Pelvic Organ Prolapse (POP)
Pelvic organ prolapse (POP) occurs when one or more pelvic organs descend from their normal position into or through the vagina because the pelvic floor support structures become weakened. It may involve the bladder, uterus, vaginal vault, rectum, or bowel.
This updated UKMLA guide to POP is based on NICE NG123 and NG 210, which covers types, staging, risk factors, symptoms, diagnosis, and management.
Definition
POP refers to the descent or herniation of pelvic organ(s) from their normal anatomical position into or through the vagina due to weakness of the pelvic floor support structures.
Classification
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 |
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 |
Causes and Risk Factors
POP results from weakening of the pelvic floor support structures (muscles, fascia and ligaments) that maintain pelvic organ position.
Established risk factors: [Ref]
- Vaginal childbirth
- Advancing age
- Obesity
Other potential risk factors: [Ref]
- Chronic constipation
- Parity (irrespective of mode of delivery)
- Heavy lifting occupations
- Previous hysterectomy
- Connective tissue disorders
Clinical Features
POP is common, and many mild cases are asymptomatic.
Common symptoms in advanced POP:
| Vaginal |
|
| Urinary |
|
| Bowel |
|
| Sexual |
|
Investigation and Diagnosis
POP is primarily diagnosed clinically [Ref]
- Perform a pelvic examination in the dorsal lithotomy position with the patient performing a Valsalva manoeuvre+/- on standing or squatting
- Use a Sims speculum (split / half speculum) to assess the anterior, posterior and apical vaginal compartments one at a time
- Assess pelvic floor muscle strength
Do NOT routinely perform imaging if prolapse is detected on physical examination.
Management
1st Line: General / Conservative Management
| Category | Description / management |
|---|---|
| Lifestyle modifications | Offer to ALL patients:
|
| Pelvic floor muscle exercises (e.g. Kegel exercises) | Supervised pelvic floor muscle training programme (at least 16 weeks) is 1st line for symptomatic stage 1 and 2 POP |
| Vaginal pessary | Consider a pessary in all stages of POP
|
All symptomatic POP patients should be offered nonsurgical management first, which includes pelvic floor muscle training and/or a pessary trial. [Ref]
2nd Line: Surgical Management
Offer surgery if symptoms persist despite non-surgical options or declined non-surgical options.
| Type of prolapse | Surgical options |
|---|---|
| Uterine prolapse |
|
| Vault (vaginal) prolapse |
|
| Anterior wall prolapse |
|
| Posterior wall prolapse |
|
Consider colpocleisis in:
- Uterine / vault prolapse, and
- Frail for surgery, or vaginal sex not intended