Sei sulla pagina 1di 9

BMJ 2016;354:i3853 doi: 10.1136/bmj.

i3853 (Published 20 July 2016) Page 1 of 9




Pelvic organ prolapse

Matthew D Barber professor of surgery and vice chair for research
Center for Urogynecology and Pelvic Floor Disorders, Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland OH 44195,

A woman’s lifetime risk of surgery for pelvic organ prolapse

(POP) is 12-19% with over 300 000 prolapse surgeries What are the risk factors for pelvic organ
performed annually in the US alone.1-3 POP accounts for about prolapse?
15-18% of hysterectomies, and uterovaginal prolapse is the
most common indication for hysterectomy in postmenopausal Vaginal childbirth, advancing age, increasing body mass index,
women.4 About one in 12 women living in the community in and prior hysterectomy are the most consistent risk factors for
the UK report symptoms of pelvic organ prolapse.5 POP (see box 1).20 21
POP is the downward decent of the female pelvic organs
(vagina, uterus, bladder, and/or rectum) into or through the How do women with pelvic organ prolapse
vagina. This review provides an evidence based update on the present?
epidemiology, evaluation, and management of this condition.
The symptom that most strongly correlates with and is most
How common is pelvic organ prolapse? specific for POP is a feeling of vaginal bulging or a vaginal
Loss of vaginal or uterine support is seen in up to 30-76% of bulge that can be seen or felt.7-22 Women who develop symptoms
women presenting for routine gynaecology care, with 3-6% of may present with a single symptom such as feeling a vaginal
those with descent beyond the vaginal opening (that is, level of bulge or pelvic pressure, or they may present with a combination
the hymen).6-8 One population based study found that about 3% of symptoms.23 Loss of normal vaginal support occurs in most
of 1961 adult women surveyed reported symptomatic vaginal women with advancing age, particularly if they have had
bulging.9 children.7-17 Severity of symptoms varies and is the driving factor
in patient presentation and when to offer treatment (box 2). A
Prolapse of the anterior vaginal wall, or cystocele, is the most
cross-sectional study of 237 women evaluated for POP found
common form of POP, detected twice as often as posterior
73% with concurrent urinary incontinence, 86% with urinary
vaginal prolapse (that is, the rectocele), and three times more
urgency/frequency, 34-62% with voiding dysfunction and 31%
common than apical prolapse (uterine and/or post-hysterectomy
with faecal incontinence.6 Importantly, other than vaginal
vaginal vault prolapse) (fig 1⇓).10 11 However in most cases of
bulging symptoms, none of these associated symptoms are
symptomatic POP, prolapse of multiple segments of the vagina
specific to POP. Considerable overlap exists with other pelvic
are noted.
floor disorders and clinicians should be aware of other potential
Epidemiological studies of POP incidence and remission are sources for the patient’s complaints including primary bladder
rare. One prospective cohort of 259 postmenopausal women or bowel dysfunction.22 Women with severe prolapse may
found that the incidence of prolapse (defined as prolapse to or develop erosions of the vagina or cervix which can present with
beyond the hymen) was 26% (95% confidence interval 20% to vaginal bleeding or spotting.
33%) after one year and 40% (26% to 56%) after three years.12
In this same study, the spontaneous resolution rates at one and
three years were 21% (11% to 33%) and 19% (7% to 39%).
How should women with pelvic organ
prolapse be evaluated?
Offer a pelvic examination to women presenting with symptoms
suggestive of POP to define the extent of prolapse and establish
the segments of the vagina affected (anterior, posterior, or
apical).24 Observe the woman while resting and straining both
standing and supine to reproduce the maximum extent of

For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 2 of 9


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

Box 1: Risk factors for pelvic organ prolapse (POP)

