What is the recommended evaluation and initial management for pelvic organ prolapse in an adult female with typical risk factors (post‑menopausal, overweight, vaginal deliveries, chronic constipation, heavy lifting)?

Evaluation and Management of Pelvic Organ Prolapse

Initial Evaluation

Begin with a focused history documenting specific symptoms: vaginal bulge sensation, pelvic pressure, urinary dysfunction (stress incontinence, urgency, incomplete voiding, need for splinting), bowel dysfunction (constipation, incomplete evacuation), and sexual dysfunction. 1, 2, 3

Key History Elements

• Document all risk factors present in this patient: postmenopausal status, obesity, vaginal parity, chronic constipation, and heavy lifting history—all established contributors to pelvic floor weakening through increased intra-abdominal pressure and fascial stress 1, 4
• Query for abnormal bleeding: if present in a perimenopausal or postmenopausal woman, endometrial sampling must be performed before any prolapse treatment to exclude hyperplasia or malignancy 2

Physical Examination

• Perform external genital assessment and speculum examination to determine which compartments are involved: anterior (bladder/cystocele), apical (uterus/cervix or vaginal cuff), or posterior (rectum/rectocele) 2, 3
• Assess levator muscle integrity during examination, as defects predict surgical recurrence and influence treatment planning 2
• Stage the prolapse severity using standardized grading systems 3

Laboratory and Imaging

Physical examination alone is adequate for most straightforward cases; imaging should only be ordered when clinical evaluation is difficult, inadequate, or discordant with symptoms. 1, 2

When to Image

• Severe or recurrent prolapse 1
• Suspected multicompartment involvement requiring comprehensive assessment 1, 2
• Enteroceles or defecatory dysfunction where clinical evaluation is limited 1
• Pre-surgical planning when detailed anatomic assessment is needed 2, 5

Imaging Modality Selection

• Transperineal ultrasound (TPUS) with dynamic maneuvers is the preferred first-line imaging: non-invasive, less expensive, provides real-time functional assessment, and can detect levator muscle avulsion that predicts recurrence 2, 5
• MR defecography is reserved for comprehensive multicompartment evaluation when TPUS is insufficient or when detailed assessment of all pelvic floor muscles and fascia is needed 1, 2, 5
• Fluoroscopy cystocolpoproctography has 96% sensitivity for cystoceles but involves radiation exposure and is less commonly used 5

Initial Management Algorithm

Asymptomatic or Minimally Symptomatic Prolapse

Observation is appropriate for asymptomatic pelvic organ prolapse, as the condition primarily causes morbidity affecting quality of life rather than mortality. 1, 3

Symptomatic Prolapse: Conservative Management First-Line

All symptomatic patients should begin with conservative management before considering surgery. 3, 6, 7

Weight Loss and Exercise

• Weight loss and regular exercise are strongly recommended for obese women with prolapse to reduce chronic intra-abdominal pressure 2

Pelvic Floor Muscle Training (PFMT)

• Pelvic floor muscle training with a physical therapist (not self-taught Kegels) is strongly recommended as first-line therapy, particularly for associated urinary incontinence 2, 8, 7
• For stress urinary incontinence, PFMT alone is the preferred first-line therapy 2
• For urgency urinary incontinence, bladder-training programs are strongly recommended 2
• For mixed urinary incontinence, combine PFMT plus bladder training 2

Pessary Management

• Pessaries are an effective nonsurgical option for patients not desiring surgery or medically unfit for surgery 3, 8, 7
• Pessaries require regular follow-up care to minimize complications 8

Address Contributing Factors

• Treat chronic constipation and defecatory disorders early through pelvic floor retraining by biofeedback therapy to prevent progressive pelvic floor damage and reduce pathologic straining patterns 4

When to Consider Surgery

Surgery is indicated only when conservative measures have not met patient expectations, symptoms are disabling and related to prolapse, or prolapse is stage 2 or greater on examination. 2, 3

Pre-Surgical Requirements

• In perimenopausal women with abnormal bleeding, endometrial biopsy must be performed before any prolapse treatment to exclude hyperplasia or malignancy 2
• Transvaginal ultrasound should assess endometrial thickness; if inconclusive, saline-infusion sonohysterography provides 96-100% sensitivity for detecting intracavitary pathology 2
• Surgery should only proceed after complete evaluation has excluded endometrial malignancy and other structural pathology 2

Surgical Approach Selection

• Sacrocolpopexy (abdominal approach) has better long-term success for apical prolapse than vaginal techniques, though vaginal surgery is an acceptable alternative with shorter operating times and less pain 8
• Minimally invasive (laparoscopic or robotic) sacrocolpopexy is equally effective as open abdominal sacrocolpopexy 8
• Uterosacral ligament suspension and sacrospinous ligament suspension show equal efficacy at 1 year for vaginal approaches 8

Critical Pitfalls to Avoid

• Do not treat prolapse before confirming endometrial pathology is absent in perimenopausal women with abnormal bleeding 2
• Do not fail to assess all compartments, including lateral vaginal wall defects, as multicompartment involvement is common and overlooking defects leads to incomplete repair 1, 2
• Do not overlook levator muscle defects, which predict surgical recurrence and should influence surgical planning 2
• Do not prescribe systemic pharmacologic therapy for stress urinary incontinence—it is strongly discouraged 2
• Do not order imaging routinely; physical examination is adequate for most straightforward cases 1, 2