Management of Vaginal Prolapse: Assessment and Treatment Options
Pelvic organ prolapse (POP) should be initially managed with conservative measures including pelvic floor muscle training and pessaries as first-line therapy before considering surgical intervention for symptomatic cases. 1
Presenting Symptoms
- Pelvic pressure or bulge sensation
- Vaginal protrusion that worsens with exertion and improves with rest
- Low back pain
- Bleeding from mucosal ulcerations (in severe cases)
- Associated urinary symptoms:
- Involuntary leakage
- Frequent urination
- Urgency
- Straining to void
- Incomplete emptying
- Associated bowel symptoms:
- Need for "splinting" or digital maneuvers to defecate
- Recurrent urinary infections
Assessment
Clinical Examination
- Evaluate prolapse compartment by compartment:
- Anterior (cystocele and/or urethrocele)
- Apical (uterine/cervical and/or vaginal prolapse)
- Posterior (rectocele)
- Document the extent of externalization for each compartment
- Assess for cul-de-sac hernias (peritoneocele, enterocele, sigmoidocele)
- Evaluate impact on daily life and quality of life
Imaging (when clinical evaluation is difficult or inadequate)
- MR defecography or fluoroscopic cystocolpoproctography are appropriate for:
- Confirming clinically suspected prolapse
- Assessing severity
- Evaluating associated structural defects
- Differentiating between cul-de-sac hernias and anterior rectoceles 2
- Transperineal ultrasound can be useful for evaluating:
- Levator muscle avulsion
- Pelvic floor hiatal area
- Functional assessment during strain or Valsalva 2
Treatment Algorithm
1. Conservative Management (First-Line)
Pelvic Floor Muscle Training (PFMT)
Vaginal Pessaries
- Effective non-surgical option
- Can be used in combination with PFMT
- Most women can be successfully fitted with a vaginal pessary 4
Lifestyle Modifications
- Weight management for obese patients
- Treatment of chronic cough
- Management of constipation
- Avoidance of heavy lifting
2. Surgical Management (When Conservative Options Fail)
Surgery should be considered when:
- Symptoms are disabling
- Symptoms are related to POP detected on examination
- Prolapse is significant (stage 2 or more on POP-Q classification)
- Conservative measures have failed to meet patient expectations 1
Surgical Options:
Vaginal Approach with Autologous Tissue
- Recommended for elderly and fragile patients
- Appropriate for isolated rectocele repair
- Better for older patients with primary or less severe prolapse 5
Abdominal Approach with Mesh Placement
Obliterative Surgery
- Highly effective for older women with severe prolapse who are not interested in sexual activity
- High satisfaction rates 5
Post-Treatment Follow-Up
- All patients should be reassessed by the surgeon post-surgery, even in absence of symptoms
- Long-term follow-up by primary care or specialist doctor is recommended 1
Important Considerations and Pitfalls
Mesh Complications: Decision to place mesh must be made in consultation with a multidisciplinary team due to potential complications including contraction, exposure, or extrusion 1
Concurrent Conditions: Evaluate and address associated conditions such as urinary incontinence or fecal incontinence
Surgical Decision-Making: An interactive consent process is mandatory as decisions about route of surgery, use of hysterectomy, slings, grafts, and vaginal capacity for sexual intercourse require informed patient input 5
Referral: Consider referral to specialists in Female Pelvic Medicine and Reconstructive Surgery for complex and recurrent cases 5