Established risk factors
• Higher parity—Observational study found increasing vaginal parity was the strongest risk factor for POP in women <60 years old.
Compared with nulliparous women, relative risk of developing POP was 8.4 for a woman who had delivered two children and 10.9
(95% CI 4.7 to 33.8) for someone with four or more children.13
• Vaginal childbirth—Cross sectional study of 3050 women from a California health maintenance organisation found the attributable
risk of vaginal delivery for development of symptomatic POP was 46%.14
• Advancing age—Studies suggest that the prevalence of POP increases by 40% with each decade of life.15 Peak age of surgery for
POP is 71-73 years with an annual risk of 4.3/1000 women.
• Obesity
• Previous hysterectomy

Potential risk factors

• Forceps delivery—Caesarean section seems to protect against prolapse development, whereas forceps delivery enhances risk.14 16
• Other obstetric factors—High infant birth weight (>4500 g), prolonged second stage of labour, age <25 years at first delivery, and
perhaps even pregnancy itself have been associated with POP.16 17
• Family history of pelvic organ prolapse—One study found a higher risk of prolapse in women with a mother or sister reporting POP
(odds ratios 3.2 (95% CI 1.1 to 7.6) and 2.4 (1.0 to 5.6) respectively).18
• Shape and orientation of the bony pelvis
• Occupations entailing heavy lifting
• Constipation
• Connective tissue disorders—A recent meta-analysis found moderate epidemiological credibility for association between POP and a
variation of the collagen type 1 gene (COL1A1).19

prolapse that the patient has in her daily life. The pelvic organ When to offer treatment
prolapse quantification system (POPQ)24 is the POP grading
system with the highest reliability and is the most widely used Treatment is unnecessary in women with mild prolapse who
internationally. This examination defines systematically the are asymptomatic. Some women with advanced POP (stage 3
amount of anterior, posterior, and apical segment prolapse in or 4) can have few symptoms and report little or no bother. In
centimetres relative to a fixed anatomical structure—the vaginal these cases, observation is appropriate.25 Offer treatment for
hymen. Additionally, this includes a five point staging system women with POP if they develop symptoms attributable to the
(fig 2⇓). A split-speculum examination with a Sims speculum prolapse that they find bothersome.
or the posterior blade of a Graves speculum is used to assess
anterior and posterior vaginal descent. To assess for anterior What treatments for pelvic organ prolapse
vaginal prolapse, the speculum is used to retract away the are available in the non-specialist setting?
posterior vagina while the patient strains. Conversely, to assess
for posterior vaginal prolapse, the speculum is placed anteriorly Conservative management options for POP with demonstrated
during straining. efficacy include pelvic floor muscle training and pessary use.26 27
Most women will need little additional testing, and this should Offer these options to all patients with symptomatic POP before
be guided by the presenting symptoms. For those with POP and considering surgery. They are particularly useful for women
lower urinary tract symptoms, offer urine analysis and post-void with a mild degree of prolapse, those who wish to have more
residual volume evaluation to test for urinary tract infection, children, who are frail and elderly, and those unwilling or not
haematuria, and incomplete bladder emptying. Urodynamics suitable to undergo surgery.27 Lifestyle advice that is commonly
can be considered in women with substantial urinary offered patients with POP—including weight loss, minimising
incontinence, irritative voiding symptoms, or voiding straining or constipation, and avoidance of heavy lifting,
dysfunction. Defecography, anal manometry and endoanal coughing, or high impact exercise—is not supported by evidence
ultrasound can be considered in women with outlet constipation but, as it offers little risk, may be reasonable.
or faecal incontinence. Radiographic imaging is generally not
necessary but dynamic magnetic resonance imaging or Pelvic floor muscle training
ultrasonography may be considered when the patient’s Several recent randomised trials have demonstrated pelvic floor
symptoms cannot be adequately explained by the office muscle training is effective as a conservative option for
evaluation improving symptoms in women with mild to moderate POP,
but no improvement was noted in the degree of POP on
examination.28 29 In each of these trials, patients received regular
supervised pelvic floor physiotherapy sessions with a trained
physiotherapist that included education and manual biofeedback
For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 3 of 9


