Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management

INTRODUCTION — Pelvic organ prolapse (POP), the herniation of the pelvic organs to or beyond the vaginal walls, is a common condition. Many individuals with prolapse experience symptoms that impact daily activities, sexual function, and exercise. The presence of POP can have a detrimental impact on body image and sexuality [1]. Treatment of POP requires significant health care resources; the annual cost of ambulatory care of pelvic floor disorders in the United States from 2005 to 2006 was almost $300 million [2] and surgical repair of prolapse was the most common inpatient procedure performed in women older than 70 years from 1979 to 2006 [3]. The health care impact of prolapse is likely to expand based upon estimates of an increasing prevalence in the growing population of older adult women [4].

The epidemiology, risk factors, clinical manifestations, and general principles of management are reviewed here. Diagnostic evaluation and management options for POP are discussed separately.

●(See "Pelvic organ prolapse in women: Diagnostic evaluation".)

●(See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

●(See "Vaginal pessaries: Indications, devices, and approach to selection".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

TERMINOLOGY

●Pelvic organ prolapse (POP) – The herniation of the pelvic organs to or beyond the vaginal walls.

Commonly used terms to describe specific sites of female genital prolapse include:

●Anterior compartment prolapse – Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele) (figure 1).

●Posterior compartment prolapse – Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele) (picture 1).

●Enterocele – Hernia of the intestines to or through the vaginal wall.

●Apical compartment prolapse (uterine prolapse, vaginal vault prolapse) – Descent of the apex of the vagina into the lower vagina, to the hymen, or beyond the vaginal introitus (picture 2). The apex can be either the uterus and cervix, cervix alone, or vaginal vault, depending upon whether the woman has undergone hysterectomy. Apical prolapse is often associated with enterocele.

●Uterine procidentia – Hernia of all three compartments through the vaginal introitus.

The terms anterior vaginal wall prolapse and posterior vaginal wall prolapse are preferred to cystocele and rectocele because vaginal topography does not reliably predict the location of the associated viscera in POP [5,6].

Division of the vagina into separate compartments is somewhat arbitrary, because the vagina is a continuous organ and prolapse of one compartment is often associated with prolapse of another. As an example, approximately half of anterior prolapse can be attributed to apical descent [7].

ANATOMY OF PELVIC SUPPORT — Anatomic support of the pelvic organs in women is provided by an interaction between the muscles of the pelvic floor and connective tissue attachments to the bony pelvis (figure 2). The levator ani muscle complex, consisting of the pubococcygeus, puborectalis and iliococcygeus muscles, provides primary support to the pelvic organs, providing a firm, yet elastic-base upon which the pelvic organs rest (figure 3 and figure 4). The endopelvic fascial attachments, in particular condensations of the endopelvic fascia referred to as the uterosacral and cardinal ligaments, stabilize the pelvic organs in the correct position so that the pelvic muscles can provide optimal support (figure 5) [8].

Levels of pelvic organ support — A system of three integrated levels of vaginal support has been described by DeLancey (figure 6) [9,10].

All levels of vaginal support are connected through a continuous endopelvic fascia support network:

●Level 1 – Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. Level 1 support represents vertical fibers of the paracolpium that are a continuation of the uterosacral/cardinal ligament complex which inserts variably into the cervix and vagina (figure 6) [11]. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent [12]. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

●Level 2 – Paravaginal attachments along the length of the vagina to the superior fascia of the levator ani muscle and the arcus tendineus fascia pelvis (also referred to as the "white line"). Loss of level 2 support contributes to anterior vaginal wall prolapse (cystocele).

●Level 3 – Perineal body, perineal membrane, and superficial and deep perineal muscles, which support the distal one third of the vagina. Anteriorly, loss of level 3 support can result in urethral hypermobility. Posteriorly, loss of level 3 support can result in a distal rectocele or perineal descent.

Nerve supply — The innervation of the pelvic region derives from the S2, S3, and S4 segments of the spinal cord, which fuse to form the pudendal nerve. The pudendal nerve innervates the external anal sphincter, whereas the levator muscles, coccygeus muscles, and urogenital diaphragm appear to be innervated by a direct connection of S2, S3, and S4 nerve fibers [13].

PREVALENCE — The exact prevalence of POP is difficult to ascertain, for several reasons: (1) different classification systems have been used for diagnosis; (2) studies vary by whether the rate of prolapse reported is for women who are symptomatic or asymptomatic; and (3) it is unknown how many women with POP do not seek medical attention [14]. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Classification of pelvic organ prolapse'.)

