Treatment Guidelines for Uterine and Bladder Prolapse
The treatment of pelvic organ prolapse should begin with conservative approaches including pelvic floor muscle training and pessaries as first-line therapy, with surgery reserved for cases where conservative management fails or symptoms are severe. 1
Initial Assessment and Conservative Management
Non-Surgical Options (First-Line Treatment)
- Pelvic floor muscle training (PFMT) is recommended as a first-line treatment for mild to moderate prolapse, showing improvement in both prolapse symptoms and anatomical severity 1, 2
- Pessaries are an effective non-surgical option for women who are not candidates for surgery or prefer non-surgical management 1, 3
- Conservative management should be combined with addressing modifiable risk factors for prolapse 1
- For severe (grade 4) prolapse that cannot be managed with a single pessary, a double pessary technique may be effective - using either a Donut or Inflatoball pessary inserted first, followed by a flexible Gellhorn or Shaatz pessary 4
Benefits of Conservative Management
- PFMT has been shown to increase the chance of improvement in prolapse stage by 17% compared to no treatment 2
- Conservative approaches can improve quality of life and reduce symptoms without surgical risks 3
- Pessaries provide immediate symptom relief while avoiding surgical complications 5
Surgical Management
Indications for Surgery
- Surgery should be considered when:
- Conservative options fail to meet patient expectations
- Symptoms are disabling and clearly related to the prolapse
- Prolapse is significant (stage 2 or greater on POP-Q classification) 1
- In cases of complicated prolapse with signs of shock, gangrene, or perforation, immediate surgical treatment is recommended 6
Surgical Approach Selection
- Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse 1
- Autologous vaginal surgery (including colpocleisis) is recommended for elderly and fragile patients 1
- For isolated rectocele, posterior vaginal repair with autologous tissue is preferred over the transanal approach 1
- In patients with complicated prolapse without peritonitis or hemodynamic instability, the decision between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 6
- For patients with complicated prolapse and signs of peritonitis, an abdominal approach is suggested 6
- In hemodynamically unstable patients with complicated prolapse, an abdominal open approach is recommended 6
Perioperative Considerations
- Multimodal postoperative analgesic protocols should be used routinely, with minimal opioid prescriptions 6
- Patients should be encouraged to eat a light snack up to 6 hours and clear fluids up to 2 hours before surgery 6
- For vaginal surgery, retrograde bladder filling should be considered 6
- Urinary catheters should be used for postoperative bladder drainage in complex vaginal surgery but may be safely removed after a short period 6
Follow-Up Care
- After surgery, patients should be reassessed by the surgeon even in the absence of symptoms or complications 1
- Long-term follow-up should be conducted by a primary care or specialist doctor 1
Important Considerations and Pitfalls
- Delaying surgical management in hemodynamically unstable patients with complicated prolapse to attempt conservative management is not recommended 6
- Mesh placement decisions must be made in consultation with a multidisciplinary team 1
- Imaging investigations should not delay appropriate treatment in hemodynamically unstable patients 6
- For incarcerated rectal prolapse without signs of ischemia or perforation, conservative measures and gentle manual reduction under mild sedation or anesthesia can be attempted before considering surgery 6