Box 2: Symptoms associated with pelvic organ prolapse*

Vaginal symptoms
• Sensation of vaginal bulging or protrusion
• Seeing or feeling a bulge
• Pelvic or vaginal pressure
• Heaviness in pelvis or vagina

Urinary symptoms
• Urinary incontinence
• Urinary urgency and/or frequency
• Weak or prolonged urinary stream
• Feeling of incomplete emptying
• Manual reduction of prolapse to start or complete voiding (“splinting to void”)
• Position change to start or complete voiding

Bowel symptoms
• Incontinence of flatus or stool (liquid or solid)
• Feeling of incomplete emptying
• Hard straining to defecate
• Urgency to defecate
• Digital evacuation to complete defecation
• Splinting vagina or perineum to start or complete defecation

Sexual symptoms
• Dyspareunia
• Decreased sensation
• Decreased arousal or orgasm
• Decreased body image

• Pain in vagina, bladder, or rectum
• Pelvic or low back pain
*Adapted from Barber23

to ensure proper pelvic floor muscle contraction and were given POP symptoms and quality of life are improved more in women
an individualised home exercise programme for 12-16 weeks.28 29 using a pessary with pelvic floor muscle exercises compared
In one study, symptom improvement was greater than in controls with exercises alone.32 The 2013 Cochrane review identified
through 12 months after start of treatment, but there was no only one randomised controlled trial which compared ring and
difference from controls in the proportion of women going on Gellhorn pessaries.26 The trial showed that both pessaries were
to surgery (11% v 10% by 12 months, P=0.84).28 The efficacy effective for the roughly 60% of women who completed the
of pelvic floor muscle training beyond 12 months is unknown. study, with no statistically significant differences between the
Similarly, there have been no studies evaluating pelvic muscle two types of pessary.33
exercises for POP performed without the aid of a trained Patients are typically unable to remove Gellhorn or donut
physiotherapist. However, as there is little risk, this is a pessaries on their own, so these pessary types are often not a
reasonable recommendation in areas where trained good choice for sexually active women. Because of the risk of
physiotherapists are not available. developing vaginal erosions and new bowel and bladder
symptoms, offer women examination every three to six months
Pessary to identify pessary related complications.31 Age greater than 65
Pessaries are mechanical devices inserted into the vagina. They years, severe comorbidity, and maintenance of urinary
reduce prolapsed tissue inside the vagina, provide support to continence are predictors of continued pessary use after one
related pelvic structures, and relieve pressure on the bladder year.34
and bowel in order to avert or delay the need for surgery.26
Pessaries are available in different shapes and sizes. The most What surgical treatments are available?
commonly used are the ring, ring with support, Gellhorn, and
doughnut pessaries (fig 3⇓).30 A ring pessary or ring with The goal of POP surgery is to restore normal pelvic anatomy,
support, which is easy to insert and remove, is a good first option eliminate POP symptoms, and normalise bowel, bladder, and
for most patients. In a prospective study of 110 women, pessaries sexual function. Surgery is usually reserved for patients who
were successfully fitted in 74% of patients.31 Of these, 96% have at least stage 2 POP on examination, report bothersome
received a ring pessary. If a device of this type cannot be symptoms, and have failed or declined more conservative
successfully inserted, trial and error is usually necessary to find treatments. About one in eight women with POP undergo
the correct pessary size and shape for an individual patient. surgery by age 80.1 Of those who receive prolapse surgery, some
13% will require a repeat operation within five years, and as
In spite of its frequent use, there are few publications on the many as 29% will undergo another surgery for genital prolapse
appropriate indications, proper management, and effectiveness or a related condition at some point during their life.35 36 Surgery
of pessary treatment of POP. A recent clinical trial found that can be performed transvaginally or transabdominally (via
For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 4 of 9


