CME

Pelvic organ prolapse: An overview

Taryn A. Smith, PA-C; Tamara A. Poteat, PA-C; S. Abbas Shobeiri, MD

ABSTRACT
Pelvic organ prolapse is a common gynecologic complaint
in which the vaginal walls are weakened, resulting in
descent of pelvic organs through the vagina. Prolapse may
be asymptomatic or associated with pelvic pressure and
difficulties with urination and defecation, but usually is not
responsible for pelvic or lower abdominal pain. Treatment
options include conservative measures such as a pessary or
pelvic floor physical therapy, or surgical correction. Patients
should be reassured that prolapse typically is not an emergency or life-threatening condition.
Keywords: pelvic organs, prolapse, uterus, pessary, herniation, pregnancy

Prolapse represents a defect in support of one or more of

the vaginal walls, which are held in place by connective tissues and the pelvic musculature.4 Prolapse may be conceptualized as a type of herniation, and the bulge may contain
any of the pelvic organs (including the bladder, bowel, or
uterus). Incidence increases with parity beyond one pregnancy, advancing age, menopausal status, obesity, chronic
straining such as is seen with chronic cough or constipation,
heavy lifting, and connective tissue disorders.4-6 Pelvic organ
prolapse appears to run in families, although the exact
genetic cause is unknown. An ethnic correlation with pelvic
organ prolapse has been disputed, but some studies suggest
that white and Hispanic women are more likely to develop
prolapse than African American and Asian women.7

Learning objectives

EVALUATION
History Initial evaluation of prolapse should start with a
patient-oriented discussion. Ask the patient when she first
noticed the bulge, how she discovered it, and how it bothers her. Women who present with pelvic organ prolapse
may need reassurance, as they sometimes fear that the mass
is cancerous, they are at risk of internal infection, or their
pelvic organs are in danger of injury.8 Feelings of isolation
and poor self-image also are common.9 Ask the patient
about specific symptoms that she associates with the prolapse. Some women must push the prolapsed tissue back
into the vagina in order to urinate or defecate, an act termed
splinting. Patients often describe low back pain, pelvic
heaviness or pressure, vaginal dryness, and/or bleeding of
the exposed tissue.10 Women with mild prolapse may report
significant discomfort, and women with severe prolapse
may report no discomfort. Many women also suspend
sexual activity or their partners may avoid intercourse due
to fear of worsening the problem.9 This can cause significant
relationship stress and decreased quality of life and should
be sensitively addressed. Compile a history of the patients
abdominal and pelvic surgeries, especially previous prolapse
surgeries. Specific questionnaires are available to aid historytaking. The Pelvic Floor Distress Inventory (PFDI) and the
Pelvic Floor Impact Questionnaire (PFIQ) are two of the
most frequently used tools.11
Physical examination A standardized physical examination for pelvic organ prolapse should include abdominal
examination. Encourage the patient to empty her bladder
before the examination. She should undress from the waist
down and cover her lap with a drape. Before asking a

Describe the three major categories of pelvic organ

prolapse.
Identify relevant aspects of patient history and the physical
examination of prolapse.
Identify treatment options for prolapse, including conservative therapies.

elvic organ prolapse, defined as herniation of the

pelvic organs against the vaginal walls and often
through the vaginal introitus, is noted in up to
60% of parous women but is symptomatic in fewer
than 30% of all women. 1,2 Clinical presentation of
pelvic organ prolapse is anticipated to almost double
with the projected rise in the older female population
in coming decades.3 Although the patient herself may
be unaware of any changes in her anatomy, or simply
describe a bulge down there, a clinical assessment
and understanding of possible types of pelvic organ
prolapse help to guide treatment options and improve
patient satisfaction.
Taryn A. Smith and Tamara A. Poteat practice in the Department
of Obstetrics and Gynecology at the University of Oklahoma Health
Sciences Center in Oklahoma City, Okla. S. Abbas Shobeiri is an
associate professor and chief of the section of female pelvic medicine
and reconstructive surgery at the University of Oklahoma Health
Sciences Center. The authors have disclosed no potential conflicts of
interest, financial or otherwise.
DOI: 10.1097/01.JAA.0000443963.00740.4d
Copyright 2014 American Academy of Physician Assistants

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Pelvic organ prolapse: An overview

ILLUSTRATIONS COURTESY OF S. ABBAS SHOBEIRI, MD

Key points
Pelvic organ prolapse is a common gynecologic complaint
that will be encountered by PAs in various specialties,
especially primary care.
Prolapse may involve one or more regions of the pelvic
organs and may be asymptomatic or may affect organ
function.
Patients may choose to receive conservative treatment,
surgical repair, or observe the condition.
For surgical correction, patients should be referred to
a subspecialty practice, such as urogynecology, or to a
gynecologist experienced in the surgical management of
prolapse.
FIGURE 1. Digital examination of the pelvic floor muscles (anteri-

supine patient to move into the dorsal lithotomy position,

ask her to plant her feet in the middle of the examination
table, bend her knees, and move herself down toward the
end of the table before guiding her feet into the stirrups.
This method helps to prevent leg cramping.
Initial examination for pelvic organ prolapse includes
noting the condition of the labia and introitus. Grossly
prolapsed tissue may or may not be apparent at rest. If
prolapsed tissue is present, inspect it for ulceration or bleeding, which may occur with chronic rubbing of the delicate
and often atrophic genital tissue against clothing. Lesions
of the posterior fourchette may occur in the same manner.
The examination of women with pelvic organ prolapse
is different from a normal well-woman examination in two
respects. In a well-woman examination, the examiner is
interested in performing a Pap smear and measuring the
uterine size. In an examination for pelvic organ prolapse,
the examiner is interested in grading the prolapse and
ascertaining the status of pelvic floor strength.
To grade the prolapse, ask the patient to perform a Valsalva maneuver before reducing any visible prolapse. Straining will help display the greatest degree of prolapse and is
useful for obtaining Pelvic Organ Prolapse Quantification
(POP-Q) measurements, which will be described later in
this article.12 After initial POP-Q measurements are taken,
the prolapse may be gently reduced and the examination
continued with a lubricated speculum. Lubrication is especially important during examination of women with vaginal atrophy, to minimize burning and discomfort. Once the
speculum is inserted, the vaginal walls and cervix should
be inspected for lesions or other abnormalities. Remaining
POP-Q measurements are taken using a half speculum.
To measure pelvic floor strength, an Oxford measurement
is recorded by asking the patient to perform a Kegel exercise (squeezing the pelvic floor muscles). A score of 0
denotes no strength, and a score of 5 denotes normal
strength.13 The muscles themselves should be examined
with one or two digits if possible to evaluate for hypertonicity (Figure 1). A bimanual examination will rule out

or view as if looking through the abdomen with the vaginal wall,

rectum, and bladder removed), showing the obturator internus
(W), puborectalis (M), obturator foramen (E), arcus tendineus
(F), digit in the vagina (N), pubococcygeus muscle (O), iliococcygeus (P), coccygeus (Q), and sacrospinous ligament (R)

FIGURE 2. Rectocele, viewed through the vagina with the

patient in dorsal lithotomy position

obvious adnexal masses and tenderness. Finally, perform

a rectal examination to check for an obvious weakness of
the anterior rectal wall, such as is expected in a patient
with a rectocele (Figure 2).14
Several types of prolapse may be identified on pelvic
examination, and a patient may have any combination of
these types.
Anterior compartment prolapse, also called cystocele,
represents a defect of the anterior compartment, resulting in
a bulge created by the bladder moving into the vaginal space.
Cystocele is what many patients expect when they think of
pelvic organ prolapse, as evidenced by the common statement,
My bladder is falling out. Cystocele also is the most commonly encountered form of pelvic organ prolapse.15,16

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CME

Posterior compartment prolapse consists of two subtypes:

rectocele, a bulge caused by a defect of the rectum into the
vaginal cavity, and enterocele, a bulge caused by the small
intestines or even sigmoid colon pressing into the vaginal
canal (Figure 3). In enterocele, a careful examiner may feel
the peristalsis of bowel during digital rectal examination.
Apical prolapse occurs when the apex of the vaginal
canal descends.
Procidentia refers to the most advanced stage of uterine
prolapse, in which all three compartments-anterior,
posterior, and apical-prolapse simultaneously. A patient
with procidentia is in danger of incarceration of the
prolapsed contents: the prolapsed bladder may fill with
urine, the bowel may become necrotic, or the uterus may
swell to a degree that it cannot return within the pelvic
cavity. Any of these scenarios constitutes a surgical emergency (Figure 4).
POP-Q The POP-Q method of describing prolapse creates
a numeric map of the location and extent of the defects.12
Points are measured using the vaginal introitus as a reference point designated as 0. Each point in the POP-Q scale
represents 1 cm of movement proximal or distal to 0, or 1
cm in length (in the case of points GH and PB). Points GH,
PB, Aa, Ba, C, D, Ap, and Bp are all measured with the
patient performing a Valsalva maneuver; she should be
encouraged beforehand not to guard against vaginal bulging or urinary or fecal incontinence, as these are all relevant
findings on examination. The overall stage of the prolapse
is based on the most distal edge of the prolapse at maximum
Valsalva effort. Stages range from 0 to IV, in ascending
degree of severity. These staging designations may help the
surgeon determine which levels of DeLancey support may
be deficient.17 The levels of support are:
Level 1 support, provided by the uterosacral and cardinal ligamentous attachments to the sacrum and lateral
pelvis. These support the vaginal apex, cervix, and uterus.
Uterine descent or apical prolapse may occur when Level
1 support is lost.
Level 2 support is provided by the pubocervical and
rectovaginal attachments to the levator ani fascia and arcus
tendineus fascia pelvis. These attachments support the
lateral walls of the vagina. A cystocele may occur when
Level 2 support is compromised.
Level 3 support consists of the perineal membrane,
perineal body, and superficial and deep perineal muscles,
which support the distal third of the vagina. Depending
on the location of compromise, loss of Level 3 support
may lead to urethral hypermobility (a risk factor for stress
urinary incontinence), rectocele, or enterocele.18
During the examination, observe the patients vulva,
urethra, and vagina for lesions. Moderate, steady pressure
applied to the vaginal walls with the pads of two fingers
should not cause pain.19 If the patient reports pain, she
may have underlying muscle spasm that must be treated
separately from prolapse. Note that some patients will not
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FIGURE 3. Right lateral view of a vaginal vault prolapse con-

taining bladder and small bowel, showing the anorectum (A),

bladder (B), enterocele (E), and pubic symphysis (PS)

FIGURE 4. Complete procidentia. Note ulceration of chronically

exposed vaginal epithelium and dermal abrasions on the thighs.

verbalize pain; observe for changes in facial expression or

ask specifically about discomfort. Occasionally, fasciculations will be palpated and confirm the presence of muscle
spasm. Finally, insert a small catheter to check postvoid
residual, the amount of urine left in the bladder after a
spontaneous void. During rectal examination, hard stool
in the rectal vault signifies underlying constipation, a risk
factor for pelvic organ prolapse.
MANAGEMENT
During the discussion phase of the visit, use diagrams
and pelvic models to help clarify the different types and
stages of prolapse. Send the patient home with reliable
resources, such as trusted pamphlets and/or websites. If
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Pelvic organ prolapse: An overview

surgical management is planned, bring the patient back

to the office to discuss her condition and expectations for
treatment. Separating a patients problems into the categories of prolapse, urinary complaints, and bowel complaints helps to emphasize the independent nature of the
issues and underscores the expectation that treating
prolapse may not improve urinary leakage, bowel issues,
and pain.
A challenging aspect of treating pelvic organ prolapse
revolves around understanding what the patient expects to
gain from treatment. She may be bothered by bladder,
bowel, or bulge symptoms that she attributes to pelvic organ
prolapse. Some women, on the other hand, are bothered
purely by the knowledge that their genital anatomy has
changed and not by any prolapse-related symptoms in
particular.8
Practitioners must carefully elicit the patients expectations
for prolapse treatment and address them appropriately.
One area of management that deserves special attention is
the relationship between low abdominal or pelvic pain and
prolapse. Patients and providers alike commonly assume
that prolapsed tissue causes pain, and therefore that surgical correction of prolapse will alleviate that pain. This is
often not the case.20 Pain is more commonly associated with
muscle spasm or strain, vaginal atrophy, or conditions such
as chronic low back pain and fibromyalgia. One way to
clarify this for the patient is to suggest a short-term trial of
a pessary. A pessary allows reversible correction of prolapse
that will help the patient appreciate how she is likely to feel
after surgery. If pain is not relieved, proceed with workup
or referral to address the cause of pain. Similar pessary
trials can be applied for constipation and urinary complaints
that the patient attributes to prolapse.
Management options for prolapse depend on the patients
goals. If the prolapse is not bothersome to her, she may be
assured that it can be safely observed and surgical treatment deferred without risk of harm. The exception to this
is in cases of urinary retention, as indicated by elevated
postvoid residual and the sensation of poor bladder emptying, caused by kinking of the urethra in the presence of
a cystocele. In such cases, the bladder should be lifted by
either a pessary or surgical means. Otherwise, the patient
will need to learn clean intermittent self-catheterization
to avoid potentially damaging vesicoureteral reflux and
hydronephrosis.21,22
Another exception is incarceration of the prolapse, as
described earlier. Generally prolapse that does not go past
the introitus is not bothersome to patients. These prolapses
can be observed conservatively if asymptomatic. Prolapses
that pass the introitus can be expected to worsen.23 No
other reliable predictors for progressive prolapse have been
identified.24 Should the patient desire prolapse correction,
a variety of conservative and surgical choices are available.
Pessaries and pelvic floor physical therapy constitute the
conservative approach. Pessaries are easily fit and managed

FIGURE 5. Various types of pessaries

by PAs, and are discussed in more detail shortly. Physical

therapy should be performed by a specially trained pelvic
floor physical therapist if possible. The American Physical
Therapy Association designates specialized physical therapists as womens health providers and maintains an online
directory on its website.25 Interestingly, research indicates
that a statistically significant number of women who receive
pelvic floor physical therapy experience both subjective
and objective improvement in prolapse symptoms and
staging, respectively.26,27
Surgical correction of pelvic organ prolapse is not a single
procedure, but rather represents an array of choices. Prolapse
surgeries are beyond the scope of this article. However, they
are generally divided into reconstructive or obliterative
repairs, and may involve a hysterectomy in a woman who
still has a uterus. The specialty of female pelvic medicine
and reconstructive surgery is now the specialist body that
provides care for this population. These specialists are called
urogynecologists and finish 3 years of Accreditation Council for Graduate Medical Education-accredited fellowship
training after completing an obstetrics/gynecology or urology
residency.28
The primary care provider may have a small supply of
pessaries available (Figure 5). Pessaries are the backbone
of conservative therapy for the woman with symptomatic
prolapse, and have been used in varying forms for thousands
of years.29 Pessary use is generally well-tolerated and relieves
prolapse symptoms satisfactorily in most patients who
elect for a pessary trial.10 Pessaries can be especially helpful in women who do not want surgery, who are poor
surgical candidates, who have not yet completed childbearing, and those who desire symptom relief while awaiting
a surgery date. Most pessaries can be autoclaved and reused,
so a patient should be allowed to try several pessaries if
needed without fear of extra cost.
Pessaries come in many shapes and sizes and are typically
made of flexible silicone, which does not cause allergic
reactions or absorb odor.29 Generally, providers should try
a ring with support model first, in the same size as the

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CME

patients GH (see previous section on POP-Q measurements). Several sizes of the ring with support shape should
be tried before it is ruled out, as it tends to be the easiest
for the patient to manage at home. However, providers
may elect to offer a comparably sized pessary of a different
design, such as a Gellhorn or doughnut.
When inserted in the vagina, the pessary provides support
to the prolapsed tissues and restores them to their original
anatomic position. A well-fitting pessary should not be uncomfortable; the patient should hardly be aware the pessary is in
place. She also should be able to easily remove the pessary for
intercourse and cleaning. If the patient is unable or unwilling
to remove and clean her own pessary, establish a regular
follow-up schedule, with visits occurring at least every 2 to 3
months. If the pessary is not routinely removed and cleaned,
its constant pressure on the vaginal walls can cause mucosal
erosions and, in the worst cases, fistulous tracts.
The patient also should be encouraged to tell a trusted
family member or friend that she is using a pessary, in the
event that she is unable to tell a provider herself. Not every
woman will find a comfortable pessary, and even a woman
who is well-fitted may decide that she will no longer tolerate the regular maintenance involved. Women with vaginal
atrophy may benefit from an initial trial of topical estrogen
cream before a pessary fitting.
In summary, if the patient desires surgical correction of
her prolapse, she should be referred to a urogynecology
practice for consultation. Many patients who read online
about prolapse surgery are reasonably concerned about
the use of synthetic vaginal mesh during repair, especially
in light of lawsuits frequently mentioned in the media.30
A specialist can address these concerns more fully; providers can tell patients that mesh has been used safely for
several decades abdominally, laparoscopically, and robotically. A specialist can clarify the patients goals for prolapse
surgery and help her choose the best option considering
the risks and benefits unique to the patients situation. JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.org.
Successful completion is defined as a cumulative score of at least 70%
correct. This material has been reviewed and is approved for 1 hour of
clinical Category I (Preapproved) CME credit by the AAPA. The term of
approval is for 1 year from the publication date of March 2014.

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