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Basic Information

Definition
Pelvic organ prolapse (POP) or uterine prolapse refers to the protrusion of the
uterus into or out of the vaginal canal. In a first-degree uterine prolapse, the
cervix is visible when the perineum is depressed. In a second-degree uterine
prolapse, the uterine cervix has prolapsed through the vaginal introitus, with the
fundus remaining within the pelvis proper. In a third-degree uterine prolapse (i.e.,
complete uterine prolapse, uterine procidentia), the entire uterus is outside the
introitus. Table 1-323 compares the various types of prolapse.
TABLE 1-323 -- Types of Genital Prolapse
Original
Prolapse
Symptoms (in addition to the general symptoms of
Position of
discomfort, dragging, the feeling of a lump and,
Organs
rarely, coital problems)
Anterior

Urinary symptoms (stress incontinence, urinary


frequency)

Urethrocele
Cystocele

Central

Cervix/uterus:
1st, 2nd, and 3rd
degree

Bleeding and/or discharge from ulceration in


association with procidentia

Procidentia
Posterior

Bowel symptoms, particularly the feeling of


incomplete evacuation and sometimes having to press
the posterior wall backwards to pass stool

Rectocele
Enterocele

From Drife J, Magowan B: Clinical obstetrics and gynaecology, Philadelphia, 2004,


Saunders.

Synonyms
Genital prolapse
Uterine descensus
Uterine prolapse
POP

ICD-9CM CODES
Genital prolapse618.8
Uterine descensus618.1
Pelvic organ prolapse618.8

Epidemiology & Demographics


Prevalence
Most prevalent in postmenopausal multiparous women.

Risk factors
Pregnancy, especially POP symptoms during pregnancy

Labor

Vaginal childbirth

Obesity

Chronic coughing

Constipation

Pelvic tumors

Ascites

Strenuous physical exertion, especially during pregnancy

Maternal history of prolapse

Caucasian race
Genetics
Increased incidence in women with spina bifida occulta.

Physical Findings & Clinical Presentation


Pelvic pressure

Bearing-down sensation

Bilateral groin pain

Sacral backache

Coital difficulty

Protrusion from vagina

Spotting

Ulceration

Bleeding

Examination of patient in lithotomy, sitting, and standing positions and before, during,
and after a maximum Valsalva effort

Erosion or ulceration of the cervix possible in the most dependent area of the protrusion
Etiology
Vaginal childbirth and chronic increases in intraabdominal pressure leading to
detachments, lacerations, and denervations of the vaginal support system

Further weakening of pelvic support system by hypoestrogenic atrophy

Direct injury to the levator ani, neurologic injury from stretching of the pudendal nerves

Some cases from congenital or inherited weaknesses within the pelvic support system

Neonatal uterine prolapse mostly coexistent with congenital spinal defects

Ferri: Ferri's Clinical Advisor 2014, 1st ed.


Copyright 2013 Mosby, An Imprint of Elsevier
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Diagnosis

Differential Diagnosis
Occasionally, elongated cervix; body of the uterus remains undescended.

Diagnosis is based on history and physical examination. Currently there is only one
genital tract prolapse classification system that has attained international acceptance and
recognition: the patient pelvic organ prolapse quantification (POP-Q) (Boxes 1-43 and
1-44).
BOX 1-43
Staging of Pelvic Organ Prolapse Based on POP-Q Examination
Stage 0 No prolapse.
Stage I Most distal prolapse <1 cm above hymenal ring.
Stage
II

Most distal point is 1 cm above hymenal ring.

Stage
III

Most distal point is <1 cm below the hymenal ring but not farther than 2 cm less
than the total vaginal length (TVL) (i.e., 1 cm but (TVL 2) cm.

Stage
IV

Complete vaginal eversion.

From Pemberton J (ed): The pelvic floor, Philadelphia, 2002, Saunders.