laparotomy or laparoscopy with or without robotic assistance), Synthetic mesh in pelvic organ prolapse
and 80-90% are performed via the transvaginal approach.35-37 surgery
Native tissue (non-mesh) and synthetic mesh augmented repairs The increased rate of complications seen with vaginal mesh for
exist (table 1⇓). POP led the US Food and Drug Administration to issue two
In women with advanced POP, prolapse of multiple segments public health notifications in 2008 and 2011.39 Erosion or
of the vagina is the norm, and usually some combination of exposure of the mesh into the vagina or other viscera is the most
resuspension of the anterior, apical, or posterior vaginal walls common mesh-specific complication. Patients with
is necessary. There is currently no consensus regarding which complications from mesh may present with vaginal bleeding,
surgical approach is superior, and each has its own risk-benefit pelvic pain, dyspareunia, or bowel or bladder dysfunction. In
profile, although transvaginal mesh augmented repairs have 2014 the Scottish government called for a suspension on
come under scrutiny by national regulatory agencies and synthetic mesh use, but the UK Medicines and Healthcare
professional medical societies in recent years because of an products Regulatory Agency (MHRA) concluded that the
increased risk of adverse events relative to other approaches.25-39 benefits of POP mesh devices outweigh the risks.49 50
Over the past five years, the use of vaginal mesh devices
Apical pelvic organ prolapse worldwide has declined substantially, and many such devices
Loss of apical support is common in women with POP that are no longer commercially available. National and international
extends beyond the hymen. In women with uterine prolapse, professional bodies have issued guidelines on appropriate use,
hysterectomy is often performed along with an apical suspension patient selection, and informed consent processes (see box of
procedure, though uterine suspension procedures (hysteropexy) additional educational resources). Generally, vaginal mesh repair
are also available for those who wish to preserve uterine should be performed by specialists and reserved for high risk
function. A hysterectomy performed alone without additional patients in whom the benefit of mesh placement may justify the
apical suspension procedure is not adequate treatment for uterine risk, such as individuals with recurrent prolapse (particularly
prolapse. of the anterior segment) or with medical comorbidities that
Various surgical techniques exist for correcting apical POP, preclude more invasive and lengthier open and endoscopic
with the two most common transvaginal approaches being procedures.38
uterosacral ligament fixation and sacrospinous ligament fixation. Transabdominal mesh procedures (that is, sacrocolpopexy) have
A recent large multicentre surgical trial showed that vaginal not come under similar scrutiny because of lower risk of mesh
uterosacral ligament suspension has similar anatomic and complications and more favourable risk-benefit profile.39
subjective outcomes to sacrospinous ligament fixation at two
years’ follow-up.40 The most commonly used abdominal Competing interests: I have read and understood the BMJ Group policy
technique is sacrocolpopexy, in which the upper vagina is on declaration of interests and declare the following interests: None.
suspended to the sacrum with synthetic mesh. Native tissue Provenance and peer review: Commissioned; externally peer reviewed.
(non-mesh) vaginal repairs offer decreased morbidity compared Patient consent obtained.
with mesh augmented sacrocolpopexy; however, sacrocolpopexy
has greater anatomical success than native tissue vaginal 1 Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress
repairs.41 42 Sacrocolpopexy is most often performed via urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 2014;123:1201-6.
doi:10.1097/AOG.0000000000000286 pmid:24807341.
laparoscopy with or without robotic assistance and is associated 2 US Food and Drug Administration. Update on the safety and effectiveness of transvaginal
with lower blood loss and quicker recover than when performed mesh placement for pelvic organ prolapsed. 2011.

via laparotomy.43-45 Native tissue repairs and transvaginal 3

Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic
commercial mesh devices (“mesh kits”) support the vaginal organ prolapse. Obstet Gynecol 2010;116:1096-100. doi:10.1097/AOG.
apex with similar efficacy, but mesh is associated higher rates 0b013e3181f73729 pmid:20966694.
4 Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the
of complications.42 46 United States, 2000-2004. Am J Obstet Gynecol 2008;198:34.e1-7. doi:10.1016/j.ajog.
2007.05.039 pmid:17981254.

