What are the treatment options for vaginal prolapse?

Treatment for Vaginal Prolapse

For symptomatic vaginal prolapse, begin with conservative management including pelvic floor physical therapy and pessaries as first-line treatment, reserving surgery for patients who fail conservative measures and have stage 2 or greater prolapse causing disabling symptoms. 1

Initial Conservative Management

Pelvic Floor Physical Therapy

• Supervised pelvic floor muscle training (PFMT) with a physical therapist is superior to self-taught Kegel exercises and should be the primary conservative approach for mild to moderate prolapse 2, 3
• PFMT increases the chance of improvement in prolapse stage by 17% compared to no treatment, with benefits in both anatomical correction and symptom reduction 3
• Six months of supervised PFMT demonstrates benefits for prolapse symptoms and severity, though effectiveness may be limited for high-stage or apical prolapse 2, 3

Pessary Management

• Pessaries are effective non-surgical options that can be offered alone or in combination with PFMT 1
• Regular follow-up care is mandatory to minimize complications 2
• Pessaries are particularly appropriate for patients not desiring surgery or those medically unfit for surgical intervention 4

Lifestyle Modifications

• Address modifiable risk factors for prolapse progression 1

Surgical Indications

Surgery should be offered when:

• Conservative options fail to meet patient expectations 1
• Symptoms are disabling and directly related to prolapse 1
• Prolapse is stage 2 or greater on POP-Q classification 1
• Clinical examination confirms significant prolapse 1

Surgical Approach Selection

For Apical and Anterior Prolapse

Laparoscopic sacrocolpopexy is the recommended approach for apical and anterior prolapse, offering superior long-term success compared to vaginal techniques 1, 2

• Minimally invasive sacrocolpopexy (laparoscopic or robotic) is as effective as open abdominal sacrocolpopexy 2
• Robotic-assisted and laparoscopic sacrocolpopexy are equally effective; choice should be based on surgeon expertise 2
• Sacrocolpopexy with polypropylene mesh is recommended for younger women, those with severe prolapse, recurrent prolapse after vaginal surgery, or women with short prolapsed vaginas 5

For Vaginal Approaches

• Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are equally effective at one year and can be combined with vaginal hysterectomy 2
• Autologous vaginal surgery is recommended for elderly and fragile patients 1
• Transvaginal repairs are appropriate for older patients, those with primary or less severe prolapse, and those at increased surgical risk 5

For Isolated Posterior Compartment Prolapse (Rectocele)

• The posterior vaginal route with autologous tissue should be performed preferentially over the transanal route 1
• Ventral rectopexy is recommended for high rectoceles or those associated with other pelvic floor disorders 6
• Stapled Transanal Rectal Resection (STARR) can reduce rectocele size (average reduction from 3.8 cm to 1.9 cm), but long-term outcomes are disappointing despite initial improvement 6

For Elderly Patients Not Interested in Sexual Activity

• Obliterative procedures (colpocleisis) are highly effective with high satisfaction rates and should be considered definitive surgery 2, 5

Important Caveats and Pitfalls

Mesh Considerations

• The decision to place mesh must be made in consultation with a multidisciplinary team 1
• Transvaginal mesh shows superior anatomic outcomes in some studies but has higher complication rates and should be reserved for surgeons with adequate training 2
• Mesh should be used selectively for apical suspensions, as it may improve cure rates but increases risk of complications 5

Surgical Complications

• Abdominal approaches have longer operating times, increased pain, and higher costs compared to vaginal surgery, despite potentially increased long-term durability 2
• For rectocele repair, rare but serious complications after STARR include fistula, peritonitis, and bowel perforation 6
• The correlation between symptom improvement and anatomical correction is often weak; anatomical abnormalities may be caused by underlying functional disorders not corrected by surgery 6

Hysterectomy Decisions

• Operations for uterovaginal prolapse can be offered with or without hysterectomy, but must include a specific apical support procedure to be effective 5

Postoperative Management

• Patients should be reassessed by the surgeon even in the absence of symptoms or complications, with long-term follow-up by primary care or specialist 1
• Slings should be added selectively to reduce postoperative stress incontinence 5
• An interactive consent process is mandatory given the multiple decisions required regarding surgical route, use of hysterectomy, grafts, slings, and preservation of vaginal capacity for sexual intercourse 5