a first option for symptomatic stage 1–2 prolapse in NICE guidance. Address constipation and relevant lifestyle factors.[1] Vaginal estrogen can be considered for associated menopausal genitourinary symptoms.[1]
A 2025 placebo-controlled trial randomized 420 postmenopausal women already successfully fitted with a ring pessary with support. Among the 411 women with at least one follow-up visit in the modified intention-to-treat analysis, conjugated estrogen cream did not improve the 12-month combined endpoint of pessary continuation and substantial improvement: 181/208 (87.0%) versus 176/203 (86.7%); difference 0.3 percentage points (95% CI −6.2 to 6.9). Some pessary-related adverse events were less frequent with estrogen, but these were secondary findings. Do not promise better continuation or prescribe estrogen solely as a proven way to improve pessary success.[7]
Choosing a Repair
| Decision | Practical approach |
|---|---|
| Apical prolapse | Document how apical support will be restored. Choose a vaginal native-tissue suspension or abdominal/laparoscopic/robotic sacral suspension according to anatomy, operative risk, mesh preferences and expertise; address associated wall defects.[1][2][9] |
| Anterior or posterior wall prolapse | Native-tissue vaginal repair is the standard option in NICE guidance. Evaluate coexisting apical loss and urinary/bowel symptoms.[1] |
| Uterine prolapse | Offer hysteropexy as well as hysterectomy, each with an apical-support plan. Consider uterine/cervical pathology, bleeding, future surveillance and the patient's preference.[1][4][5][14] If cervical elongation is present during uterine-preserving repair, consider trachelectomy after reviewing future pregnancy plans.[14] NICE excludes Manchester repair when a woman may wish to have children, and a 2026 review recommends reserving it for patients who have completed childbearing.[1][20] |
| Obliterative surgery | Discuss colpocleisis with patients who do not intend future penetrative vaginal intercourse, particularly when health conditions increase reconstructive operative risk. Explain the permanent change in vaginal access and function.[1] A 2026 global expert consensus advises against uterus- or cervix-sparing colpocleisis when cervical screening shows isolated high-risk HPV without another cervical abnormality.[21] |
Age, BMI, POP-Q stage or prior recurrence can inform counseling. Mesh exposure, visceral injury, recovery, recurrent symptoms and possible further surgery should be discussed for the actual proposed procedure.[1][2] In a 2026 network meta-analysis of 58 randomized apical-repair trials (6,846 participants), network estimates for anatomic recurrence at 1–3 years favored abdominal mesh sacrocolpopexy (RR 0.59) and a pooled laparoscopic mesh sacrocolpopexy and cervicopexy group (RR 0.66) over vaginal native-tissue repair.[17] Vaginal mesh had more mesh-related reoperations than native-tissue repair. These anatomical estimates are distinct from bothersome symptoms or reoperation.[17]
Native-tissue apical suspension: E-OPTIMAL
The E-OPTIMAL trial compared bilateral uterosacral ligament suspension (ULS) with unilateral sacrospinous ligament fixation (SSLF). The original trial enrolled women with SUI and planned concomitant retropubic midurethral slings; 374 were originally randomized, 285 entered extended follow-up and 244 completed it. At five years, modeled first composite failure was 61.5% after ULS versus 70.3% after SSLF; adjusted difference −8.8 percentage points (95% CI −24.2 to 6.6).[9]
The endpoint counted specified anatomic descent, bothersome bulge or retreatment, and a participant remained a failure after first meeting a criterion. Symptoms remained improved despite rising composite failure. Choose between ULS and SSLF with their different anatomic and complication considerations.[9]
Post-hysterectomy vault prolapse: ASPIRe
ASPIRe (Menefee 2024) randomized 376 women with symptomatic vault prolapse after total hysterectomy; 360 underwent a study operation. Modeled 36-month composite failure was 28% with sacrocolpopexy, 29% with transvaginal mesh and 43% with vaginal native-tissue repair. Failure meant retreatment, prolapse beyond the hymen or bothersome bulge.[2]
Sacrocolpopexy was superior to native-tissue repair (adjusted HR 0.57; 99% CI 0.33–0.98). Transvaginal mesh did not meet the trial's superiority threshold versus native tissue. Its noninferiority comparison with sacrocolpopexy used a per-protocol population: HR 1.05, one-sided 97% upper confidence bound 1.65, below the prespecified margin of 1.93.[2]
Most failures were anatomic; actual repeat prolapse surgery was much less frequent. Apical mesh exposure occurred in 4/120 sacrocolpopexy patients and 6/115 transvaginal-mesh patients.[2] During trial follow-up, urinary tract infections were reported in 17/120 (14%) after sacrocolpopexy, 43/125 (34%) after vaginal native-tissue repair and 42/115 (37%) after transvaginal mesh.[2] Variable follow-up, missing pandemic-era examinations and concomitant repairs limit interpretation. The Uphold LITE transvaginal product used in ASPIRe is no longer marketed in the US.[2][11]
For primary uterovaginal prolapse when hysterectomy is chosen, see the September 2026 U-POP review and its study-design limits.
