Pelvic Organ Prolapse

Clinical Expert Series

Editor’s Note: Continuing medical education credit is available online atwww.greenjournal.org.

Pelvic Organ ProlapseAnne M. Weber, MD, MS, and Holly E. Richter, PhD, MD

Abstract: Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse,and enterocele, is a common group of clinical conditions affecting millions of American women.This article, designed for the practicing clinician, highlights the clinical importance of prolapse, itspathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range ofdisorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated withsevere urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorialand may operate under a “multiple-hit” process in which genetically susceptible women areexposed to life events that ultimately result in the development of clinically important prolapse. Theevaluation of women with prolapse requires a comprehensive approach, with attention to functionin all pelvic compartments based on a detailed patient history, physical examination, and limitedtesting. Although prolapse is associated with many symptoms, few are specific for prolapse; it is oftenchallenging for the clinician to determine which symptoms are attributable to the prolapse itself andwill therefore improve or resolve once the prolapse is treated. When treatment is warranted basedon specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical,which includes pelvic floor muscle training and pessary use; and surgical, which can bereconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptomsrequire additional management. Virtually all women with prolapse can be treated and theirsymptoms improved, even if not completely resolved.(Obstet Gynecol 2005;106:615–634)

CLINICAL IMPORTANCEBecause the prevalence of pelvic organ prolapseincreases with age, the changing demographics of theworld’s population will result in even more affectedwomen. Based on projections from the United StatesCensus Bureau, the number of American womenaged 65 years and over will double in the next 25years, to more than 40 million women by 2030.1 Byone estimate, the demand for health care servicesrelated to pelvic floor disorders will increase at twicethe rate of the population itself.2 The lifetime risk thata woman in the United States will have surgery for

prolapse or urinary incontinence is 11%, with up toone third of surgeries representing repeat proce-dures.3 Although the overall rate of prolapse surgeryhas dropped, this represents a substantial drop in therate of surgery for women less than 50 years old anda moderate increase for women aged 50 years andgreater (Fig. 1).4 Perioperative death is uncommon (3per 10,000 surgeries), although that figure underesti-mates mortality occurring outside of the index hospi-talization for surgery. The direct cost of prolapsesurgery is greater than $1 billion per year.5

Surgically treated prolapse represents the severeend of the clinical spectrum. Where is the cutoffbetween early prolapse and “normal” pelvic support?Two factors make this question difficult to answer.Changes in vaginal anatomy are exceedingly com-mon, especially in parous women; and beyond thesensation of protruding tissue with advanced pro-lapse, symptoms of prolapse are notoriously nonspe-cific. Prolapse is commonly found on physical exam-ination in women without pelvic symptoms.6,7 For thevast majority of asymptomatic women with physical

From the Department of Obstetrics, Gynecology, and Reproductive Sciences,Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pitts-burgh, Pennsylvania; Department of Obstetrics and Gynecology, University ofAlabama Hospital, University of Alabama at Birmingham School of Medicine,Birmingham, Alabama.

Corresponding author: Anne M. Weber, MD, MS, Magee-Womens Hospital,300 Halket Street, Pittsburgh, PA 15213; e-mail: [email protected].

© 2005 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/05

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findings of prolapse, no treatment is indicated. Incontrast to traditional concepts that predict inevitableprogression of prolapse with time, prolapse is adynamic condition; regression of prolapse occurs atthe same or higher rate as incidence.8 Factors relatedto progression and remission need further study. Thisreview will outline our recommendations, combinedwith an evidence-based approach when available, forthe evaluation and treatment of the postreproductivewoman with pelvic organ prolapse.

PATHOPHYSIOLOGYA useful approach to understanding the pathophysi-ology of prolapse is to consider risk factors as predis-posing, inciting, promoting, or decompensatingevents (Table 1).9 Depending on the combination ofrisk factors in an individual, prolapse may or may notdevelop over her lifetime. As a hypothetical example,

imagine a woman who is genetically predisposed toprolapse. She has a family history of prolapse, andunknown to her, she carries a subclinical defect inconnective tissue remodeling. She experienced aninciting event in the birth of her 9-pound posttermson, with prolonged second stage followed by forcepsdelivery over midline episiotomy that extended todisrupt the anal sphincter. Over the next 10 years, shegained 60 pounds. She has chronic excessive strainingat defecation. At menopause, she had a simple hys-terectomy for atypical endometrial hyperplasia, withno attention given to reattaching the uterosacral liga-ments to the vaginal cuff. At age 55, she is diagnosedwith stage III vaginal prolapse.

Now let’s give this woman an identical twin sister,who carries the same genetic predisposition but whoexperiences different life events. She never experi-enced pregnancy or delivery. She maintained normalweight and an active lifestyle. She never developed anindication for hysterectomy. At age 55, her pelvicsupport is excellent. Although hypothetical, these 2cases emphasize the multifactorial nature of prolapse.Risk factors have been and will continue to beidentified; with progress such as the Human GenomeProject, eventually we may be able to predict those athighest risk of developing prolapse. Modifiable riskfactors can be altered to decrease the likelihood ofsubsequent prolapse.

Risk factors for prolapse include increasing age,higher gravidity and parity (especially the number ofvaginal births), and history of hysterectomy, espe-cially hysterectomy for prolapse or other prolapse orincontinence operations.3,6,7,10 Although increasedparity is a risk factor for prolapse, nulliparity does notprovide absolute protection against prolapse. In theWomen’s Health Initiative, almost one fifth of nullip-arous women had some degree of prolapse.7 Thesedata should give pause to enthusiasts promoting ce-sarean delivery for all women to prevent prolapse.Obesity is one of the few modifiable risk factorsidentified so far.7,10 In the Women’s Health Initiative,

Fig. 1. Age-adjusted rates of prolapse procedures per 1,000women from 1979 to 1997 in the United States, stratified bypatient age. Red line, all ages; blue line, women less than50 years of age; green line, women 50 years or older.Modified from Boyles SH, Weber AM, Meyn L. Proceduresfor pelvic organ prolapse in the United States, 1979–1997.Am J Obstet Gynecol 2003;188:108–15. Copyright 2003,with permission from Elsevier.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

Table 1. Potential Risk Factors for Pelvic Organ Prolapse

Predispose Incite Promote Decompensate

Genetic (congenital or hereditary) Pregnancy and delivery Obesity AgingRace: White � African-American Surgery such as hysterectomy

for prolapseSmoking Menopause

Gender: Female � Male Myopathy Pulmonary disease (chronic coughing) NeuropathyNeuropathy Constipation (chronic straining) Myopathy

Recreational or occupational activities(frequent or heavy lifting)

Debilitation

Medication

Adapted from Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am1998;25:723–46. Copyright 1998, with permission from Elsevier.