Anterior pelvic organ prolapse

5 Cooper J, Annappa M, Dracocardos D, Cooper W, Muller S, Mallen C. Prevalence of
genital prolapse symptoms in primary care: a cross-sectional survey. Int Urogynecol J
2015;26:505-10. doi:10.1007/s00192-014-2556-x pmid:25381004.
Anterior colporrhaphy uses native tissue to repair anterior 6 Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of
vaginal prolapse. The success rate ranges from 80-100% in cases symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol
2001;185:1332-7, discussion 1337-8. doi:10.1067/mob.2001.119078 pmid:11744905.
series to only 40-60% in randomised trials.47 Commercial mesh 7 Swift SE. The distribution of pelvic organ support in a population of female subjects seen
devices have been used to augment anterior POP repairs to for routine gynecologic health care. Am J Obstet Gynecol 2000;183:277-85. doi:10.1067/

improve durability. Use of mesh results in better anatomical 8

mob.2000.107583 pmid:10942459.
Trowbridge ER, Fultz NH, Patel DA, DeLancey JO, Fenner DE. Distribution of pelvic organ
and functional success but is associated with longer operating support measures in a population-based sample of middle-aged, community-dwelling
time, greater blood loss, greater apical or posterior compartment African American and white women in southeastern Michigan. Am J Obstet Gynecol
2008;198:548.e1-6. doi:10.1016/j.ajog.2008.01.054 pmid:18455530.
prolapse, and mesh erosion or exposure in 10.4% (with 6.3% 9 Nygaard I, Barber MD, Burgio KL, et al. Pelvic Floor Disorders Network. Prevalence of
requiring surgical correction).42 47 symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-6. doi:10.1001/
jama.300.11.1311 pmid:18799443.
10 Handa VLGE, Garrett E, Hendrix S, Gold E, Robbins J. Progression and remission of
Posterior pelvic organ prolapse pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol
2004;190:27-32. doi:10.1016/j.ajog.2003.07.017 pmid:14749630.
Posterior colporrhaphy is associated with success rates of 11 Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse
in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol
80-95% for correcting posterior vaginal prolapse.41 Resolution 2002;186:1160-6. doi:10.1067/mob.2002.123819 pmid:12066091.
or improvement in bowel symptoms can be expected in most 12 Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse

women after posterior colporrhaphy and pelvic reconstruction, in postmenopausal women. Obstet Gynecol 2007;109:848-54. doi:10.1097/01.AOG.
0000255977.91296.5d pmid:17400845.
while new bowel symptoms develop in 11%.48 Use of 13 Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the
polypropylene mesh has not been associated with improved Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997;104:579-85. doi:
10.1111/j.1471-0528.1997.tb11536.x pmid:9166201.
outcomes and is not recommended for posterior vaginal POP 14 Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity, mode of delivery,
surgery.41 42 and pelvic floor disorders. Obstet Gynecol 2006;107:1253-60. doi:10.1097/01.AOG.
0000218096.54169.34 pmid:16738149.

For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 5 of 9


Sources and selection criteria

The literature search used a combination of MeSH, text words and appropriate word variants of “pelvic organ prolapse,” “uterine prolapse,”
“vaginal prolapse,” “cystocele,” “rectocele,” and “enterocele.” Medline and Cochrane reviews were searched, as well as evidence based
guidelines, personal references, and reference lists in general articles of pelvic organ prolapse. Searching was limited to English and women.

