What are the treatment options for uterine prolapse?

Treatment Options for Uterine Prolapse

For symptomatic uterine prolapse, pelvic floor muscle training (PFMT) delivered by a physiotherapist and pessaries are recommended as first-line conservative treatments, with surgery reserved for patients who fail conservative management or have stage 2 or greater prolapse with disabling symptoms. 1

Conservative Management (First-Line)

Pelvic Floor Muscle Training

• Supervised PFMT by a physiotherapist is more effective than self-taught Kegel exercises and should be the preferred conservative approach 2, 3
• Six months of supervised PFMT demonstrates anatomical and symptom improvement in women with symptomatic prolapse 4
• PFMT increases the chance of improvement in prolapse stage by 17% compared to no treatment 4
• PFMT reduces prolapse severity, improves pelvic floor muscle function, and decreases urinary and bowel symptom frequency 4
• Important caveat: PFMT may not be effective for high-stage or apical prolapse 2

Pessaries

• Pessaries are the most commonly used conservative management option and can be offered alone or in combination with PFMT 2, 1
• Pessaries require regular follow-up care to minimize complications 2
• Should be considered first-line therapy alongside PFMT before proceeding to surgical options 1

Lifestyle Modifications

• Address modifiable risk factors including weight loss, reduction of heavy lifting, and treatment of constipation 1, 5

Surgical Management (For Failed Conservative Treatment)

Surgery should only be offered when conservative options fail to meet patient expectations AND symptoms are disabling, related to prolapse detected on examination, and significant (stage 2 or more on POP-Q classification). 1

For Apical and Anterior Prolapse

Laparoscopic sacrocolpopexy is the recommended surgical approach for apical and anterior prolapse 1

• Sacrocolpopexy has better long-term success for apical prolapse than vaginal techniques 2
• Minimally invasive sacrocolpopexy (laparoscopic or robotic) is as effective as the gold standard abdominal sacrocolpopexy 2
• Robotic-assisted and laparoscopic sacrocolpopexy are equally effective; choice should be based on surgeon expertise 2
• Trade-offs: Abdominal approaches have longer operating times, increased pain, and higher cost compared to vaginal surgery, despite potentially increased long-term durability 2

Vaginal Approaches

Vaginal hysterectomy with vault suspension is a recommended procedure for patients with uterine prolapse 6

• Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are equally effective at 1 year and can be combined with vaginal hysterectomy 2
• Autologous vaginal surgery (including colpocleisis) is the recommended option for elderly and fragile patients 1
• Vaginal surgery offers shorter operating times and faster recovery compared to abdominal approaches 2

For Isolated Posterior Compartment Prolapse

• For isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route 1

Special Considerations

Mesh Use

• The decision to place mesh must be made in consultation with a multidisciplinary team 1
• Transvaginal mesh shows superior anatomic outcomes compared to native tissue repairs in some studies, but has higher complication rates 2
• Transvaginal mesh should be reserved for surgeons with adequate training to minimize complications 2

Obliterative Procedures

• Obliterative procedures (such as colpocleisis) are effective but are considered definitive surgery and eliminate vaginal function 2
• Best suited for elderly, fragile patients who are not sexually active 1

Post-Treatment Follow-Up

• After surgery, patients should be reassessed by the surgeon even in the absence of symptoms or complications 1
• Long-term follow-up should be provided by a primary care or specialist physician 1

Clinical Pitfalls to Avoid

• Do not proceed directly to surgery without offering conservative management first unless the patient has severe, disabling symptoms with stage 2 or greater prolapse 1
• Avoid self-taught Kegel exercises as the sole conservative intervention; supervised PFMT is significantly more effective 2, 3
• Do not use transvaginal mesh without adequate surgical training and multidisciplinary consultation due to complication risks 2, 1
• Recognize that PFMT may be ineffective for high-stage or apical prolapse, requiring earlier surgical consideration 2