The distinction between symptomatic and asymptomatic POP is clinically relevant, since treatment is generally indicated only for women with symptoms. However, there are few high quality data regarding the prevalence of symptomatic POP. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Symptomatic prolapse'.)

In a cross-sectional study, the United States (US) National Health and Nutrition Examination Survey (NHANES), 1961 women aged 20 to 80 years were interviewed. The authors defined symptomatic prolapse as a positive response to the question, "do you experience bulging or something falling out you can see or feel in the vaginal area?" and reported a 2.9 percent prevalence of symptomatic POP [15]. The question used in this study was derived from the Pelvic Floor Distress Inventory; a positive response correlates with the presence of a vaginal bulge on examination. However, the question has higher specificity than sensitivity for POP based on examination [16]. Population based surveys have found that 6 to 8 percent of women report symptoms of POP; no physical examination to assess prolapse was performed in these studies [17,18]. Prolapse estimates using only questionnaires underreport the true prevalence of prolapse based on clinical examination as surveys are likely to only identify women with advanced prolapse.

A higher prevalence of symptomatic POP is suggested by the number of women who undergo surgical prolapse repair. Approximately 200,000 surgical procedures for prolapse are performed annually in the United States [19,20]. Population based studies report an 11 to 19 percent lifetime risk in women undergoing surgery for prolapse or incontinence [21,22]. These data likely underestimate the number of women with symptomatic POP, since many women do not undergo surgery.

Rates of asymptomatic POP are probably even higher. Several studies have used clinical examination to assess the prevalence of POP in a community-based setting. One study included 497 women who were seen in an outpatient clinic for routine gynecologic care and were assessed using the Pelvic Organ Prolapse Quantitation (POP-Q) system. The overall distribution of POP-Q system stages was as follows: stage 0, 6.4 percent; stage 1, 43.3 percent; stage 2, 47.7 percent; and stage 3, 2.6 percent. No subjects examined had POP-Q system stage 4 prolapse. The distribution of the POP-Q system stages in the population revealed a bell-shaped curve, with most subjects having stage 1 or 2 support. Few subjects had either stage 0 (excellent support) or stage 3 (moderate to severe pelvic support defects) [23].

In the Women's Health Initiative study, which used a non-validated physical examination to assess pelvic organ support in postmenopausal women, the overall rates for prolapse in this population were 41 percent for women with a uterus and 38 percent posthysterectomy [24]. Anterior vaginal wall defects (33 to 34 percent) were significantly more common than posterior wall (18 percent) or apical defects (14 percent); it is important to note that the vagina is a continuous organ and defects in the apex contribute to anterior and posterior vaginal wall prolapse [7]. This study, however, did not assess women who had undergone previous surgeries other than hysterectomy and so women who have undergone prolapse surgery may have been included in this study population.

In another study of younger women, the total rate of prolapse on pelvic examination in women was 31 percent, with only 1.6 percent of women with prolapse to the hymen and none beyond the hymen [25].

RISK FACTORS — Established risk factors for POP include parity, advancing age, and obesity [26,27]. Risk factors for prolapse recurrence after surgical correction include levator ani avulsion, advanced prolapse stage, and family history [28,29].

●(See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

●(See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)".)

Parity — The risk of POP increases with increasing parity [15,30,31]. As an example, the Oxford Family Planning study, a prospective cohort study of more than 17,000 women followed for 17 years found that, compared with nulliparity, the risk of hospital admission for POP increased markedly after the first (fourfold) and second (eightfold) birth, and then increased less rapidly for subsequent births (third [ninefold]; fourth [10-fold]) [31]. Among parous women, estimates are that 75 percent of prolapse can be attributed to pregnancy and childbirth [32]. Injury to the levator ani or local nerves, especially the pudendal nerve, during childbirth may be responsible for the anatomic abnormality [33,34].

Other childbirth-related factors associated with prolapse include high infant birth weight, prolonged second stage of labor, and maternal age less than 25 years at first delivery [35,36]. However, vaginal prolapse can also occur in a nulliparous woman [37]. A detailed discussion of the effects of pregnancy and childbirth on POP can be found separately. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Prevalence in parous women'.)