Additional educational resources

Resources for healthcare professionals
• British Society of Urogynaecology Guidelines (
• American Urogynecologic Society website (
• American College of Obstetrics and Gynecology and American Urogynecologic Society joint recommendations on the use of vaginal
mesh (
• The Scottish independent review of the use, safety and efficacy of transvaginal mesh implants in the treatment of stress urinary
incontinence and pelvic organ prolapse in women: interim report. Chapter 2: The clinical uses of mesh for stress urinary incontinence
and pelvic organ prolapse. 2015 (

Resources for patients

• Pelvic organ prolapse patient information leaflet (
• Website providing patient information on pelvic floor disorders including pelvic organ prolapse sponsored by the American Urogynecologic
Society (
• Patient leaflets from the International Urogynecologic Association (IUGA) website (
• US Food and Drug Administration. Patient information on vaginal mesh for pelvic organ prolapse (

How were patients included in the creation of this article?

Debra Pyle, a patient who has undergone surgery for pelvic organ prolapse, critically reviewed this manuscript and provided helpful input
about patient symptoms and made suggestions for and reviewed the resources for patients.

15 Swift S, Woodman P, O’Boyle A, et al. Pelvic Organ Support Study (POSST): the 33 Cundiff GW, Amundsen CL, Bent AE, et al. The PESSRI study: symptom relief outcomes
distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. of a randomized crossover trial of the ring and Gellhorn pessaries. Am J Obstet Gynecol
Am J Obstet Gynecol 2005;192:795-806. doi:10.1016/j.ajog.2004.10.602 pmid:15746674. 2007;196:405.e1-8. doi:10.1016/j.ajog.2007.02.018 pmid:17403437.
16 Moalli PA, Jones Ivy S, Meyn LA, Zyczynski HM. Risk factors associated with pelvic floor 34 Clemons JL, Aguilar VC, Sokol ER, Jackson ND, Myers DL. Patient characteristics that
disorders in women undergoing surgical repair. Obstet Gynecol 2003;101:869-74.pmid: are associated with continued pessary use versus surgery after 1 year. Am J Obstet
12738142. Gynecol 2004;191:159-64. doi:10.1016/j.ajog.2004.04.048 pmid:15295358.
17 Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support 35 Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically
in a general population of women: what is pelvic organ prolapse?Am J Obstet Gynecol managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-6.
2003;189:372-7, discussion 377-9. doi:10.1067/S0002-9378(03)00698-7 pmid:14520198. doi:10.1016/S0029-7844(97)00058-6 pmid:9083302.
18 Chiaffarino F, Chatenoud L, Dindelli M, et al. Reproductive factors, family history, 36 Clark AL, Gregory T, Smith VJ, Edwards R. Epidemiologic evaluation of reoperation for
occupation and risk of urogenital prolapse. Eur J Obstet Gynecol Reprod Biol 1999;82:63-7. surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol
doi:10.1016/S0301-2115(98)00175-4 pmid:10192487. 2003;189:1261-7. doi:10.1067/S0002-9378(03)00829-9 pmid:14634551.
19 Cartwright R, Kirby AC, Tikkinen KA, et al. Systematic review and metaanalysis of genetic 37 Brown JS, Waetjen LE, Subak LL, Thom DH, Van den Eeden S, Vittinghoff E. Pelvic
association studies of urinary symptoms and prolapse in women. Am J Obstet Gynecol organ prolapse surgery in the United States, 1997. Am J Obstet Gynecol 2002;186:712-6.
2015;212:199.e1-24. doi:10.1016/j.ajog.2014.08.005 pmid:25111588. doi:10.1067/mob.2002.121897 pmid:11967496.
20 Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. 38 Committee on Gynecologic Practice. Committee opinion No. 513: vaginal placement of
Int Urogynecol J 2013;24:1783-90. doi:10.1007/s00192-013-2169-9 pmid:24142054. synthetic mesh for pelvic organ prolapse. Obstet Gynecol 2011;118:1459-64. doi:10.1097/
21 Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse AOG.0b013e31823ed1d9 pmid:22105294.
and its recurrence: a systematic review. Int Urogynecol J 2015;26:1559-73. doi:10.1007/ 39 US Food and Drug Administration. FDA public health notification: serious complications
