Treatment Options for Pelvic Organ Prolapse
For symptomatic pelvic organ prolapse, begin with conservative management using pelvic floor muscle training (PFMT) with a trained physical therapist and/or pessary placement as first-line therapy, reserving surgery for stage 2 or greater prolapse when conservative measures fail to meet patient expectations. 1
Conservative Management (First-Line Treatment)
Pelvic Floor Physical Therapy
- Supervised PFMT with a trained physical therapist is superior to self-taught Kegel exercises and should be the primary conservative approach for mild to moderate prolapse 2, 3
- Six months of supervised PFMT demonstrates anatomical and symptom improvement in women with prolapse, with evidence showing 17% increased chance of improvement in prolapse stage compared to no treatment 3
- PFMT improves pelvic floor muscle function, reduces urinary symptoms (frequency and bother), and decreases bowel symptom frequency 3
- Important caveat: PFMT may not be effective for high-stage or apical prolapse 2
Pessary Management
- Pessaries are effective non-surgical options that can be offered alone or combined with PFMT 1
- Pessaries require regular follow-up care to minimize complications such as erosion, discharge, or infection 2
- Particularly appropriate for women not desiring surgery or those medically unfit for surgical intervention 4
Lifestyle Modifications
- Address modifiable risk factors including chronic constipation, obesity, and activities involving heavy lifting or straining 1
Surgical Management (When Conservative Treatment Fails)
Indications for Surgery
- Surgery should be offered when symptoms are disabling, related to prolapse detected on examination, and stage 2 or greater on POP-Q classification 1
- Approximately 13% of women undergo surgery for prolapse in their lifetime 4
Surgical Approach Selection Algorithm
For Apical and Anterior Prolapse:
- Laparoscopic sacrocolpopexy is the recommended approach, demonstrating superior long-term success compared to vaginal techniques 2, 1
- Robotic-assisted sacrocolpopexy (RASC) and laparoscopic sacrocolpopexy (LASC) show equal efficacy; choice depends on surgeon expertise 2
- Minimally invasive sacrocolpopexy is as effective as open abdominal sacrocolpopexy but with reduced morbidity 2
For Vaginal Approaches (Alternative Options):
- Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) demonstrate equal efficacy at 1 year and can be combined with vaginal hysterectomy 2
- Autologous vaginal surgery is the recommended option for elderly and fragile patients with significant comorbidities 1
- Vaginal surgery has shorter operating times, less pain, and lower cost compared to abdominal approaches, though potentially less long-term durability 2
For Isolated Posterior Compartment (Rectocele):
- Posterior vaginal route with autologous tissue should be performed preferentially over transanal approach 1
- Ventral rectopexy is recommended for high rectoceles or those associated with other pelvic floor disorders 5
For Elderly/High-Risk Patients:
- Obliterative procedures (colpocleisis) are effective definitive surgery options for patients not desiring vaginal intercourse 2
Critical Surgical Considerations
Mesh Use:
- Transvaginal mesh shows superior anatomic outcomes compared to native tissue repairs but has higher complication rates 2
- Mesh placement decisions must be made in consultation with a multidisciplinary team and reserved for surgeons with adequate training 2, 1
- Laparoscopic sacrocolpopexy with mesh is preferred over transvaginal mesh approaches 1
Common Pitfalls to Avoid:
- Posterior rectopexy can cause severe constipation in up to 50% of patients 6
- Bowel resection should be avoided in patients with preexisting diarrhea or incontinence as symptoms may worsen 6
- The correlation between anatomical correction and symptom improvement is often weak; surgery does not always alleviate defecation difficulties 5