616 Weber and Richter Pelvic Organ Prolapse OBSTETRICS & GYNECOLOGY

body mass index greater than 30 kg/m2 conferred a40–75% increased risk of prolapse.7

DIAGNOSTIC APPROACHSymptomsSymptoms are not specific to different compartmentsof prolapse but may reflect the overall stage ofprolapse at its most advanced site.11 With descent ofthe cervix into the vagina, women may find they canno longer wear tampons. Women are usually notaware of an actual protrusion while prolapse is abovethe hymen, but they may have pelvic pressure orheaviness. Although pelvic pain and low back painhave classically been considered symptoms of pro-lapse, a recent study found pelvic pain was notassociated with prolapse, and women with moreadvanced prolapse actually had less back pain thanwomen with mild prolapse.12

Women with prolapse often have urinary symp-toms, although the mechanism responsible for thesesymptoms can be markedly different. Some womenhave stress incontinence symptoms due to urethralincompetence, but many women, particularly thosewith advanced anterior vaginal prolapse, are conti-nent. In some women, this reflects normal urethralsphincter competence despite lack of support. Inother cases, women with urethral incompetence arecontinent only because the prolapse causes urethralkinking and obstruction.13 This is called potential,masked, latent, or occult stress incontinence becausewomen do not have symptoms of incontinence aslong as the prolapse is untreated. In one study,urethral obstruction occurred in 58% of women withgrade 3 and 4 anterior vaginal prolapse, comparedwith 4% in women with grade 1 and 2 prolapse.14 Asprolapse advances, women are less likely to havestress incontinence and more likely to manually re-duce prolapse to void. Women may have a remotehistory of stress incontinence that resolved as theprolapse became more advanced. Women with ure-thral obstruction commonly have voiding dysfunc-tion, manifested by symptoms of urinary hesitancy,frequency, or incomplete emptying.

Defecatory symptoms such as excessive straining,incomplete rectal emptying, or the need for perinealor vaginal pressure to accomplish defecation shouldbe sought in all women with prolapse. In addition, theinfluence of prolapse on sexual functioning should beaddressed in women of all ages.15 Some women withprolapse avoid vaginal intercourse out of concern orembarrassment. Other women experience urinary orfecal incontinence (or the fear of incontinence) thatinterferes with sexual activity. Assessing sexual func-tion is particularly important before and after surgery,

so that any potentially adverse effects can be recog-nized and addressed.16

Physical ExaminationPhysical examination focuses on the pelvic examina-tion, beginning with a careful inspection of the vulvaand vagina to identify erosions, ulcerations, or otherlesions. Suspicious lesions should be biopsied imme-diately. Benign-appearing ulcers should be closelyobserved and biopsied if they do not resolve withtreatment.

The extent of prolapse should be systematicallyassessed. With advanced prolapse, determining theextent of prolapse and its constituents (anterior andposterior vagina; cervix or vaginal apex) is usually notdifficult. Paradoxically, with less advanced prolapse,it can be more difficult to identify its components,particularly by inspection alone. The use of vaginalspeculums (eg, the posterior blade of a Graves specu-lum) or retractors is very helpful in determining whatvaginal sites are affected by prolapse. An unidentifiedvaginal bulge (Fig. 2) can be clearly identified as thevaginal apex, once the anterior and posterior vaginaare retracted (Fig. 3). Similarly, anterior vaginal pro-lapse can be seen more clearly after retracting theposterior vagina. At times, posterior vaginal prolapse

Fig. 2. Stage II prolapse. By inspection, it is not possible todetermine which components of the vagina (anterior, api-cal, posterior) are affected by prolapse. Reprinted fromWeber AM, Brubaker L, Schaffer J, Toglia MR. Officeurogynecology: practical pathways in obstetrics & gynecol-ogy. 1st ed. New York (NY): McGraw-Hill; 2004. Repro-duced with permission of The McGraw-Hill Companies.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

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(rectocele) will be easily identified by vaginal exami-nation. At other times, rectovaginal examination isinvaluable in distinguishing between posterior vaginalprolapse alone, high apical prolapse (possible entero-cele), or a combination of these.

Although many systems for staging prolapse havebeen described, the standard is the system approvedby the International Continence Society, the PelvicOrgan Prolapse Quantification system.17 This systemmeasures 9 locations on the vagina and vulva incentimeters relative to the hymen. These 9 locationsare used to assign a stage (from 0 to IV) of prolapse atits most advanced site (Fig. 4). The pelvic organprolapse quantification system is probably more de-tailed than necessary for clinical care, but cliniciansshould be familiar with it because most studies nowuse the Pelvic Organ Prolapse Quantification systemto report research results. Its 2 most important advan-tages over previous grading systems are 1) the stan-dardized technique with quantitative measurements atstraining relative to a constant landmark, the hymen,and 2) prolapse assessment at multiple vaginal sites(not just the most advanced). In lieu of using the fullpelvic organ prolapse quantification system of 9 mea-surements, clinicians are encouraged to record at least

3 measurements: the most advanced extent of pro-lapse in centimeters relative to the hymen that affectsthe anterior vagina, the cervix or vaginal apex, andthe posterior vagina.

The maximal extent of prolapse is demonstratedwith a standing straining examination when the blad-der is empty.18 Standing examinations are not alwayspractical, and small differences may not be clinicallymeaningful. However, if the initial examination doesnot reproduce the patient’s symptoms or descriptionof her prolapse, a standing straining examinationshould be performed. Assessing paravaginal or lateralanterior vaginal support is not included in the pelvicorgan prolapse quantification system. Indeed,whether examination can reliably differentiate spe-cific defects of anterior vaginal support has beenquestioned.19 Until the existence of specific defects isconfirmed and better systems of measurement devel-oped, prolapse assessment relative to the hymenseems to be the most reliable way to describe pro-lapse.