Mesh and Graft Counseling
Separate the indication and implantation route. No FDA-approved surgical mesh product for transvaginal POP repair is currently marketed in the United States. Abdominal sacrocolpopexy mesh and mesh slings for SUI are distinct uses.[11]
The 2026 anterior-compartment Cochrane review included 41 RCTs and 4,531 women, with searches through April 2024. At one to two years, native-tissue repair had more anatomic recurrence than permanent transvaginal mesh (RR 3.21, 95% CI 2.27–4.55; low certainty), and probably more prolapse awareness and repeat prolapse surgery. These are separate endpoints; the often-quoted 29–58% versus 13% is an illustrative absolute-risk translation, not pooled observed rates. Many tested products have been withdrawn. In two randomized comparisons of permanent anterior vaginal mesh with abdominal sacrocolpopexy (248 women), de novo dyspareunia was probably more frequent after vaginal mesh at one year (RR 2.15, 95% CI 1.17–3.98; moderate certainty).[3] Biological grafts may improve anatomic recurrence without demonstrated improvement in awareness or repeat prolapse surgery.[3]
For posterior vaginal wall repair, NICE recommends repair without mesh. Investigate obstructed defecation or fecal incontinence separately when present; the choice of repair must reflect the patient's symptoms and anatomy.[1]
Uterine Preservation and Hysterectomy
Uterine-preserving surgery should be offered as an option to patients considering surgery for symptomatic prolapse unless contraindications exist, as recommended by AUGS in 2025.[14] The choice follows an individualized benefit-risk discussion of preservation and hysterectomy based on the patient's values.[14] At ten-year SAVE-U follow-up, stage II or greater apical recurrence with bothersome bulge or repeat apical surgery occurred in 3/44 after sacrospinous hysteropexy versus 7/49 after vaginal hysterectomy with uterosacral suspension; the difference was imprecise because fewer than half of the original randomized participants contributed long-term data.[16] See the apical-prolapse outcome discussion for compartment and functional results.[16]
Among 393 analyzed participants in SAM, a randomized comparison of first uterus-preserving operations for uterine descent not beyond the hymen, two-year composite success occurred in 172/197 (87.3%) after modified Manchester repair versus 151/196 (77.0%) after sacrospinous hysteropexy; bulge symptoms and retreatment did not differ significantly as separate outcomes.[19] See Manchester-Fothergill.
Counseling should cover the following points from the AUGS statement:[14]
- Hysterectomy offers cancer detection and prevention; the benefit is assessed individually.[14] Occult malignancy is uncommon. A 2026 global expert consensus advises considering hysterectomy for postmenopausal patients with unexplained bleeding when no other cause is found, even after normal preoperative investigations.[21]
- Cervical cancer screening continues after uterine preservation, and abnormal uterine bleeding is evaluated as usual.
- Later hysterectomy after uterine-preserving surgery is uncommon and most often follows recurrent prolapse.[14]
- Sexual function does not differ from prolapse repair with hysterectomy.
