What are the treatment options for a patient with pelvic organ prolapse?

Treatment Options for Pelvic Organ Prolapse

For symptomatic pelvic organ prolapse, first-line treatment should be pelvic floor muscle training (PFMT) and/or pessary use, with surgery reserved for those with stage 2 or greater prolapse who fail conservative management or have disabling symptoms. 1

Initial Management Algorithm

Asymptomatic Prolapse

• Observation is the appropriate management for asymptomatic pelvic organ prolapse, regardless of stage, as treatment is not necessary without bothersome symptoms 2, 3
• Patients should be counseled that prolapse may gradually progress over time but does not require intervention unless symptoms develop 3

Symptomatic Prolapse: Conservative Management (First-Line)

Pelvic floor muscle training and pessaries should be offered as first-line therapy and can be used in combination. 1

Pelvic Floor Muscle Training (PFMT)

• PFMT increases the chance of improvement in prolapse stage by 17% compared to no treatment 4
• Six months of supervised PFMT provides anatomical and symptom improvement in women with symptomatic prolapse 4
• PFMT improves pelvic floor muscle function, reduces urinary symptoms (frequency and bother), and decreases bowel symptom frequency 4
• This approach is particularly effective for mild to moderate prolapse 4

Pessary Management

• Pessaries are an effective nonsurgical option for patients not desiring surgery or medically unfit for surgical intervention 2
• Pessaries can be successfully fitted for most patients who prefer this treatment modality 3
• Pessaries should be combined with management of modifiable risk factors including weight loss, reduction of heavy lifting, and treatment of constipation 1, 5

Surgical Management Indications

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

Surgical Approach Selection

The surgical approach depends on the compartment(s) involved and patient characteristics:

For Apical and Anterior Prolapse

• Laparoscopic sacrocolpopexy is the recommended approach for apical and anterior compartment prolapse 1
• This abdominal approach with mesh placement provides superior durability compared to vaginal approaches 1
• Robotic or open approaches may be used based on surgeon expertise and patient factors 2

For Isolated Posterior Prolapse (Rectocele)

• Posterior vaginal repair with autologous tissue should be preferentially performed over the transanal route for isolated rectocele 1
• The transanal approach (STARR) can reduce rectocele size from 3.8 cm to 1.9 cm on average, with 82% of patients reporting >50% reduction in obstructed defecation scores at one year 6
• However, correlation between anatomical correction and symptom improvement is often weak, and long-term outcomes are somewhat disappointing despite initial improvement 6
• Rare but serious complications after STARR include fistula, peritonitis, and bowel perforation 6

For Elderly and Fragile Patients

• Autologous vaginal surgery, including colpocleisis, is the recommended option for elderly patients with significant comorbidities 1
• Vaginal approaches have lower perioperative morbidity but higher recurrence rates compared to abdominal approaches 7

Important Surgical Considerations

• The decision to place mesh must be made in consultation with a multidisciplinary team 1
• Native tissue transvaginal surgeries avoid mesh-related complications but may have higher recurrence rates 3
• Bowel resection should be avoided in patients with preexisting diarrhea and/or incontinence, as these symptoms may worsen 7
• Posterior rectopexy can result in severe constipation in up to 50% of patients 7

Common Pitfalls to Avoid

• Do not assume all pelvic symptoms are due to prolapse: bladder and bowel symptoms may not correlate with prolapse severity and may require additional evaluation 2, 1
• Do not rush to surgery: approximately 13% of women undergo surgery for prolapse in their lifetime, but many can be managed conservatively 2
• Do not neglect postoperative follow-up: patients should be reassessed by the surgeon even in the absence of symptoms or complications, and require long-term monitoring 1
• Do not ignore the weak correlation between anatomical correction and symptom improvement: anatomical abnormalities may be caused by underlying functional disorders not corrected by surgery 6

Risk Factor Modification

Concurrent management should address modifiable risk factors including weight loss, reduction of heavy lifting, treatment of constipation, and consideration of pelvic floor physical therapy 5