Pelvic muscle function should be assessed in allwomen.20 After the bimanual examination while thepatient is in lithotomy position, the examiner canpalpate the pelvic muscles a few centimeters inside

Fig. 3. Stage II prolapse of the vaginal apex (the samepatient as in Fig. 2). With retraction of the anterior andposterior vagina, it is now clear that this prolapse affects thevaginal apex, possibly with an enterocele. Reprinted fromWeber AM, Brubaker L, Schaffer J, Toglia MR. Officeurogynecology: practical pathways in obstetrics & gynecol-ogy. 1st ed. New York (NY): McGraw-Hill; 2004. Repro-duced with permission of The McGraw-Hill Companies.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

Fig. 4. Diagrammatic representation of the pelvic organprolapse quantitation system for staging prolapse by phys-ical examination findings, showing the 6 sites (points Aaand Ba anteriorly, points Ap and Bp posteriorly, point C forthe cervix or apex, and point D for the cul-de-sac), genitalhiatus (gh), perineal body (pb), and total vaginal length (tvl)used for pelvic organ prolapse quantitation. Modified fromBump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO,Klarskov P, et al. The standardization of terminology offemale pelvic organ prolapse and pelvic floor dysfunction.Am J Obstet Gynecol 1996;175:10–7. Copyright 1996,with permission from Elsevier.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.


the hymen, along the pelvic sidewalls at the 4 and 8o’clock positions. Baseline muscle tone and increasedtone with voluntary contraction should be assessed,along with the strength, duration, and symmetry ofcontraction. This serves as a baseline measure forcomparison with subsequent examinations. It alsoidentifies women who may benefit from focusedintervention to strengthen the pelvic muscles. If awoman has no awareness of her pelvic muscles andcannot perform a voluntary contraction, one wouldexpect little or no benefit from an unsupervisedprogram of pelvic muscle exercise. She will need tobe taught to locate and contract her pelvic muscles byan experienced clinician, whether a physical thera-pist, nurse or nurse practitioner, or physician.

In addition, resting tone and voluntary contrac-tion of the anal sphincters should be assessed duringrectovaginal examination. With normal resting toneof the anal sphincters, the examiner will feel the ringof muscle snugly around the examining finger; duringvoluntary contraction, the ring of muscle shouldtighten circumferentially. Abnormalities should benoted, such as low resting tone (looseness of the ringof muscle), weak or absent voluntary contraction, analsphincter defect (usually at the 12 o’clock position, asa result of obstetric injury), hemorrhoids, or rectalprolapse.

TestingBladder TestingAt a minimum, for all patients with prolapse, 3 piecesof information should be obtained: 1) screening forurinary tract infection; 2) postvoid residual urinevolume; and 3) presence or absence of bladder sen-sation (by voided volume with sensation of fullness,by voiding diary, or by bladder filling). Althoughthere is no consensus on a postvoid residual cutoffthat is “normal” versus “abnormal,” less is better as anindicator of efficient bladder emptying. Provided theinitial voided volume was more than 150 mL,postvoid residual volume less than 100 mL indicatesacceptable bladder emptying. Postvoid residual vol-ume over 100 mL indicates impaired bladder empty-ing, which may or may not be caused by prolapse.

Women with prolapse and urinary incontinenceshould have stress testing performed with the pro-lapse reduced because this will mimic bladder andurethral function when the prolapse is treated. Pro-lapse reduction with bladder testing has not beenstandardized. Different techniques include using theposterior blade of a speculum, ring forceps, pessary,vaginal packing, or large cotton swabs. Regardless oftechnique, avoid overcorrection of anterior vaginalprolapse and ensure that the urethra is not obstructed

with prolapse reduction to avoid falsely negativestress testing. In the setting of a positive reductionstress test, we recommend that an incontinence pro-cedure should be performed at the time of prolapsesurgery. However, little evidence is available fromcontrolled trials for patients with and those withoutpreoperative symptoms of stress incontinence com-bined with prolapse warranting surgery. We need tocounsel patients extensively about the risks and ben-efits of performing or withholding an incontinenceprocedure in this clinical situation. When an inconti-nence procedure is added to prolapse repair, at worst,the patient may receive overtreatment and risk void-ing dysfunction. Conversely, when the incontinenceprocedure is not performed at the same time as theprolapse repair, the patient may need a second sur-gery to treat new (unmasked) or persistent stressincontinence. With effective minimally invasive pro-cedures that can be performed with local anesthesia,this situation is less problematic than in the recentpast. The key is open communication with the patientabout her options and expected outcomes, so that shecan participate in making an informed decision.

ImagingImaging is not usually necessary in women withprolapse unless the information obtained would becritical in formulating recommendations for manage-ment. Imaging tests in women with prolapse, such asmagnetic resonance imaging21 and cystoproctogra-phy,22 are primarily for research at this point; they arenot recommended routinely for clinical care.

THERAPEUTIC APPROACHManagement for prolapse includes observation, pel-vic floor rehabilitation, pessary use, and surgery.Unfortunately, there is little evidence-based informa-tion with which to counsel our patients. There is adearth of rigorously conducted trials that comparemanagement approaches.23–25 In most cases, cliniciansmust rely on their best judgment and the patient’spreferences to select a management plan.