Advancing age — Epidemiologic studies have generally reported an increased risk of POP with advancing age [21,24,38,39]. As an example, one study of over 1000 women presenting for a routine gynecologic examination reported a progressive increase in the rate of prolapse with increasing age; every additional 10 years of age conferred an increased risk of prolapse of 40 percent [39]. Similarly, in the larger Women's Health Initiative trial (over 27,000 women) there was a small, but statistically significant, progressive increase in the prevalence of rectocele with age (50 to 59 compared with 60 to 69 and 70 to 79 years) [24]. In another study looking at a managed health care population, the number of women seeking care for symptomatic pelvic floor disorders (prolapse and incontinence) increased by age, with the largest number of consults generated by women in their 60s and 70s [40].

Menopause — Although advancing age is a risk factor for POP and menopause is associated with increased age, a direct and independent correlation between menopause and an increased risk for POP has been reported [41]. Estrogen receptors are found in key pelvic-support structures such as levator ani muscles and in the uterosacral-cardinal ligament complex. One study reported that postmenopausal women with POP had significantly lower concentrations of serum estrogen and lower concentrations of estrogen receptors in the pelvic floor ligaments when compared with women without POP [42].

Obesity — Overweight (body mass index ≥25 to 29.9 kg/m²) and obese (body mass index ≥30 kg/m²) women have an increased risk of POP when compared with normal-weight peers. In a meta-analysis of 22 studies reporting the effect of weight on risk of prolapse, overweight and obese women had a nearly 40 and 50 percent increased risk of POP compared with normal-weight peers (risk ratio 1.36, 95% CI 1.20-1.53 and 1.47, 95% CI 1.35-1.59, respectively) [43].

While weight gain is a risk factor for developing prolapse, it is controversial whether weight loss results in prolapse regression. A study of 16,608 postmenopausal women found no association with weight loss and regression of POP [44]. However, there are reports of POP regression in women after bariatric surgery [45].

Hysterectomy — The role of hysterectomy in the development of subsequent POP is controversial. The risk may depend on age, whether prolapse is present at the time of hysterectomy, and on the surgical approach, including apical support procedures at the time of hysterectomy. In a retrospective cohort study of nearly 100,000 women undergoing POP surgery, hysterectomy at the time of the index POP surgery reduced the risk of future repeat POP surgery by approximately 30 percent [46]. Use of hysteropexy instead of hysterectomy at the time of prolapse repair does not appear to change the short-term (<3 years) risk of recurrent prolapse [47].

A detailed discussion of the risk of prolapse after hysterectomy and the role of apical repair can be found separately. (See "Prophylactic vaginal apex suspension at the time of hysterectomy", section on 'Impact of hysterectomy on future prolapse risk'.)

Retropubic urethropexy or needle suspension procedures may result in a more anterior deviation of the anterior vaginal wall, which alters the distribution of force on the vaginal walls. As a result, the apex and posterior vaginal wall may become prone to the development of support defects, including enterocele or rectocele.

Race and ethnicity — Minority populations have typically not been represented equitably in database studies of POP and knowledge is therefore limited [48]. Data suggest that African American women have a lower prevalence of symptomatic POP than other racial or ethnic groups in the US [18,24,49]. In a prospective cohort study of 2270 women, the risk in Latina and White women for POP was four- to fivefold higher than in African American women [49]. In contrast, other studies have found no relationship between POP and race or ethnicity [15,50].

Other risk factors

●Elevated intraabdominal pressure – Chronic constipation appears to be a risk factor for POP, likely due to repetitive increases in intraabdominal pressure [51-53]. Chronic constipation and other conditions that cause repetitive elevated intraabdominal pressure, such as chronic obstructive pulmonary disease, may cause stretch injury to the pudendal nerve [52].

Data conflict regarding whether the risk of prolapse is increased in women with occupations that involve heavy lifting [39,54]. One study of over 1000 women reported that women who are laborers/factory workers have significantly more severe POP than the other job categories, likely because of increased intraabdominal pressure related to lifting [55].

●Collagen abnormality – Some connective tissue disorders (eg, Ehlers-Danlos syndrome) or congenital abnormalities (eg, bladder exstrophy) contribute to POP [56-58]. Women with hypermobile joints have a higher prevalence of prolapse than women with normal joint mobility, suggesting abnormalities of collagen may play a role in both disorders [59,60]. One possibility is that these women may metabolize collagen such that there is a decrease in type I collagen and an increase in type III collagen. Type I collagen forms large, high tensile strength fibers that constitute such tissues as ligaments, tendons, skin, and bone. Type III collagen forms smaller fibers of lower tensile strength, and predominates in more flexible, distensible tissue types, and is the major collagen subtype in the vagina. Type V collagen forms small fibers of low tensile strength. Type III and V collagen fibers copolymerize with type I collagen to form fibrils of varying diameters and tensile strength. A higher ratio of type I collagen to type III and type V collagen results in higher tensile strength [59].

