Pelvic Organ Prolapse (POP)
NICE guideline [NG123] Urinary incontinence and pelvic organ prolapse in women: management. Last updated: Jun 2019.
NICE guideline [NG210] Pelvic floor dysfunction: prevention and non-surgical management. Published: Dec 2021.
Background Information
Classification
Classification by Severity
NICE recommends using the Pelvic Organ Prolapse Quantification (POP-Q) system
| Stage | Description (location of the most distal part of prolapse) |
|---|---|
| 0 | No prolapse |
| 1 | >1 cm above the hymen |
| 2 | Within +/-1 cm of the hymen (1cm above or 1cm below) |
| 3 | >1 cm below the hymen but NOT fully outside the vagina |
| 4 | Complete eversion – visible outside the vagina |
Classification by Anatomy
| Compartment | Type of Prolapse | Description / Structure Involved |
|---|---|---|
| Anterior | Cystocele | Herniation of the bladder into the anterior vaginal wall |
| Urethrocele | Herniation of the urethra into the anterior vaginal wall. Often occurs with cystocele (cystourethrocele) | |
| Apical | Uterine prolapse | Descent of the uterus and cervix down into the vaginal canal |
| Vaginal vault prolapse | Prolapse of the vaginal apex after hysterectomy | |
| Posterior | Rectocele | Herniation of the rectum into the posterior vaginal wall |
| Enterocele | Herniation of the small bowel into the upper posterior vaginal wall, typically through the pouch of Douglas. |
Guidelines
Investigation and Diagnosis
Perform a physical examination
- Examination of the woman in standing / squatting can unmask the findings
Do not routinely perform imaging if prolapse is detected on physical examination.
Management
Lifestyle Modification
Advise the women:
- Lose weight if BMI >30 kg/m2
- Minimise heavy lifting
- Prevent / treating constipation
Non-Surgical Management
Supervised pelvic floor muscle training (at least 16 weeks of a supervised programme)
- 1st line in symptomatic stage 1/2 pelvic organ prolapse
Consider vaginal pessary alone or together with supervised pelvic floor muscle training
- Can be inserted in the clinic
- Advise to remove once every 6 months (to prevent and monitor for complications like ulceration, infection or displacement)
Surgical Management
Offer surgery if symptoms persist despite non-surgical options, or declined non-surgical options.
Choice of Surgical Approach
| Type of Prolapse | Surgical Options | Notes |
|---|---|---|
| Uterine prolapse | Take women's preference in preserving the uterus or not:
|
If fertility is desired:
|
| Vault (vaginal) prolapse |
|
n/a |
| Anterior wall prolapse | Anterior colporrhaphy (repair without mesh) | Do not use mesh |
| Posterior wall prolapse | Posterior colporrhaphy (repair without mesh) | Do not use mesh |
Consider colpocleisis in:
- Uterine / vault prolapse, and
- Frail for surgery, or vaginal sex not intended
Follow Up
Follow up 6 months after any surgeries.