s00192-015-2695-8 pmid:25966804. associated with transvaginal placement of surgical mesh in repair of pelvic organ prolapse
22 Barber MD, Neubauer NL, Klein-Olarte V. Can we screen for pelvic organ prolapse without and stress urinary incontinence.
a physical examination in epidemiologic studies?Am J Obstet Gynecol 2006;195:942-8. PublicHealthNotifications/ucm061976.htm.
doi:10.1016/j.ajog.2006.02.050 pmid:16681989. 40 Barber MD, Brubaker L, Burgio KL, et al. Eunice Kennedy Shriver National Institute of
23 Barber MD. Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Child Health and Human Development Pelvic Floor Disorders Network. Comparison of 2
Gynecol 2005;48:648-61. doi:10.1097/01.grf.0000170424.11993.73 pmid:16012232. transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal
24 Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic prolapse: the OPTIMAL randomized trial. JAMA 2014;311:1023-34. doi:10.1001/jama.
organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. doi:10. 2014.1719 pmid:24618964.
1016/S0002-9378(96)70243-0 pmid:8694033. 41 Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse
25 Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1027-38. doi: in women. Cochrane Database Syst Rev 2013;4:CD004014.pmid:23633316.
10.1016/S0140-6736(07)60462-0 pmid:17382829. 42 Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Marjoribanks J.
26 Bugge C, Adams EJ, Gopinath D, Reid F. Pessaries (mechanical devices) for pelvic organ Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.
prolapse in women. Cochrane Database Syst Rev 2013;2:CD004010.pmid:23450548. Cochrane Database Syst Rev 2016;2:CD012079.pmid:26858090.
27 Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse 43 De Gouveia De Sa M, Claydon LS, Whitlow B, Dolcet Artahona MA. Laparoscopic versus
in women. Cochrane Database Syst Rev 2011;(12):CD003882.pmid:22161382. open sacrocolpopexy for treatment of prolapse of the apical segment of the vagina: a
28 Hagen S, Stark D, Glazener C, et al. POPPY Trial Collaborators. Individualised pelvic systematic review and meta-analysis. Int Urogynecol J 2016;27:3-17. doi:10.1007/s00192-
floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre 015-2765-y pmid:26249236.
randomised controlled trial. Lancet 2014;383:796-806. doi:10.1016/S0140-6736(13)61977- 44 Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic compared with
7 pmid:24290404. robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol
29 Wiegersma M, Panman CM, Kollen BJ, Berger MY, Lisman-Van Leeuwen Y, Dekker JH. 2011;118:1005-13. doi:10.1097/AOG.0b013e318231537c pmid:21979458.
Effect of pelvic floor muscle training compared with watchful waiting in older women with 45 Anger JT, Mueller ER, Tarnay C, et al. Robotic compared with laparoscopic
symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. BMJ sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014;123:5-12. doi:10.
2014;349:g7378. doi:10.1136/bmj.g7378 pmid:25533442. 1097/AOG.0000000000000006 pmid:24463657.
30 Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use 46 Barber MD, Maher C. Apical prolapse. Int Urogynecol J 2013;24:1815-33. doi:10.1007/
by members of the American urogynecologic society. Obstet Gynecol 2000;95:931-5.pmid: s00192-013-2172-1 pmid:24142057.
10831995. 47 Maher C. Anterior vaginal compartment surgery. Int Urogynecol J 2013;24:1791-802. doi:
31 Wu V, Farrell SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management. 10.1007/s00192-013-2170-3 pmid:24142055.
Obstet Gynecol 1997;90:990-4. doi:10.1016/S0029-7844(97)00481-X pmid:9397117. 48 Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD. Bowel symptoms
32 Cheung RY, Lee JH, Lee LL, Chung TK, Chan SS. Vaginal Pessary in Women With 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair.
Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial. Obstet Gynecol Am J Obstet Gynecol 2007;197:76.e1-5. doi:10.1016/j.ajog.2007.02.045 pmid:17618766.
2016;128:73-80. doi:10.1097/AOG.0000000000001489 pmid:27275798.