●Family history – A systematic review of 16 studies found a 2.5-fold increased risk of prolapse in women with a family history of the condition [61], while a meta-analysis of three studies reported an 80 percent increased risk of recurrent prolapse with a positive family history (odds ratio 1.84, 95% CI 1.19-2.86) [28]. In addition, one retrospective, population-based study reported an increasing risk of prolapse with increasing number of first-degree relatives with POP [62]. The potential genes and inheritance patterns are not known; there are few data regarding a genetic component of prolapse [63].

PREVENTION — Prolapse prevention strategies have not been extensively studied. Although vaginal childbirth is associated with an increased risk of prolapse, it is unclear that cesarean delivery will prevent the occurrence of prolapse. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Approach to obstetric management'.)

Prevention of progression of prolapse has not been well studied. Some data suggest that women with prolapse who use a vaginal pessary have a lower stage of prolapse on subsequent exams [64]. Interventions such as weight loss, treatment of chronic constipation, and avoidance of jobs that require heavy lifting are potential interventions to avoid the development or progression of POP and deserve further investigation. However, caution should be exercised in recommending these life-altering interventions without robust data to support their efficacy.

A systematic review of six randomized trials evaluated the effects of estrogens or medications with estrogenic effects (eg, selective estrogen receptor modulators), either alone or in conjunction with other treatments, for prevention of POP [65]. The only finding with sufficient data for meta-analysis for prevention of prolapse was that use of raloxifene in women who were 60 years or older resulted in a significant reduction in the proportion of women who subsequently underwent surgery (0.8 versus 1.5 percent, odds ratio 0.5, 95% CI 0.3-0.8). No significant association between raloxifene and surgery was found in women who were less than 60 years old. Further study is needed concerning the role of estrogenic agents in the prevention of POP.

CLINICAL MANIFESTATIONS — Patients with POP may present with symptoms related specifically to the prolapsed structures, such as a bulge or vaginal pressure or with associated symptoms including urinary, defecatory or sexual dysfunction [26]. Symptoms such as low back or pelvic pain have often been attributed to POP, but this association is not supported by well-designed studies [36,66].

Severity of symptoms does not correlate well with the stage of prolapse [39,67-71]. Symptoms are often related to position; they are often less noticeable in the morning or while supine and worsen as the day progresses or women are active in an upright position.

Many women with prolapse are asymptomatic; treatment is generally not indicated in these women. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Symptomatic prolapse'.)

Bulge or pressure symptoms — Women with POP often present with the complaint of vaginal or pelvic pressure and/or the sensation of a vaginal bulge or something falling out of the vagina.

In a study of 1912 women presenting to a pelvic floor disorder clinic, symptoms of "a bulge or that something is falling out of the vagina" had a sensitivity of 67 percent and a specificity of 87 percent for POP at or past the hymen [72]. Although complaints of a bulge are associated with the presence of prolapse, it is only weakly correlated with prolapse stage, and does not predict site of prolapse [67].

The anatomic threshold for symptomatic prolapse appears to be the hymen. The specificity of vaginal bulge symptoms for predicting prolapse beyond the hymen is high (99 percent to 100 percent); however, the sensitivity is low (16 percent to 35 percent) because some women with advanced prolapse report an absence of symptoms [73,74]. A cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using POP-Q examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms determined that the anatomic threshold of 0.5 cm distal to the hymen had sensitivity (69 percent) and specificity (97 percent) for protrusion/bulge symptoms [68].

Some women are able to see a protrusion of the prolapse beyond the introitus (picture 3). Protrusion of the vagina may result in chronic discharge and/or bleeding from ulceration.

Urinary symptoms — Loss of support of the anterior vaginal wall or vaginal apex may affect bladder and/or urethral function. Symptoms of stress urinary incontinence (SUI) often coexist with stage I or II prolapse [67,75].

