Management of Bladder or Uterine Prolapse in Postmenopausal Women
For postmenopausal women with symptomatic bladder or uterine prolapse, begin with conservative management including pelvic floor physical therapy and pessary fitting, reserving surgery for those with stage 2 or greater prolapse who fail conservative measures or have disabling symptoms. 1, 2
Initial Assessment and Diagnosis
The diagnosis requires documenting specific symptoms including pelvic pressure sensation, vaginal bulge, urinary dysfunction (leakage, frequency, urgency, incomplete voiding), bowel dysfunction, or sexual dysfunction 2. Physical examination must assess all three compartments (anterior, apical, posterior) using the validated POP-Q staging system, as failing to evaluate all compartments leads to incomplete diagnosis and treatment planning 2, 3. Critically, examine for levator muscle defects, as these predict surgical recurrence and must influence treatment decisions 2.
Imaging is indicated only when clinical examination is inadequate, symptoms persist after treatment, or comprehensive multi-compartment evaluation is needed 4, 2. When imaging is necessary, fluoroscopy colpocystodefecography (CCP) or MR defecography are the appropriate initial studies 4.
Conservative Management (First-Line)
Lifestyle Modifications
- Weight loss and exercise are essential for obese women, as obesity increases chronic intra-abdominal pressure on pelvic structures 1
- Treat chronic constipation aggressively to reduce straining that worsens prolapse progression 1, 5
- Avoid heavy lifting and modify occupational factors involving prolonged standing 1
Pessary Management
Pessaries are the primary nonsurgical option for women not desiring surgery or medically unfit for operative intervention 6, 7. They provide effective symptom relief without surgical risks and should be offered before proceeding to surgery in appropriate candidates 6.
What Does NOT Work
- No systemic pharmacologic therapy exists for prolapse itself, though medications may address associated urinary symptoms 1
- Pelvic floor biofeedback using vaginal EMG lacks evidence for prolapse treatment 1
- Topical estrogens may help with vaginal atrophy symptoms but do not treat the prolapse itself 8, 7
Surgical Management Indications
Surgery is indicated when: 2
- Conservative options fail to meet patient expectations
- Symptoms are disabling and clearly related to prolapse
- Prolapse is stage 2 or greater on examination
Preoperative Considerations for Concurrent Stress Incontinence
In women with high-grade prolapse but without stress urinary incontinence (SUI) symptoms, perform stress testing with prolapse reduction to assess for occult SUI, as a significant proportion will demonstrate incontinence that may alter the surgical plan 4. This can be done with pessary, ring forceps, or vaginal pack 4.
Multichannel urodynamic studies are optional but not mandatory in uncomplicated patients considering surgery 4. However, urodynamics with prolapse reduction may be useful in complicated cases to assess for occult stress incontinence and detrusor dysfunction, particularly when findings would change the surgical approach 4.
Surgical Approach Selection
Surgery can be performed through transvaginal, laparoscopic/robotic, or open approaches, using either native tissue or mesh augmentation 6. The choice depends on:
- Compartments involved (anterior, apical, posterior)
- Extent of prolapse severity
- Medical and surgical comorbidities
- Differences in durability and risk profiles between procedures
- Shared decision-making with the patient 6
For concurrent prolapse repair with incontinence procedures, synthetic midurethral slings show cure/dry rates of 85-87% at 12-47 months 4. Autologous fascial slings demonstrate comparable efficacy with 73-85% cure rates 4.
Critical Pitfalls to Avoid
- Do not overlook lateral vaginal wall defects during examination, as incomplete assessment leads to surgical failure 2
- Always assess levator muscle integrity, as defects predict recurrence and should modify surgical planning 2
- Recognize that up to 10% of women require repeat surgery for prolapse, making conservative management attempts worthwhile initially 7
- When performing stress testing with prolapse reduction, be aware that the reduction instrument itself may obstruct the urethra, creating falsely elevated leak point pressures 4
Follow-Up and Monitoring
Patients should be reevaluated periodically (every 3-6 months) to determine if treatment remains necessary and effective 8. For those with an intact uterus receiving any hormonal therapy, monitor closely for signs of endometrial cancer with appropriate diagnostic measures for persistent or abnormal vaginal bleeding 8.