- Future pregnancy plans should be considered before choosing the operation; pregnancy-outcome data are limited.
The Ruffolo 2025 meta-analysis concerned vaginal native-tissue operations. It found no clear difference in several recurrence and patient-reported outcomes, with perioperative advantages for hysteropexy. Brennand 2025 was a prospective, self-selected cohort of 321 women, not a randomized trial. Its lower adjusted one-year recurrence with uterine preservation supports counseling.[4][5]
When hysterectomy accompanies sacral suspension, decide between total and supracervical hysterectomy using uterine or cervical findings, bleeding and surveillance preferences, operative factors and the applicable mesh evidence. See Supracervical Hysterectomy for the evidence and tradeoffs.
Continence and Operative Safety
Assess symptomatic SUI, leakage unmasked by prolapse reduction, and emptying dysfunction before deciding on a concomitant continence procedure. Testing should answer a management question.[1] NICE recommends multichannel cystometry before planned SUI surgery when anterior or apical prolapse, voiding dysfunction, unclear incontinence type or urge-predominant mixed incontinence, or prior SUI surgery is present.[1]
The 2026 continence Cochrane review supports discussing concomitant MUS for symptomatic or occult SUI. For women with occult SUI undergoing vaginal prolapse repair, a concomitant midurethral sling probably reduced subjective postoperative SUI (RR 0.38, 95% CI 0.26–0.55; five RCTs, 369 women; moderate certainty), while adverse-effect estimates remained less certain. A staged procedure is also feasible.[6] For stress-continent women, the evidence differs by operation and is less consistent.[6]
In CARE, adding Burch during abdominal sacrocolpopexy reduced the corrected three-month composite SUI endpoint from 57.4% to 33.6%.[10] This combined symptoms, stress testing or treatment; the 2016 correction supersedes the original values. NICE takes a more restrictive position, recommending against prophylactic continence surgery when incontinence is absent. See the Burch evidence discussion for procedure-specific counseling.[1][6][10]
Intraoperative cystoscopy: the AUGS consensus recommends it during prolapse reconstructive surgery except isolated posterior-compartment repair, with inspection for bladder or urethral injury and confirmation of ureteral efflux. A normal examination does not exclude every injury, including delayed thermal injury.[12]
Arrange a postoperative encounter at 6–12 weeks to assess symptoms, examination findings and complications; the IUC consensus recommends longer-term follow-up after mesh-based surgery.[15] NICE includes a six-month vaginal examination, checking for exposure when mesh was used, and access to reassessment for recurrent symptoms or suspected complications.[1]
Videos
References
1. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management. NG123. 2019; current recommendations, sections 1.3 and 1.6–1.9. Recommendations.
2. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159:845–855. doi:10.1001/jamasurg.2024.1206. ASPIRe; corrected July 10, 2024.
3. Christmann-Schmid C, Baessler K, Yeung E, et al. Surgery for women with anterior compartment prolapse. Cochrane Database Syst Rev. 2026;4:CD004014. doi:10.1002/14651858.CD004014.pub7.
4. Ruffolo AF, Salvatore S, Torella M, et al. The uterus debate in vaginal native tissue repair for pelvic organ prolapse: hysteropexy versus hysterectomy—a systematic review and meta-analysis. Maturitas. 2025;203:108755. doi:10.1016/j.maturitas.2025.108755.
5. Brennand EA, Scime NV, Huang B, et al. Hysterectomy versus uterine preservation for pelvic organ prolapse surgery: a prospective cohort study. Am J Obstet Gynecol. 2025;232:461.e1–461.e20. doi:10.1016/j.ajog.2024.10.021.
6. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.
7. Zhou Y, Yin R, Zhang Y, et al. Effects of intravaginal conjugated oestrogen on pessary continuation for pelvic organ prolapse: multicentre, randomised, double blind, placebo controlled trial. BMJ. 2025;389:e084418. doi:10.1136/bmj-2025-084418.
