Treatment of Complete Pelvic Organ Prolapse (Anterior, Posterior, and Uterine)
For complete pelvic organ prolapse involving all compartments (anterior, posterior, and uterus), laparoscopic sacrocolpopexy with mesh is the recommended surgical approach when surgery is indicated, particularly for patients desiring preserved vaginal capacity and sexual function. 1
Initial Management Strategy
Conservative Management (First-Line)
- Pelvic floor muscle training and pessaries are recommended as first-line therapy for all symptomatic pelvic organ prolapse, regardless of severity. 1
- These can be offered in combination and should address modifiable risk factors (obesity, chronic cough, constipation, heavy lifting). 1, 2
- Most women can be successfully fitted with a vaginal pessary, making this an effective non-surgical option. 2
- Observation alone is appropriate for asymptomatic prolapse, though patients should be counseled that progression may occur over time. 3, 4
When to Proceed to Surgery
Surgery should be offered when: 1
- Conservative options fail to meet patient expectations
- Symptoms are disabling and directly related to the prolapse
- Clinical examination confirms stage 2 or greater prolapse (POP-Q classification)
- Patient desires definitive treatment
Surgical Approach Selection
Preferred Surgical Option: Laparoscopic Sacrocolpopexy
Laparoscopic sacrocolpopexy is specifically recommended for cases involving apical and anterior prolapse, which applies to complete multi-compartment prolapse. 1
- Superior durability compared to vaginal approaches
- Maintains vaginal capacity and sexual function
- Lower morbidity than open abdominal approach
- Addresses the apical compartment, which is paramount to preventing recurrent prolapse 5
Alternative Surgical Approaches
For elderly or medically fragile patients:
- Vaginal surgery with autologous tissue (native tissue repair) is recommended. 1
- Colpocleisis (obliterative surgery) offers lower morbidity but eliminates vaginal capacity. 1, 2
- The vaginal approach has lower overall morbidity and is appropriate for those with medical comorbidities. 5
For isolated posterior compartment (rectocele):
- Posterior vaginal route with autologous tissue is preferred over transanal approaches. 1
Mesh Considerations
- The decision to use mesh must be made in consultation with a multidisciplinary team. 1
- Polypropylene mesh via abdominal sacrocolpopexy has established efficacy for multi-compartment prolapse. 5, 1
- Vaginal polypropylene mesh remains controversial but may have a role in recurrent prolapse, particularly anterior compartment. 5
Critical Decision Algorithm
Step 1: Assess patient fitness and goals
- Sexually active, desires vaginal capacity → Laparoscopic sacrocolpopexy 1
- Elderly/frail, high surgical risk → Vaginal native tissue repair or colpocleisis 1
- Desires fertility preservation → Abdominal sacrohysteropexy (uterine preservation) 5
Step 2: Evaluate compartments involved
- Multi-compartment with apical involvement → Abdominal approach addresses all compartments simultaneously 5, 1
- Isolated posterior → Vaginal posterior repair 1
Step 3: Consider surgical expertise
- Surgeon must be proficient in multiple techniques to tailor treatment appropriately 5
Common Pitfalls to Avoid
- Failing to address the apical compartment increases risk of recurrent prolapse. 5
- Anatomical correction does not always correlate with symptom improvement; careful patient selection and counseling about realistic expectations is essential. 6
- Neglecting conservative management as first-line therapy, even in severe prolapse, misses an opportunity for effective non-surgical treatment. 1
- Performing vaginal mesh procedures without multidisciplinary consultation given ongoing controversy. 1