Indications for TreatmentChoice of treatment for prolapse usually depends onsymptom severity and severity of prolapse, in linewith the patient’s general health and activity. Impor-tantly, the correlation between many pelvic symp-toms and the extent of prolapse is weak.26,27 Symp-toms associated with stage I or stage II prolapserequire careful evaluation, especially if surgery isbeing considered.28 Many women with stress urinaryincontinence have stage I or II prolapse, althoughstress incontinence is not a symptom of prolapse; it issimply a coincident symptom. Factors that determine


how clinicians make recommendations and how pa-tients make decisions have not been well studied.Patient and clinician goals of treatment may differconsiderably and lead to dissatisfaction if expectations(that may be unrealistic) are not met. In symptomaticwomen choosing treatment, patients were more likelyto choose surgery, compared with expectant manage-ment or pessary use, with more advanced prolapse,with increasing age, and with prior prolapse surgery.28

ObservationObservation is appropriate for women whose symp-toms are not sufficiently bothersome to warrant activeintervention. When first learning of prolapse, manywomen require only information and reassurance thattreatment is available when and if they becomesymptomatic. As outlined in the section “DiagnosticApproach,” a careful evaluation will serve as a base-line with which subsequent examinations can becompared. For an otherwise healthy woman, repeatassessment can be conveniently performed at heryearly health maintenance visit. The patient shouldbe instructed to call for an interval visit if she experi-ences any symptoms that concern her. She can becounseled that acute changes rarely occur in thesetting of early prolapse. There is virtually no indica-tion for treatment, particularly surgery, for womenwith asymptomatic prolapse “before the problem getsany worse.” The old adage “You can’t make anasymptomatic patient better; you can only make herworse” was never more true than it is for prolapse.

Occasionally, a patient will present with ad-vanced prolapse, yet she will say that she is asymp-tomatic. Is observation still appropriate? An impor-tant consideration is her efficiency of bladderemptying. If she has partial urinary retention, she is atrisk for persistent or recurrent urinary tract infectionsand possibly urosepsis, depending on her overallmedical status. The exposed vaginal epithelium is atrisk for erosion, which rarely can become secondarilyinfected and serve as a source for sepsis. Even morerare is the risk of evisceration, an event of highmorbidity and mortality. After considering these risksand discussing them with the patient (and familymembers, as appropriate), if she still prefers observa-tion, we recommend close follow-up, such as every 3months, to reassess potential risks and the decision forobservation versus active management.

Nonsurgical ManagementNonsurgical management of prolapse includes ad-junct therapy to address concomitant symptoms, pel-vic floor muscle training, and pessaries. Ideally, non-surgical management will decrease the frequency andseverity of symptoms, delay or avoid surgery, and

potentially prevent worsening the prolapse. We rec-ommend nonsurgical management if observation isnot (or is no longer) suitable, when surgery presentshigher-than-average risks, or in women who do notwant surgery. Pessaries may also be used beforeprolapse surgery to estimate whether symptom reliefwill be obtained with surgery. This strategy is partic-ularly useful in patients whose symptoms do notmatch their physical findings (such as severe symp-toms with mild prolapse) or in patients with nonspe-cific symptoms, such as back pain, that are notdefinitely caused by prolapse. We recommend dis-cussing nonsurgical management with most, if not all,women before surgery. In addition, some compo-nents of nonsurgical management can be effectivelyadded to surgery to maximize outcomes.

Adjunct TherapyAdjunct therapy addresses symptoms of urinary, def-ecatory, and sexual dysfunction as appropriate toeach individual. As one example of a commonlyencountered clinical problem, patients will oftenpresent with defecatory symptoms, such as excessivestraining at stool and a feeling of incomplete evacua-tion, and physical examination reveals stage II orearly stage III posterior vaginal prolapse (rectocele). Itis usually not possible to determine whether thesymptoms predated the physical findings, or viceversa. In fact, from a clinical standpoint, it is probablyirrelevant. First and foremost, the patient’s symptomsneed to be addressed. The patient should have athorough evaluation from the gastrointestinal (GI)perspective, either by referral or by the interestedobstetrician-gynecologist. Age-appropriate screeningfor colorectal cancer should be obtained. Begin with afocused diet history (including fiber and fluid intake),exercise history, review of medications for GI adverseeffects, and bowel history, including frequency andconsistency of bowel movements. Physical examina-tion should focus on anorectal examination, prolapsestaging (if present), and pelvic muscle assessment.

Provided no GI pathology is diagnosed, we rec-ommend treatment to regulate her bowel habit andprevent straining. Based on the patient’s history, sheshould alter her fluid and fiber intake (to a total of6–8 glasses of fluid and at least 20 grams of fiber perday) and her exercise level. She should arrange aregular schedule to allow time for defecation aftermeals. Add osmotic (eg, polyethylene glycol) or ca-thartic laxatives (eg, bisacodyl), as necessary. In se-lected cases, use suppositories or enemas on a daily oras-needed basis. For women who contract (instead ofrelax) their pelvic muscles at attempted defecation,consider adding biofeedback.29 If her symptoms arerelieved, we recommend no further treatment. Mon-


itor her posterior vaginal prolapse at regular intervals,such as annually. However, if the patient experiencesno relief from her defecatory symptoms despite anadequate trial (eg, the above changes for a month withescalating doses of cathartic laxatives), we recom-mend a gastroenterology consultation.

If the patient is still bothered by protrusion ofprolapse after resolution of her defecatory symptoms,we recommend that surgery be considered. The cli-nician and patient should clearly understand the goalof surgery, ie, to reduce the bulge in the posteriorvagina. It is important to note that if this patient’scondition was approached in the opposite order (rec-tocele surgery first, treatment of her defecatory symp-toms later), it is likely that she would not have asatisfactory outcome. Counsel the patient to resumeher individualized bowel regimen after surgery, in-cluding fiber and fluids, with adjustments as necessaryduring recovery with its reduced activity level, possi-ble dietary changes, and use of constipating medica-tions. Advise the patient to use laxatives early to avoidconstipation and impaction. We recommend bisaco-dyl, 5-mg tablets, to be taken as soon after surgery asliquids are tolerated, increased by 2 tablets each nightuntil a bowel movement occurs (usually the followingmorning). Instruct the patient to repeat this process asneeded until her regular bowel habit is restored.

Adjunct therapy often includes advice on lifestylealterations, weight loss, and a general exercise pro-gram. Although data are lacking to support theserecommendations specifically for prolapse, many fitinto general guidelines for a healthy lifestyle.

