Last updated:
November 17, 2025
Table Of Contents
Overview
Pelvic organ prolapse is an abdnormal herniation of pelvic organs from their normal anatomic position. It is the third most common reason for elective hysterectomy.
11% of women undergo surgery for prolapse or incontinence in their lifetime.
Levels of vaginal support
| Level | Structure | Defect |
|---|---|---|
| Level I | Cardinal and uterosacral ligaments. Holds the | Defect leads to apical prolapse associated with uterine descent and enterocele |
| Level II | Paravaginal attachments contiguous with cardinal and uterosacral complex | Defect leads to lateral or paravaginal prolapse which is associated with cystocele |
| Leve III | Perineal body, perineal musculature and connective tissue supporting the distal 1/3 of the vagina | Defect leads to anterior and posterior prolapse |
Types of prolapse
| Defect | Prolapse |
|---|---|
| Anterior vaginal wall prolapse | Cystocele or urethrocele or cystourethrocele |
| Lateral vaginal wall/ paravaginal prolapse (most common defect) | Cystocele |
| Posterior vaginal wall prolapse | Rectocele (more distal) or enterocele (more proximal) |
| Apical vaginal wall prolapse | Enetrocele or uterine prolapse |
Grading of uterine prolapse
| Degree | Description |
|---|---|
| 1st degree | Cervix protrudes below its normal level on valsava |
| 2nd degree | Cervix protrudes from vulva on straining |
| 3rd degree (complete procidentia) | Whole uterus is completely prolapse outisde the vulva, even without valsava |
- Risk factors
- Multiparity
- Older age: decreased oestrogen decreases strength of ligaments
- Other obstetric risk factors
- Macrosomia
- Prolonged second stage
- Episiotomy
- Lacerations
- Epidural analegesia
- Forceps use
- Connective tissue disease e.g. Marfans and Ehler’s Danlos
- Race: whites and hispanics > blacks and asians
- Increased abdominal pressure e.g. chronic constipation
- Pathophysiology
- Pelvic floor support is provided by the levator ani (iliococcygeus, pubococcygeous, and puborectalis), fascia and ligaments
- Direct damage to these structures or nerves can weaken the pelvic floor
- Fascia and ligaments get weaker with age causing pelvic organ prolapse
- Signs and symptoms
- Bulge symptoms (more specific to pelvic organ prolapse)
- Sensation of vaginal protrusion or pressure
- “Heaviness”
- Urinary symptoms
- Stress incontinence
- Urgency and Frequency
- Weak or prolonged stream and hesitancy
- Feeling of incomplete emptying
- Difficulty with complete emptying
- Bowel symptoms
- Feeling of incomplete emptying
- Incontinence
- Digital evacuation
- Sexual symptoms: dyspareunia
- Pain: back pain, genital pain
- Bulge symptoms (more specific to pelvic organ prolapse)
- Physical examination
- Visual examination while standings, with and without valsava
- Bimanual examination
- Bivalve speculum examination
- Split speculum examinaiton
- Investigations
- Urodynamic testing (not required in most cases)
- Cystometry: to measure pressure in the bladder during filling
- Uroflowmetry: to measure volume and speed of urine flow over time
- Pressure flow studies: to meausre the bladder pressure required to urinate and flow rate at a given pressure
- Pelvic floor electromyography (EMG): to measure the electrical activity of muscles and detect neuromuscular abnormalities
- Simple cystometrics: infuse saline or sterile water into the bladder and ask the patient to indicate when they feel the liquid, when their bladder feels full, and when they experience an urge to urinate
- Pelvic floor ultrasound: trans-anal, trans-perineal, and vaginal view to capture images during coughing or straining to see how pelvic organs move
- Anorectla manometry and defecography (proctography)
- Urodynamic testing (not required in most cases)
- Non-surgical treatment
- Pessary: first-line treatment for pelvic organ prolapse. Evaluate for vaginal atrophy prior to placement. Remove nightly to weekly
- Ring pessary: for first and second degree prolapse
- Gellhorn pessary: for third degree prolapse
- Kegel exercise
- Pessary: first-line treatment for pelvic organ prolapse. Evaluate for vaginal atrophy prior to placement. Remove nightly to weekly
- Surgical treatment
- Obliterative
- Reconstructive