Management of pelvic organ prolapse

Mild prolapse without symptoms usually do not require treatment. Patients with advanced POP (stage 3 or 4) with few symptoms and report little or no bother, can be kept under observation (1).

Treatment is offered for women with bothersome symptoms caused by the prolapse.

Treatment options available for POP include:

Conservative management.

• should be offered before surgical treatment for symptomatic patients
• especially useful for
  • mild degree of prolapse
  • women who wish to have more children
  • women who are frail and elderly,
  • those unwilling or not suitable to undergo surgery
    
    
• options include:
  • pelvic floor muscle training
    • effective in improving symptoms of mild to moderate POP
    • efficacy of pelvic floor muscle training beyond 12 months is unknown
  • pessary use
    • commonly used vaginal pessaries are - ring, ring with support, Gellhorn, and doughnut pessaries
      • ring pessary or ring with support is a good first option for majority of patients since they are easy to insert and remove.
      • Gellhorn or donut pessaries are not recommended for sexually active women due to the difficulty in removing them on their own
    • trial and error method can be used to find the appropriate pessary for individual patient
    • pessary together with pelvic floor muscle training has shown improve both POP symptoms and quality of life than exercise alone
    • women should be offered examination every three to six months to identify complications caused by the use of pessaries
    • continued pessary use after one year can be observed in women >65 years, in severe comorbidity, and for maintenance of urinary continence
    • the pessary should be removed at least once every 6 months to prevent serious pessary complications (3)
      
      
• lifestyle advice, although not supported by evidence, can be offered to patients
  • weight loss
  • minimising straining or constipation
  • avoidance of heavy lifting, coughing, or high impact exercise

Surgical management

The aim of surgery is to restore normal pelvic anatomy, eliminate POP symptoms, and normalise bowel, bladder, and sexual function

• around one in eight women with POP go through surgery by the age of 80
  • 13% of people who had a prolapse surgery will undergo a repeat operation within five years and 29% will have another surgery for genital prolapse or a related condition at some point during their life (2)

Surgery should be considered in patients:

• with stage 2 POP on examination
• with symptoms affecting daily life
• who have failed or declined further conservative treatments (2)

Surgery can be performed

• transvaginally – in around 80-90% of cases
• transabdominally - via laparotomy or laparoscopy with or without robotic assistance

Surgical repair can be native tissue (non-mesh) or synthetic mesh augmented repairs (2)

NICE have stated options for surgical management of pelvic organ prolapse (3)

• surgery should be offered for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment
  
  
• surgery should not be offered to prevent incontinence in women having surgery for prolapse who do not have incontinence
  
  
  • if uterine prolapse
    • for women with uterine prolapse who have no preference about preserving their uterus, NICE suggest a choice of:
      • vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures or
      • vaginal sacrospinous hysteropexy with sutures or
      • Manchester repair
      • option of sacro-hysteropexy with mesh (abdominal or laparoscopic)
        
        
    • for women with uterine prolapse who wish to preserve their uterus, NICE suggest a choice of:
      • vaginal sacrospinous hysteropexy with sutures or
      • Manchester repair, unless the woman may wish to have children in the future
      • option of sacro-hysteropexy with mesh (abdominal or laparoscopic)
        
        
  • surgery for vault prolapse
    • vaginal sacrospinous fixation with sutures or
    • sacrocolpopexy (abdominal or laparoscopic) with mesh
      
      
• colpocleisis should be considered for women with vault or uterine prolapse who do not intend to have penetrative vaginal sex and who have a physical condition that may put them at increased risk of operative and postoperative complications
  
  
  • surgery for anterior prolapse
    • anterior repair without mesh to women with anterior vaginal wall prolapse
    • synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse may considered after MDT review and discussion with the woman about the risks of mesh insertion
      • and if apical support is adequate or an abdominal approach is contraindicated
        
        
  • surgery for posterior prolapse
    • vaginal repair without mesh

NOTE

NICE states that current evidence on the safety of transvaginal mesh repair of anterior or posterior vaginal wall prolapse shows there are serious but well-recognised safety concerns. Evidence of long-term efficacy is inadequate in quality and quantity. As a result, NICE guidance states that if other types of mesh surgery is to take place, the woman should be informed of the type of mesh that is to be used and whether or not it is permanent. Written information should also be given to the woman about the implant, including its name, manufacturer, date of insertion, and the implanting surgeon's name and contact details. The details of the procedure and its subsequent short- and long-term outcomes should also be recorded in a national register (details of how to do this are available within the guidance).

Reference:

1. Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam Physician. 2010;81(9):1111-7
2. Barber MD. Pelvic organ prolapse. BMJ. 2016;354:i3853
3. NICE (April 2019). Urinary incontinence and pelvic organ prolapse in women: management