As prolapse advances, women may experience improvement in SUI, but increased difficulty voiding. Advanced anterior or apical prolapse, the prolapse may "kink" the urethra, thereby resulting in symptoms of obstructed voiding, such as a slow urine stream, the need to change position or manually reduce (splint) the prolapse to urinate, a sensation of incomplete emptying and, in rare cases, complete urinary retention [26]. The correlation of obstructive symptoms with advancing prolapse was illustrated in the study of women presenting to a pelvic floor clinic described above, in which urinary splinting was reported by 5 to 12 percent of women with stage II anterior prolapse and 23 to 36 percent of those with stage III or IV anterior prolapse [72]. (See 'Bulge or pressure symptoms' above.)

Thirteen to 65 percent of continent women develop symptoms of SUI after surgical correction of prolapse. Elevation of prolapse during pelvic examination may unmask "occult" SUI. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)

Women with POP have a two- to fivefold risk of overactive bladder symptoms (urgency, urgency urinary incontinence, frequency) compared with the general population [76,77]. Data are mixed regarding whether the anatomic site (apical, anterior, posterior) and severity of prolapse correlate with the presence of such symptoms.

In addition, some women with POP experience enuresis or incontinence with sexual intercourse [78-80]. Importantly, among women undergoing treatment for prolapse, resolution of urinary symptoms is an important goal [81,82].

Defecatory symptoms — Defecatory symptoms are more prevalent in women with POP compared with the general population. Defecatory dysfunction affects 20 percent of women in the general population and 24 to 52 percent of those with POP. Two of the most common symptoms associated with prolapse are constipation and incomplete emptying [67,69,83]. Other defecatory symptoms include fecal urgency, fecal incontinence (accidental bowel leakage), and obstructive symptoms [eg, straining, or the need to apply digital pressure to the vagina or perineum (splint) to completely evacuate]; some women report fecal incontinence during sexual intercourse [26,80].

Defecatory symptoms may be present in women with any anatomic site of prolapse, although they tend to be found more commonly associated with posterior or apical defects [51,67]. In the study of women presenting to a pelvic floor clinic described above, women with stage I prolapse were the least likely to require splinting to defecate (8 to 15 percent), but the likelihood of splinting symptoms did not continue to increase with advancing prolapse (stage II: 21 to 38 percent; stage III to IV: 26 to 29 percent) [72]. (See 'Bulge or pressure symptoms' above.)

Defecatory symptoms can occur with any posterior compartment defect, including rectocele, enterocele, sigmoidocele, perineocele, internal rectal prolapse (intussusception), or full mucosal rectal prolapse. Rectal prolapse is a rare condition with an incidence of 0.25 to 0.42 percent. Patients may complain of a bulge and confuse their symptoms with vaginal prolapse. Women with rectal prolapse commonly report fecal incontinence and may have associated rectal bleeding. Rectal prolapse is often worsened with constipation and resultant straining, although data regarding causality are lacking. For women who present with symptoms consistent with rectal prolapse yet the prolapse is not visible on pelvic examination, the prolapse can become visible if the woman is examined while sitting on a toilet and straining. Another approach is to ask the patient to take a photograph when the prolapse is present. (See "Overview of rectal procidentia (rectal prolapse)".)

Effects on sexual function — Mild prolapse does not appear to be associated with decreased sexual desire or with dyspareunia, although reports vary according to whether POP is associated with adverse effects on orgasm or sexual satisfaction [80,84]. Some women report that they avoid sexual activity because of fear of discomfort or embarrassment associated with POP, particularly those with urinary or fecal incontinence during sexual activity [85,86]. (See "Sexual function in females with pelvic floor and lower urinary tract disorders".)

DIAGNOSIS AND CLASSIFICATION — POP is diagnosed using pelvic examination. A medical history is also important to elicit prolapse-associated symptoms, since treatment is generally indicated only for symptomatic prolapse. Since its introduction in 1996 and adoption by the Society of Gynecologic Surgeons, American Urogynecologic Society, and International Continence Society, the Pelvic Organ Prolapse Quantitation (POP-Q) system is the most commonly used prolapse staging system. In addition, a group of validated questionnaires, labeled IMPACT, has been proposed to assess patient-reported outcomes specific to pelvic floor disorders [87].

