Pelvic organ prolapse is downward descent of female pelvic organs, including the bladder, uterus or post-hysterectomy vaginal cuff, and the small or large bowel, resulting in protrusion of the vagina, uterus, or both. Prolapse development is multifactorial, with vaginal child birth, advancing age, and increasing body-mass index as the most consistent risk factors. Vaginal delivery, hysterectomy, chronic straining, normal ageing, and abnormalities of connective tissue or connective-tissue repair predispose some women to disruption, stretching, or dysfunction of the levator ani complex, connective-tissue attachments of the vagina, or both, resulting in prolapse. Patients generally present with several complaints, including bladder, bowel, and pelvic symptoms; however, with the exception of vaginal bulging, none is specific to prolapse. Women with symptoms suggestive of prolapse should undergo a pelvic examination and medical history check. Radiographic assessment is usually unnecessary. Many women with pelvic organ prolapse are asymptomatic and do not need treatment. When prolapse is symptomatic, options include observation, pessary use, and surgery. Surgical strategies for prolapse can be categorised broadly by reconstructive and obliterative techniques. Reconstructive procedures can be done by either an abdominal or vaginal approach. Although no effective prevention strategy for prolapse has been identified, considerations include weight loss, reduction of heavy lifting, treatment of constipation, modification or reduction of obstetric risk factors, and pelvic-floor physical therapy.
Pelvic organ prolapse, also called urogenital prolapse, is downward descent of the pelvic organs that results in a protrusion of the vagina, uterus, or both.1 It is a disorder exclusive to women and can affect the anterior vaginal wall, posterior vaginal wall, and uterus or apex of the vagina, usually in some combination.2 Pelvic organ prolapse is distinct from rectal prolapse, in which the rectum protrudes through the anus, affecting both men and women. In 1997, more than 225 000 inpatient surgical procedures for pelvic organ prolapse were undertaken in the USA (22·7 per 10 000 women), at an estimated cost of more than US$1 billion.3 and 4 In the UK, the disorder accounts for 20% of women on the waiting list for major gynaecological surgery.5 Pelvic organ prolapse is the leading indication for hysterectomy in postmenopausal women and accounts for 15–18% of procedures in all age-groups.6 It rarely results in severe morbidity or mortality; rather, it causes symptoms of the lower genital, urinary, and gastrointestinal tracts that can affect a woman's daily activities and quality of life.7
The anterior vaginal wall is the most typical segment of the vagina to prolapse.8 This type of prolapse usually includes descent of the bladder: when the bladder protrudes, it is called a cystocoele (figure 1). Apical prolapse entails either the uterus or post-hysterectomy vaginal cuff and can affect the small intestine (enterocoele), bladder, or colon (sigmoidocoele). Posterior vaginal wall prolapse concerns the rectum (rectocoele) but can also include the small or large bowel. Uterovaginal support can be measured with the pelvic organ prolapse quantitation system (table).9 In addition to describing precisely the degree of anterior, posterior, and apical vaginal-wall descent, this measure broadly classifies uterovaginal support with a staging system that ranges from 0 (perfect support) to IV (total procidentia or complete vaginal eversion).