8. van der Vaart LR, Vollebregt A, Milani AL, et al. Effect of pessary vs surgery on patient-reported improvement in patients with symptomatic pelvic organ prolapse: a randomized clinical trial. JAMA. 2022;328:2312–2323. doi:10.1001/jama.2022.22385.
9. Jelovsek JE, Barber MD, Brubaker L, et al. Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the OPTIMAL randomized clinical trial. JAMA. 2018;319:1554–1565. doi:10.1001/jama.2018.2827.
10. Brubaker L, et al. Abdominal sacrocolpopexy with Burch colposuspension: author correction letter. N Engl J Med. 2016;374:2295. doi:10.1056/NEJMc1605817.
11. US Food and Drug Administration. Urogynecologic surgical mesh implants. Current regulatory overview.
12. American Urogynecologic Society. American Urogynecologic Society consensus statement: cystoscopy at the time of prolapse repair. Female Pelvic Med Reconstr Surg. 2018;24:258–259; reaffirmed 2021. doi:10.1097/SPV.0000000000000529. Full statement.
13. Carberry CL, Tulikangas PK, Ridgeway BM, Collins SA, Adam RA. American Urogynecologic Society best practice statement: evaluation and counseling of patients with pelvic organ prolapse. Urogynecology (Phila). 2025;31(5):471–481. doi:10.1097/SPV.0000000000001641. AUGS update of the 2017 statement.
14. Chang OH, Carter Ramirez A, Edwards A, et al. The role of uterine preservation at the time of pelvic organ prolapse surgery. Urogynecology (Phila). 2025;31(5):482–495. doi:10.1097/SPV.0000000000001667. AUGS Clinical Practice Statement.
15. Kowalski JT, Barber MD, Klerkx WM, Grzybowska ME, Toozs-Hobson P, Rogers RG, et al. International urogynecological consultation chapter 4.1: definition of outcomes for pelvic organ prolapse surgery. Int Urogynecol J. 2023;34(11):2689–2699. doi:10.1007/s00192-023-05660-9
16. Oegema K, Schulten SFM, Stekelenburg J, Kluivers KB, van Eijndhoven HWF. "Sacrospinous hysteropexy versus vaginal hysterectomy in women with uterine prolapse: 10-year follow-up of a randomised controlled trial." Int Urogynecol J. Published online August 13, 2026. doi:10.1007/s00192-026-06822-1
17. Nguyen TTT, Aryan P, Taheri M, et al. "Surgical strategies for apical pelvic organ prolapse: a systematic review and network meta-analysis." Int Urogynecol J. Published online September 23, 2026. doi:10.1007/s00192-026-06857-4
18. Hagen S, Kearney R, Goodman K, et al. "Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial." EClinicalMedicine. 2023;66:102326. doi:10.1016/j.eclinm.2023.102326
19. Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. "Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial." JAMA. 2023;330(7):626-635. doi:10.1001/jama.2023.13140
20. Elissaoui S, El Issaoui M, Klarskov N, Husby K. "The Manchester procedure: A systematic review of recurrence, perioperative measures, and financial cost, and a scoping review of sexual dysfunction, gynecologic cancer, and obstetric outcomes." Acta Obstet Gynecol Scand. 2026;105(7):1371–1383. doi:10.1111/aogs.70209
21. Sullivan ME, Vendramini A, Cattani L, et al. "Patient Risk Factors for Incidental Pathology After Uterovaginal Surgery for Apical Prolapse: Systematic Review and Global Expert Consensus Statements." Int Urogynecol J. Published online September 29, 2026. doi:10.1007/s00192-026-06849-4
22. Bugge C, Kearney R, Best C, et al. "Four Year Clinical and Cost Effectiveness of Vaginal Pessary Self-Management Versus Clinic-Based Care for Pelvic Organ Prolapse (TOPSY): Long Term Follow-Up of a Randomised Controlled Superiority Trial." BJOG. 2025;132(12):1762–1771. doi:10.1111/1471-0528.18333