A detailed discussion of the diagnosis and classification of prolapse can be found separately. Classification of the prolapsed compartment helps guide surgical treatment planning. Distinguishing between an enterocele and rectocele or, less commonly, a cystocele and enterocele may be clinically challenging. For patients with severe bulge symptoms but in whom the physical examination reveals little to no prolapse, imaging may be helpful to better delineate the presence of an enterocele or intussusception. (See "Pelvic organ prolapse in women: Diagnostic evaluation".)

NATURAL HISTORY — Prolapse is traditionally regarded as a progressive disease, with mild prolapse inexorably leading to more advanced disease. However, data suggest that the course is progressive until menopause, after which the degree of prolapse may follow a course of alternating progression and regression [88-90]. Prolapse regression was demonstrated in a prospective cohort study of 249 women who were followed over a three-year period [88]. Prolapse increased by at least 2 cm in 11 percent of women and regressed by the same amount in 3 percent of women.

APPROACH TO MANAGEMENT

Indications for treatment — Treatment is indicated for women with symptoms of prolapse or associated conditions (urinary, bowel, or sexual dysfunction). Obstructed urination or defecation or hydronephrosis from chronic ureteral kinking are all indications for treatment, regardless of degree of prolapse [26]. Treatment is generally not indicated for women with asymptomatic prolapse [89].

Establishing patient goals — Treatment is individualized according to each patient's symptoms and their impact on her quality of life. Studies have demonstrated that patient satisfaction after pelvic reconstructive surgery correlates highly with achievement of self-described, preoperative surgical goals, but poorly with objective outcome measures [91-93]. Establishing realistic patient expectations is also important because medical comorbidities impact the patient's experience of symptoms. In a study of 91 women with POP, those with a positive screen for depressive symptoms reported worse Pelvic Floor Distress Inventory (PFDI-20) and Prolapse Quality of Life (P-QoL) scores than women without such symptoms despite no differences in objective measurements [94].

Management options — Women with symptomatic prolapse can be managed expectantly or treated with conservative or surgical therapy. Both conservative and surgical treatment options should be offered. No high-quality data comparing these two approaches exist.

The choice of therapy depends upon the patient's preferences, as well as the ability to comply with conservative therapy or tolerate surgery. Some data suggest that age, the degree of POP as measured by descent of leading edge of prolapse, preoperative pelvic pain scores, and prior prolapse surgery are independently associated with treatment choices. In a study of 152 women, older patients and those with increased preoperative pelvic pain scores were more likely to choose pessary over surgery [66]. On the other hand, the likelihood of choosing surgery was increased in women with more severe prolapse or a prior POP repair.

Expectant management — Expectant management is a viable option for women who tolerate their symptoms and prefer to avoid treatment.

Women with symptomatic or asymptomatic prolapse who decline treatment, particularly stage III or IV, should be evaluated on a regular basis to assess for the development or worsening of urinary or defecatory symptoms.

Conservative management — Conservative therapy is the first line option for all women with POP, since surgical treatment incurs the risk of complications and recurrence [95]. However, prolapse is typically a chronic problem, and many women ultimately prefer surgery to conservative therapy since successful surgery does not require ongoing maintenance.

Vaginal pessary — The mainstay of nonsurgical treatment for POP is the vaginal pessary. Pessaries are silicone devices in a variety of shapes and sizes, which support the pelvic organs. Approximately half of the women who use a pessary continue to do so in the intermediate term of one to two years. Pessaries must be removed and cleaned on a regular basis. (See "Vaginal pessaries: Indications, devices, and approach to selection".)

Pelvic floor muscle exercises — Pelvic floor muscle training (PFMT) appears to result in improvements in POP stage and POP-associated symptoms. Randomized trials have demonstrated the benefit of PFMT, particularly with individualized training and/or supervision [96-100]. In a meta-analysis of 13 trials including over 2300 women with POP, PFMT was associated with greater improvement in prolapse symptom scores (mean difference -3.07, 95% CI -3.91 to -2.23) and objective POP stage (risk ratio 1.70, 95% CI 1.19-2.44) [101]. Two subsequent trials that randomly assigned women with prolapse to combined PFMT and a lifestyle advice program or lifestyle program alone reported that the women in the combined treatment group reported improved POP symptoms, but no significant differences were reported for the quality-of-life scores between the groups [102,103]. For women with symptomatic stage 2 POP, we advise a trial of PFMT as it appears to improve symptoms and is not associated with harm. Since PFMT reduces prolapse on average 1 to 2 cm, prolapse far beyond the hymen, and its associated symptoms, is less likely to improve with PFMT.

