What is the recommended workup and specialty referral for a post-hysterectomy patient with a pelvic organ prolapse that appears to be cervical in nature?

From the Guidelines

For a post-hysterectomy patient with what appears to be cervical-like pelvic organ prolapse, I strongly recommend a comprehensive urogynecological evaluation and prompt referral to a urogynecologist or female pelvic medicine specialist. Initial workup should include a detailed history focusing on urinary, bowel, and sexual symptoms, followed by a physical examination using the Pelvic Organ Prolapse Quantification (POP-Q) system to assess the degree of prolapse, as suggested by the American College of Radiology 1. This is likely a vaginal vault prolapse rather than true cervical prolapse since the cervix is typically removed during hysterectomy. Urodynamic testing should be performed to evaluate for concurrent urinary issues.

Key Considerations

• Imaging studies such as dynamic pelvic MRI or defecography may help clarify the anatomical defect, with fluoroscopy CCP or MR defecography being appropriate initial imaging options when necessary 1.
• Conservative management options include pelvic floor physical therapy (8-12 weekly sessions) and pessary fitting (ring or Gellhorn types are often effective for vault prolapse).
• For surgical management, the specialist may consider procedures such as sacrocolpopexy (abdominal or laparoscopic) or sacrospinous ligament fixation depending on the patient's specific anatomy, age, sexual activity status, and comorbidities.

Importance of Specialty Referral

Early specialty referral is crucial as post-hysterectomy vault prolapse often involves complex support defects that may require specialized surgical approaches to prevent recurrence. The urogynecologist or female pelvic medicine specialist will be able to provide a tailored treatment plan, taking into account the patient's individual needs and circumstances.

From the Research

Workup for Pelvic Organ Prolapse

• Initial evaluation includes a history and systematic pelvic examination including assessment for urinary incontinence, bladder outlet obstruction, and fecal incontinence 2
• Additional testing may be indicated for evaluation of bowel and bladder symptoms 3
• Prolapse can represent descent of the anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff scar after hysterectomy), or posterior vaginal wall, although it represents a combination of these in many cases 3

Specialty Referral

• Patients with symptomatic pelvic organ prolapse may benefit from referral to a specialist, such as a urogynecologist or a gynecologist with expertise in pelvic floor disorders 3
• A midurethral sling should be considered for all patients undergoing vaginal prolapse surgery to prevent or treat urinary incontinence 4

Considerations for Post-Hysterectomy Patients

• Hysterectomy is not sufficient treatment for pelvic organ prolapse; subsequently, after the uterus is removed, attention should be paid to correcting the vaginal prolapse 4
• Women with a history of hysterectomy for prolapse have more pelvic floor symptoms than women who underwent hysterectomy for other indications, regardless of the current presence of POP 5
• Creating more knowledge and awareness of the impact of hysterectomy on the pelvic floor can help women in the future 5

Treatment Options

• Treatment options for pelvic organ prolapse include observation, pelvic floor physical therapy, pessary use, and surgery 3
• Most women can be successfully fit with a vaginal pessary 2
• Available surgical options are reconstructive pelvic surgery with or without mesh augmentation and obliterative surgery 2