BOX 1-44
Points of Reference for POP-Q
Point A: 3 cm above the hymen on anterior vaginal wall (Aa) or posterior vaginal
wall (Ap). Point Aa roughly corresponds with the urethrovesical junction. These
points can range from 3 cm (no prolapse) to +3 cm (maximal prolapse).
Point B: The lowest extent of the segment of vagina between point A and the apex of
the vagina. Unlike point A, it is not fixed but will be the same as A if point A is the
most protruding point. In maximal prolapse it will be the same as point C.
Point C: The most distal part of the cervix or vaginal vault.
Point D: The posterior fornix, which is omitted in women with prior hysterectomy.
Genital hiatus: From midline external urethral meatus to inferior hymenal ring.
Perineal body: From inferior hymenal ring to middle of anal orifice.
Vaginal length: This should be measured without undue stretching of the vagina.
From Pemberton J (ed): The pelvic floor, Philadelphia, 2002, Saunders.
Workup
If erosion or ulceration of the cervix is present, a Pap smear followed by a cervical
biopsy should be performed if indicated.

If urinary symptoms are significant, further urodynamic workup is indicated, looking


for concurrent cystourethrocele, cystocele, enterocele, or rectocele.
Laboratory Tests
Urine culture

Imaging Studies
Ultrasound if concurrent fibroids need further evaluation, CT or MRI (Fig. 1-636) in
symptomatic patients with unclear diagnosis

FIGURE 1-636 A, Moderate global pelvic prolapse in a woman with stress urinary
incontinence, pelvic heaviness, and constipation after three vaginal deliveries. At rest, all
viscera are normally situated in the pelvis. B, With Kegel contraction, note that all viscera
remain normally situated in the pelvis. C, With maximal strain, bladder (B),
vagina (V), and rectum (R) are well below the pelvic floor.(From Fielding JR et
al: Gynecologic imaging, Philadelphia, 2011, Saunders.)

Treatment
Nonpharmacologic Therapy
Prophylactic measures
1. Diagnosis and treatment of chronic respiratory and metabolic disorders

2.

Correction of constipation

3.

Weight control, nutrition, and smoking cessation counseling

4.

Pelvic muscle exercises

Supportive pessary therapy


1. Ring-type pessary useful for first- or second-degree prolapse
2.

Gellhorn pessary preferred for more advanced prolapse

3.

Use of pessaries in conjunction with continuous hormone replacement therapy,


unless contraindicated

4.

Perineorrhaphy under local anesthesia possibly needed to support the pessary


if the vaginal outlet is very relaxed

Acute General Rx
Patients who are only infrequently symptomatic: insertion of a tampon or diaphragm for
temporary relief when prolonged standing is anticipated
Neonatal uterine prolapse: simple digital reduction or the use of a small pessary
Chronic Rx
Hormone replacement therapy at the time of menopause helps preserve tissue strength,
maintain elasticity of the vagina, and promote the durability of surgical repairs.

Gold standard for therapy is vaginal hysterectomy.

Vaginal apex should be well suspended, but a prophylactic sacrospinous ligament


fixation is not routinely required.

If occult enterocele present, McCall culdoplasty is performed.

If vaginal approach to hysterectomy is contraindicated, abdominal hysterectomy is


performed; vaginal apex likewise well supported.

Colpocleisis is considered for the elderly patient who is sexually inactive and is a highrisk patient from a surgical point of view; can be done rapidly under local anesthesia
with mild sedation if necessary.

For symptomatic women who desire childbearing: management with pessaries or pelvic
muscle exercises is recommended; if surgical correction is required, transvaginal
sacrospinous fixation is the preferred method.

Other surgical options are sling operations and sacral cervicopexy.

Trials have shown that as compared with anterior colporrhaphy, use of a standardized,

trocar-guided mesh kit for cystocele repair results in higher short-term rates of
successful treatment but also in higher rates of surgical complications and postoperative
adverse events.

Women without stress incontinence undergoing vaginal surgery for POP are at risk for
postoperative urinary incontinence. Use of a prophylactic midurethral sling inserted
during vaginal prolapse surgery has been shown to result in a lower rate of urinary
incontinence at 3 and 12 months but a higher rate of adverse events (UTIs, major
bleeding complications, incomplete bladder emptying).
Disposition
If untreated, uterine prolapse progressively worsens.

Referral
To a gynecologist/urologist if pessary fitting or surgical intervention is needed