Estrogen therapy — Currently, no data exist to support systemic or topical estrogen as a therapy as a primary treatment of POP. While a study of vaginal biopsies reported that perioperative topical vaginal estrogen increased the generation of mature collagen, increased vaginal wall thickness, and decreased degradative enzyme activity, these histologic findings need to be substantiated with clinical outcomes [104]. A systematic review evaluating the use of local estrogens for the treatment of pelvic floor disorders identified only three trials that evaluated the impact of local estrogens on prolapse, but the assessed outcomes focused on symptoms of vaginal atrophy rather than the prolapse itself [105]. A different meta-analysis reported that raloxifene (a selective estrogen receptor modulator) appeared to be associated with a decrease in the likelihood of undergoing surgery for POP, but the data were insufficient to advise raloxifene as a routine treatment [65]. (See 'Prevention' above.)

Surgical treatment — Surgical candidates include women with symptomatic prolapse who have failed or declined conservative management of their prolapse. There are numerous surgeries for prolapse including vaginal and abdominal approaches with and without graft materials.

Surgical prognosis depends upon the severity of symptoms, extent of the prolapse, surgeon experience, and patient expectations. Surgery has traditionally been associated with a recurrence/reoperation rate of up to 30 percent after the initial surgery [21,106], with some centers reporting reoperation in over 50 percent of patients who have undergone at least two prior surgical procedures for prolapse [107].

A detailed discussion of choosing a surgical therapy for prolapse can be found separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

Pregnant individuals — Women may present with new symptoms or an exacerbation of POP during pregnancy. These women are managed conservatively. This condition may manifest initially during the pregnancy; however, in the majority of cases, prolapse is a preexisting condition. This is a rarely reported condition in the United States; the overall incidence of cervical prolapse in pregnancy has been estimated to be 1 case per 10,000 to 15,000 deliveries. Higher prevalence and more severe stages of POP in pregnancy have been reported in other countries with high childbirth rates. The management of POP in women with concomitant pregnancy should be individualized based on symptomatology and clinical findings. These women are managed conservatively with either pelvic floor exercises or pessary [108,109].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery" and "Society guideline links: Rectal prolapse".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Pelvic floor muscle exercises (The Basics)" and "Patient education: Pelvic organ prolapse (The Basics)")

●Beyond the Basics topics (see "Patient education: Pelvic floor muscle exercises (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Description and prevalence – Pelvic organ prolapse (POP) is the herniation of the pelvic organs to or beyond the vaginal walls (figure 1). Specific sites of female genital prolapse include anterior, posterior, apical compartments. Estimates of the prevalence of symptomatic POP range from 3 to 11 percent of women.

•(See 'Terminology' above.)

•(See 'Prevalence' above.)

●Risk factors – Risk factors for POP include: increasing parity, advancing age, obesity, and hysterectomy. Women with chronic constipation, those who have jobs that involve heavy lifting, and those of Hispanic or White ethnicity may also have an increased risk of POP. (See 'Risk factors' above.)

●Symptoms – The most common symptom of prolapse is a sensation of pelvic pressure/heaviness or protrusion of tissue from the vagina. Patients frequently describe this as "feeling a bulge" or like something is "falling out of the vagina." Individuals with prolapse commonly have other pelvic floor disorders, including urinary, bowel and sexual complaints such as urinary incontinence, constipation, and/or sexual dysfunction. (See 'Clinical manifestations' above.)

●Treatment of symptomatic prolapse – Individuals with symptomatic POP can elect observation (ie, no intervention), conservative management, or surgical treatment. Treatment is generally not indicated for women with asymptomatic prolapse. (See 'Approach to management' above.)

•Conservative management – Conservative treatment options include vaginal pessaries and pelvic floor muscle exercises.

-(See 'Conservative management' above.)

-(See "Vaginal pessaries: Indications, devices, and approach to selection".)

•Surgical treatment – Surgical candidates include women with symptomatic prolapse, who have failed or declined conservative management of their prolapse. There are numerous surgeries for prolapse, including vaginal and abdominal approaches (open, laparoscopic, or robotic) and with and without graft materials. The prognosis varies with type of POP and surgical approach. (See 'Surgical treatment' above.)

●POP in pregnancy – POP may develop or worsen with pregnancy. Symptomatic individuals are managed conservatively with a trial of pessary and/or pelvic floor physical therapy. (See 'Pregnant individuals' above.)