Pelvic Floor Muscle TrainingPelvic floor muscle training is designed to increase thestrength and endurance of the pelvic muscles, therebyimproving support to the pelvic organs. Although nodirect evidence proves that pelvic floor muscle train-ing prevents or treats prolapse, it is effective forurinary and fecal incontinence and may be beneficialfor prolapse.30 In our experience, pelvic musclestrengthening often relieves symptoms of pelvic pres-sure that commonly accompany prolapse. Although itseems unlikely that advanced prolapse will resolvewith pelvic floor muscle training, women may stillexperience a beneficial effect on their symptoms.Therefore, we do not use any cutoff as to extent ofprolapse in recommending or not recommendingpelvic floor muscle training. With virtually no adverseeffects, its only negative is the cost of providinginstruction and follow-up for patients and the invest-ment that patients must make, as in any exerciseprogram, for its potential success.

Most women recognize what “Kegel” exercisesare; some have performed them on their own. But few

women perform pelvic floor muscle exercises cor-rectly or with the necessary intensity (frequency,duration) to obtain maximum benefit. In our experi-ence, having the patient work with an experiencedphysical therapist or dedicated nurse practitionergives her the best chance of achieving benefit, usuallystarting with a program of up to 2 visits per week for8–12 weeks, with ongoing maintenance exercisesafter that. A detailed discussion of pelvic floor muscletraining is beyond the scope of this article, but it isprobably underused as a nonsurgical therapy forprolapse, either alone or in combination with pessaryuse and other adjunct therapies. Interested readers arereferred to recent review articles31–33 for more details.Professional organizations (such as the AmericanPhysical Therapy Association, www.apta.org, underWomen’s Health) can often assist in locating practi-tioners in your geographic area.

PessariesAs for all types of nonsurgical management of pro-lapse, we recommend pessaries to decrease symptomfrequency and severity, delay or avoid surgery, andpotentially prevent worsening of prolapse. The mostimportant relative contraindication for pessary useoccurs when the patient cannot comply with follow-up. Particularly concerning is the setting of dementiaor other medical or social conditions that may resultin pessary neglect, with the resultant risk of the mostserious complications of pessaries, rectovaginal orvesicovaginal fistulae. The clinician providing thepessary must ensure that appropriate follow-up care isprovided, especially because the woman may transi-tion from her own home to an assisted living or skillednursing facility.

Another relative contraindication to pessary useis persistent vaginal erosions. Some women withadvanced prolapse will have extensive vaginal ero-sions at initial evaluation. If immediate surgery is notplanned, an attempt to heal the erosions will usuallyrequire pessary use. Erosions with advanced prolapsewill almost always persist if the prolapse remainsunreduced, the vagina being unable to heal under thecontinuous pressure of gravity and friction on thewoman’s underclothes. A different situation occurswhen a woman develops persistent vaginal erosions inthe setting of longstanding pessary use. This mayindicate that local estrogen should be added or in-creased, that a smaller pessary may now be necessary,or, rarely, that a vaginal neoplasm has developed.Pessary use must be discontinued occasionally forpersistent vaginal erosions.

Pessary use for prolapse is widespread in theclinical practices of gynecologists34 and urogynecolo-gists35 in the United States. The most commonly used


pessaries are ring (with or without support), doughnut,and Gellhorn pessaries, although there are manyother types (Fig. 5). Up to three quarters of womenwith prolapse can be successfully fitted with a pessary.Although many clinicians have biases about who canand who cannot be fitted with pessaries, few charac-teristics have been identified consistently in research.Unsuccessful fitting is associated with short vaginallength (less than 7 cm) and wide introitus (4 finger-breadths).36 However, this should not preclude fittingattempts in women with those characteristics, becausesome women can still be successfully fitted. After 2months, 92% of women who were successfully fittedwere satisfied, with resolution of nearly all prolapsesymptoms.37 Urinary symptoms improved in abouthalf the women, but stress incontinence occurred as anew symptom in about one fifth.37 Women who aresexually active accept pessary use, with 60% continu-ing long-term use (up to 2.5 years).38

Pessaries can be separated into 2 broad catego-ries: support and space-filling.39 The ring pessary(with diaphragm) and other support pessaries arecommonly recommended for stage II and early stageIII prolapse, whereas the space-filling pessaries suchas the Gellhorn are usually used for more advancedprolapse. Most pessaries are silicone, plastic, or med-ical grade rubber. Silicone has many advantages: it isnonallergenic, does not absorb odors or secretions, isresistant to repeat cleaning, and is pliable and soft.Before using a pessary that contains rubber, be surethat the patient does not have a latex allergy.

If some perineal support is preserved, a ringpessary (without support when the cervix is present,with support after hysterectomy) is a good first choice.Many clinicians start with size 4 and then move to alarger or smaller pessary, depending on fit. The ringpessary is designed to sit with one end in the posteriorvaginal fornix and the other end behind the symphy-sis pubis (Fig. 6). A well-fitted pessary should fill thevagina from side to side, with the clinician’s fingerable to easily pass between the pessary and the pelvicsidewall. When the pessary is properly placed in theupper vagina, the patient should be unaware of itspresence. The patient should be asked to stand andmove about to see if the pessary remains in place. Ifthe patient becomes aware of the pessary at theintroitus, the next larger size should be tried. If thepatient is aware of tightness, pressure, or any otherdiscomfort, fitting with the next smaller size pessaryshould be attempted. It sometimes occurs that onesize is too large and the next smaller size fails toadequately hold the prolapse in place. In that case, adifferent type of pessary can be chosen. In somewomen, such as those who have had previous vaginalsurgery, an oval pessary may fit when a ring does not.

Gellhorn pessaries are useful for women withmore advanced prolapse and less perineal supportbecause they sometimes stay in place when ringpessaries do not. Gellhorn pessaries are sized based

Fig. 5. A variety of pessaries.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.