For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 6 of 9


49 The Scottish independent review of the use, safety and efficacy of transvaginal mesh for female pelvic organ prolapse (POP). Int Urogynecol J 2016;27:655-84. doi:10.1007/
implants in the treatment of stress urinary incontinence and pelvic organ prolapse in s00192-016-3003-y pmid:26984443.
women: interim report 2015.
Published by the BMJ Publishing Group Limited. For permission to use (where not already
50 MHRA. A summary of the evidence on the benefits and risks of vaginal mesh implants2015. granted under a licence) please go to
of_the_evidence_on_the_benefits_and_risks_of_vaginal_mesh_implants.pdf. permissions
51 Haylen BT, Maher CF, Barber MD, et al. Erratum to: An International Urogynecological
Association (IUGA) / International Continence Society (ICS) joint report on the terminology

For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 7 of 9



Table Table1| Surgical procedures for pelvic organ prolapse

Type of prolapse and surgical approach Surgical route

Transvaginal Abdominal*
Anterior segment:
Native tissue (non-mesh) Anterior colporrhaphy Paravaginal repair
Paravaginal repair
Mesh augmented Free graft Sacrocolpopexy‡
Commercial mesh device†
Posterior segment:
Native tissue Posterior colporrhaphy N/A
Mesh augmented Free graft Sacrocolpopexy‡
Commercial mesh device†
Apical (post-hysterectomy):
Native tissue Vaginal vault suspension: Abdominal vaginal vault suspension:
Uterosacral Uterosacral
Sacrospinous Enterocele repair
Enterocele repair
Mesh augmented Free graft Sacrocolpopexy
Commercial mesh device†
Native tissue Vaginal hysterectomy and vaginal vault suspension: Hysterectomy with abdominal vaginal vault
Uterosacral suspension
Sacrospinous hysteropexy
Mesh augmented Commercial mesh device with or without hysterectomy† Hysterectomy and sacrocolpopexy
Obliterative¶ (all compartments):
Native tissue Colpocleisis N/A
LeFort partial colpocleisis

*Includes procedures performed via laparotomy and laparoscopy with or without robotic assistance.
†Specific commercial mesh devices consist of synthetic polypropylene mesh and mesh delivery or attachment systems and may be designed to address more
than one segment (such as anterior-apical, posterior-apical, or total (anterior, posterior, and apical)).
‡Sacrocolpopexy is primarily used for apical prolapse but may be used for anterior or posterior prolapse when apical prolapse is also present.
§In women with uterine prolapse a hysterectomy may be performed in conjunction with one of the listed procedures, or a uterine suspension (hysteropexy) can
be performed. A hysterectomy alone without additional apical procedure is not appropriate treatment for uterine prolapse.
¶Obliterative procedures close off the vaginal canal, thus precluding future vaginal intercourse. They are usually reserved for women who are elderly, medically
compromised, and no longer sexually active. They are associated with low operative risk and very low risk of recurrence.

For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 8 of 9



Fig 1 Types of pelvic organ prolapse: cystocele, rectocele, uterine prolapse, and post-hysterectomy vault prolapse

Fig 2 Stages of prolapse according to the pelvic organ prolapse quantification system (POPQ)24 (adapted from Haylen51)

For personal use only: See rights and reprints Subscribe:
BMJ 2016;354:i3853 doi: 10.1136/bmj.i3853 (Published 20 July 2016) Page 9 of 9


Fig 3 Common vaginal pessaries: ring pessary (top left), doughnut (top right), ring pessary with support (bottom left),
Gellhorn (bottom right)

For personal use only: See rights and reprints Subscribe: