Practice Clinical updates

Pelvic organ prolapse

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3853 (Published 20 July 2016) Cite this as: BMJ 2016;354:i3853
  1. Matthew D Barber, professor of surgery and vice chair for research
  1. Center for Urogynecology and Pelvic Floor Disorders, Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland OH 44195, USA
  1. barberm2{at}ccf.org

What you need to know

  • Pelvic organ prolapse can substantially affect a woman’s quality of life

  • The most consistent risk factors are vaginal childbirth, advancing age, increasing body mass index, and prior hysterectomy

  • Evaluate and offer treatment to women only if they report bothersome symptoms

  • Effective conservative treatments include vaginal pessaries and pelvic floor physical therapy

  • Surgery is generally reserved for patients with bothersome prolapse symptoms who have at least stage 2 prolapse on examination when conservative treatments have failed or no longer works

A woman’s lifetime risk of surgery for pelvic organ prolapse (POP) is 12-19% with over 300 000 prolapse surgeries performed annually in the US alone.1 2 3 POP accounts for about 15-18% of hysterectomies, and uterovaginal prolapse is the most common indication for hysterectomy in postmenopausal women.4 About one in 12 women living in the community in the UK report symptoms of pelvic organ prolapse.5

POP is the downward decent of the female pelvic organs (vagina, uterus, bladder, and/or rectum) into or through the vagina. This review provides an evidence based update on the epidemiology, evaluation, and management of this condition.

How common is pelvic organ prolapse?

Loss of vaginal or uterine support is seen in up to 30-76% of women presenting for routine gynaecology care, with 3-6% of those with descent beyond the vaginal opening (that is, level of the hymen).6 7 8 One population based study found that about 3% of 1961 adult women surveyed reported symptomatic vaginal bulging.9

Prolapse of the anterior vaginal wall, or cystocele, is the most common form of POP, detected twice as often as posterior vaginal prolapse (that is, the rectocele), and three times more common than apical prolapse (uterine and/or post-hysterectomy vaginal vault prolapse) (fig 1).10 11 However in most cases of symptomatic POP, prolapse of multiple segments of the vagina are …

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