Fig. 6. Ring pessary without support in place; patient withcervix and uterus. Note that the pessary rests at the level ofthe bladder neck anteriorly and behind the cervix posteri-orly. Reprinted from Weber AM, Brubaker L, Schaffer J,Toglia MR. Office urogynecology: practical pathways inobstetrics & gynecology. 1st ed. New York (NY): McGraw-Hill; 2004. Reproduced with permission of The McGraw-Hill Companies.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.


on the diameter of the disk. The stem and knob differonly slightly in different brands of pessaries, somewith a string attached to the stem to aid in removal.The Gellhorn is fitted so that the disk is centered inthe upper vagina and the stem points downwardbehind the perineal body (Figure 7). As with the ringpessary, when well fitted, the disk should fill the uppervagina yet still allow the examiner’s finger to passeasily between the disk and the pelvic sidewall. Forremoval, it is necessary to insert an examining fingerbehind the disk to break the suction between the diskand the vagina, and then gently maneuver the diskout. If removal is difficult in a Gellhorn without astring, it is sometimes helpful to pull on the stem usinga tenaculum or ring forceps to help in bringing thepessary closer to reach behind the disk to break thesuction.

When initiating pessary use, ideally the physiciancan teach the patient to remove and replace thepessary herself. This will put control of the pessary inthe patient’s hands, allowing her to use it as needed.Ring pessaries are usually easy for patients to removeand replace, especially for women who have useddiaphragms in the past. Gellhorn pessaries are morechallenging for patients to handle, but some womenwill find it possible. The goal of changing the pessaryat frequent intervals is to prevent vaginal irritationthat leads to discharge, infection, and erosion.

Women can remove the pessary at bedtime andreplace it in the morning. If daily changing is toobothersome, a schedule of weekly or twice-weeklyremoval can be used. In this setting, after an earlyfollow-up visit (such as 2–4 weeks later) to assesswhether the pessary is adequately relieving the pa-tient’s symptoms and to review pessary maintenance,women can be returned to annual care unless newsymptoms develop in the meantime.

Some patients will not be able or willing tomanage pessary care themselves and thus requiremore frequent office visits. After an early follow-upvisit to check the pessary’s effectiveness at relievingsymptoms, office care can be arranged, usually atintervals of 3 months. At these visits, the pessary isremoved, rinsed, and replaced after carefully inspect-ing the vagina for irritation or erosions. Vaginaldischarge is commonly present, but unless the patientexpresses bother, treatment is not required. In somepractice settings, visits related to pessary maintenancecan be efficiently accomplished by a nurse practitio-ner, physician’s assistant, or other staff. The patientshould be counseled to call if vaginal odor, discharge,or bleeding occurs because these symptoms warrantinvestigation for infection or erosion.

Vaginal estrogen is commonly employed withpessaries, although this should be individualized toeach patient. Some patients will have sufficient endog-enous estrogen that atrophy does not occur andpessary use does not cause irritation. Some womenuse nonhormonal lubricants effectively with pessaries.However, in women with vaginal atrophy at pessaryinitiation, local estrogen is important to prevent vag-inal erosions, even if women are already takingsystemic estrogen. Vaginal estrogen can be used inany form: cream, tablets, or sustained-release ring(Estring silicone ring with slow-release estradiol; Phar-macia & Upjohn, Kalamazoo, MI). It is particularlyconvenient to use Estring in women with a Gellhornpessary; the Estring is placed behind the Gellhornand is changed during office visits at 3-month inter-vals.

Pessary use in some previously continent womenwill reveal or unmask latent stress incontinence. Inselected cases, periurethral injection of bulking agents(such as collagen) can be used to treat the stressincontinence while pessary use is maintained forprolapse treatment.40 However, in most situations,pessary use will be discontinued and plans made toproceed with surgery.

In some patients with long-term pessary use, it isnecessary to switch to smaller pessaries over time. Arecent study has provided evidence that supportsclinical observations of improved prolapse status withpessary use in some patients. In 19 women with

Fig. 7. Gellhorn pessary in place; patient with cervix anduterus. Note that the disk of the Gellhorn pessary rests at thelevel of the bladder neck anteriorly, and behind the cervixposteriorly (similar to the position of a ring pessary) and thatthe knob rests behind the perineal body. Reprinted fromWeber AM, Brubaker L, Schaffer J, Toglia MR. Officeurogynecology: practical pathways in obstetrics & gynecol-ogy. 1st ed. New York (NY): McGraw-Hill; 2004. Repro-duced with permission of The McGraw-Hill Companies.Weber. Pelvic Organ Prolapse. Obstet Gynecol 2005.


pessary use for at least 1 year, no woman had worseprolapse and 4 women (21.1%, 95% confidence inter-val 0.2–43.7%) improved.41

Surgical ManagementThe primary aim of surgery is to relieve or improveprolapse symptoms and, if possible, symptoms asso-ciated with the lower urinary and gastrointestinaltracts. In some women, this means an attempt torestore normal vaginal anatomy and maintain orimprove sexual function. In others, an obliterativeapproach is more appropriate and still yields thedesired result of symptom relief.

ApproachApproaches to prolapse surgery include vaginal, ab-dominal, and laparoscopic routes or a combination ofapproaches.42–44 Depending on the extent and loca-tion of prolapse, surgery usually involves a combina-tion of repairs addressing the anterior vagina, vaginalapex, posterior vagina, and perineum; concomitantsurgery may be planned for the bladder neck or analsphincters. Procedures for posterior vaginal prolapsemost commonly use a transvaginal approach, or lesscommonly, a transanal approach. Apical and anteriorvaginal prolapse can be approached by either vaginalor abdominal routes. There is clear benefit whencomparing the vaginal approach with the abdominalapproach (ie, laparotomy), from the perspective ofcomplications and short-term effects on recovery. Byavoiding laparotomy, the vaginal approach results infewer wound complications, less postoperative pain,shorter hospital stay, and less cost than abdominalsurgery.42,43 Whether prolapse repaired abdominallyis more effective or durable than vaginally repairedprolapse is controversial; the evidence supportingboth sides of this argument will be reviewed in a latersection. Adding to the debate is the potential benefitof the laparoscopic approach compared with theabdominal or vaginal route for prolapse surgery.45 Inlaparoscopic surgery for stress incontinence, the per-ceived cost advantage of reduced hospital time isoften offset and even exceeded by increased operativetime and expense of laparoscopic instruments.46

There are no comparable data for prolapse opera-tions.

Surgical route is chosen based on the type andseverity of prolapse, the surgeon’s training and expe-rience, the patient’s preference, and the expected ordesired surgical outcome. Procedures for prolapse canbe broadly categorized into 3 groups: 1) restorative,which use the patient’s endogenous support struc-tures; 2) compensatory, which attempt to replacedeficient support with some type of graft, includingsynthetic, allogenic, xenogenic, or autologous materi-

als; and 3) obliterative, which close the vagina. Thesegroupings are somewhat arbitrary and not entirelyexclusive. Grafts may be used to reinforce repairs,such as colporrhaphy, or to replace support that isdeficient or lacking. For example, graft use in abdom-inal sacral colpopexy substitutes for the connectivetissue attachments (DeLancey’s level I) that wouldnormally support the vaginal apex.47 In addition tothe primary goal of relieving symptoms related toprolapse, urinary, defecatory, and sexual functionmust be considered as well in choosing the appropri-ate prolapse procedures. The types of procedures willbe briefly reviewed. Detailed discussion of techniqueis beyond the scope of this article and interestedreaders are referred to surgical atlases, videos, andtextbooks.

Prolapse ProceduresAnterior Vaginal RepairRecurrent anterior vaginal prolapse continues to bethe Achilles’ heel of reconstructive pelvic surgery.Anterior vaginal prolapse has traditionally been re-paired with anterior colporrhaphy, where the vaginalepithelium is separated from the underlying fibromus-cular connective tissue, followed by midline plicationof the vaginal muscularis with a series of interruptedstitches, usually of absorbable suture, excision ofexcess epithelium, and closure.48 Variations includeplacing graft material on top of or instead of themidline plication. The results of 2 randomized trialssuggest modest improvement in success, adding 12–18% to the “cure” rates after 1 year, when polyglactinmesh (Vicryl; Ethicon, Somerville, NJ) was placedover the midline plication compared with standardrepair.49,50 Until there is evidence showing long-termbenefit from the use of graft material with anteriorcolporrhaphy, we recommend the use of delayedabsorbable sutures such as Vicryl or No. 1 polydiox-anone (PDS; Ethicon, Somerville, NJ), with midlineplication.

Richardson reintroduced the concept of paravag-inal repair, which reattaches the anterior lateral vag-inal sulcus to the obturator internus muscle and fasciaat the level of the arcus tendineus fascia pelvis (“whiteline”), usually performed as a bilateral procedure, viatransvaginal or retropubic (abdominal or laparo-scopic) access.51,52 With advanced anterior vaginalprolapse, midline excision of redundant tissue may benecessary in addition to paravaginal repair. The an-terior vaginal apex can be supported by placingstitches to the level of the ischial spine on each side,although this procedure should not be used as the soletreatment for vaginal vault prolapse. The long-termeffectiveness of paravaginal repair is unknown. Fur-thermore, performance of the vaginal paravaginal


repair requires specific expertise to perform correctly.There are no randomized trials that compare out-comes after anterior colporrhaphy versus paravaginalrepair.

When prolapse repair is approached vaginally,we recommend anterior colporrhaphy when indi-cated for anterior vaginal prolapse. If the surgeon hasthe clinical experience and expertise and feels thatlateral detachment is causing the anterior vaginalprolapse, a vaginal paravaginal repair is performed,but robust apical vaginal support should also bepresent or added with a specific apical suspension.When abdominal sacral colpopexy for prolapse re-pair is planned, retropubic paravaginal repair can beperformed when the surgeon judges that support ofthe anterior vagina would be insufficient without it. Inour experience, this happens infrequently. We recom-mend that retropubic paravaginal repair be added toBurch colposuspension when necessary to provideadditional support to the mid-vagina (DeLancey levelII).47

Posterior Vaginal RepairTraditional posterior colporrhaphy involves separa-tion of the vaginal epithelium from the underlyingfibromuscular connective tissue (which includes therectovaginal septum, in between the vaginal muscu-laris and the rectovaginal adventitia), followed bymidline plication with interrupted stitches, excision ofexcess epithelium, and closure.53 As with anteriorcolporrhaphy, variations include placing graft mate-rial on top of or instead of the midline plication.Other procedures can be combined with posteriorcolporrhaphy, such as levator ani plication and perin-eorrhaphy, although the indications for these addi-tions are controversial.

Dyspareunia after posterior repair has beenblamed on levator ani plication if a band or narrowingis formed inside the vagina.54 Narrowing can alsooccur with overzealous perineorrhaphy or combina-tions of procedures that alter normal vaginal contours.For example, the vaginal configuration is altered bythe Burch procedure, where the upward displacementof the anterior vaginal tube creates a transverse ridgein the posterior vagina. A similar vaginal configura-tion may be created by other incontinence proceduresthat elevate the anterior vagina. Dyspareunia is espe-cially likely to occur when Burch is combined withposterior repair, when the altered vaginal contour andposterior transverse ridge is overlaid with the plica-tion of the posterior repair. Despite careful attentionto ensure adequate introital caliber after posteriorrepair, 38% of women after Burch and posteriorrepair had persistent dyspareunia 1 year or more aftersurgery.16

According to Richardson, isolated defects of therectovaginal “fascia” (layers that include the vaginalmuscularis, rectovaginal septum, and adventitia) oc-cur in some women with posterior vaginal prolapse.55

The site-specific repair is approached by dissectingthe vaginal epithelium from the underlying layers toexpose the defect and close it with interrupted stitchesof usually absorbable suture, followed by closing thevaginal epithelium. Initial retrospective56 and pro-spective57 uncontrolled case series reported short-term results similar to or better than posterior colpor-rhaphy. However, with longer follow-up, one serieshas reported recurrent prolapse after site-specific re-pair at higher rates than after traditional posteriorcolporrhaphy.58 No randomized clinical trials existcomparing these techniques.

We recommend reattachment of the rectovaginalconnective tissue to the perineal body in all repairswhen separation is identified. Until data demonstratesuperior or equivalent long-term outcomes with site-specific defect repairs, we recommend traditionalposterior colporrhaphy, with careful attention to pre-vent narrowing of the vagina or introitus, whenindicated to relieve symptomatic posterior vaginalprolapse. Lateral rectovaginal connective tissue isplicated in the midline using a delayed absorbablesuture, such as Vicryl or PDS, taking care not tocreate strictures in the vagina with initiation of theplication too far laterally. A finger in the rectum helpsidentify the integrity of the supportive layer formedwith plication.

In many cases, mild-to-moderate posterior vagi-nal prolapse is identified as one component of pro-lapse in women with more advanced apical or ante-rior prolapse. In those situations, clinicians andpatients must carefully weigh the risks (particularly ofdyspareunia) and benefits in deciding whether torepair otherwise asymptomatic posterior vaginal pro-lapse. Although traditional teaching has held that all“defects” should be repaired at one surgical setting,this may be the exception, where the patient is betterserved in avoiding or delaying surgery of the posteriorvagina until specific symptoms need to be addressed.In this way, many women will avoid dyspareunia forthe few women who will ultimately require a separateposterior repair.

Perineorrhaphy should be performed with anyrepair where there is separation of the perineal mus-cles. This also facilitates the natural posterior deflec-tion of the vagina in the pelvis. After dissection to freethe ends of the superficial perineal and bulbocavern-osus muscles, they are reapproximated in the midlinewithout tension. Levator ani plication is associatedwith postoperative dyspareunia, and we recommendthat this not be performed in sexually active women.


In non–sexually active women, levator ani plicationcan be performed to reinforce the repair and inten-tionally narrow the mid and lower vagina; highperineorrhaphy can be added to further close theintroitus.

Vaginal Apical RepairApical vaginal prolapse includes uterine prolapsewith or without enterocele and vaginal vault prolapse,typically with enterocele. Some cases of uterine pro-lapse present with marked elongation of the cervix aswell. In other cases, despite what appears to benormal uterine support, the elongated cervix pro-trudes to or past the hymen. This occurs particularlywhen the uterus is restricted to the abdomen, as inuterine enlargement greater than the equivalent of12–14 weeks of gestation. The standard treatment forsymptomatic uterine prolapse is hysterectomy withprocedure(s) to suspend the vaginal apex, addressenterocele when indicated, repair coexisting anteriorand posterior vaginal prolapse, and perform anti-incontinence procedures as needed. It is particularlyimportant to emphasize that, when hysterectomy isperformed for prolapse, hysterectomy alone (or hys-terectomy with colporrhaphy) is inadequate; a spe-cific vaginal vault suspension procedure must beperformed in addition to hysterectomy.

Enterocele Repair. Enterocele repair is usuallyperformed in the setting of concomitant proceduresfor prolapse, in which case the approach is based onthe combination of procedures required. Whether byvaginal, abdominal, or laparoscopic access, entero-cele repair is traditionally performed by sharply dis-secting the peritoneal sac from the rectum and blad-der. A purse-string suture can be used to close theperitoneum as high (cephalad) as possible. Whetherexcision of the peritoneum itself is necessary has notbeen determined. In addition to closing the entero-cele sac, we recommend approximation of the ante-rior to the posterior fibromuscular connective tissueof the vagina. Suspension of the vaginal apex is almostalways necessary, except in rare cases when theenterocele occurs in the presence of adequate apicalsupport.

Sacrospinous Ligament Suspension. Sacrospi-nous ligament fixation entails attachment of the vag-inal apex to the sacrospinous ligament, the tendinouscomponent of the coccygeus muscle.59 Initially de-scribed as a unilateral procedure, later series reportedbilateral fixation. Access is traditionally extraperito-neal via the posterior vagina, although variations havebeen described using the anterior vagina or evenlaparoscopic access. Although initial case series re-ported high success rates for correcting apical pro-lapse,60 subsequent reports described high rates of

anterior vaginal prolapse, attributed to the exagger-ated posterior deflection of the vaginal axis withsacrospinous ligament fixation.61 However, whetherthis is unique to sacrospinous ligament fixation orsimply represents the predilection of anterior supportto fail remains unknown. When a decision has beenmade to perform this procedure, we recommend theuse of delayed absorbable suture material such asPDS.

Iliococcygeal Vaginal Suspension. Iliococcy-geal vaginal suspension involves attachment of thevaginal apex to the iliococcygeus muscle and fascia,usually bilaterally.62 The extraperitoneal dissection tothe area of the ischial spine is approached from amidline posterior vaginal incision. Using the ischialspine as the landmark for identifying the sacrospinousligament medially and posteriorly and the iliococcy-geus fascia anteriorly and caudad, a No. 1 polydiox-anone (PDS) suture is placed and attached to thevaginal apex with a pulley stitch. We perform theprocedure bilaterally. Compared with other vaginalsuspension procedures, the iliococcygeal suspensionhas the fewest case series in the literature,62–65 but curerates appear comparable to the sacrospinous suspen-sion technique.65 We consider the iliococcygeal ap-proach to apical suspension mainly to avoid perito-neal entry or as a fall-back procedure whenuterosacral ligament suspension was planned but peri-toneal entry is not feasible. In addition, iliococcygealsuspension works well in the case of a foreshortenedvagina when a vaginal approach is planned.

Uterosacral Ligament Suspension. Originallydescribed by McCall in 1938,66 surgical variations ofthe uterosacral ligament suspension can be usedprophylactically at hysterectomy or therapeuticallyfor vaginal apical suspension.67 Once access to theposterior cul-de-sac has been attained, the uterosacralligament remnant can be found with the use of Allisclamps placed at the posterior medial aspect of theischial spine. Up to 3 sutures are placed in eachligament and incorporated into the anterior and pos-terior fibromuscular layer of the vagina as well as thevaginal epithelium (Fig. 8).67 Some surgeons approx-imate the ligaments in the midline, as described byMcCall, to close the cul-de-sac with the intention oftreating or preventing enterocele formation. We rec-ommend this in the presence of an unduly enlarged orredundant cul-de-sac. However, we usually prefer tosuspend the right and left vaginal apex to the ipsilat-eral uterosacral ligament, leaving the cul-de-sac opento avoid impinging on the rectum and adverselyaffecting bowel function. If permanent sutures areused, the knots should be tied to the peritoneal side ofthe repair. Absorbable sutures can be tied in the


vaginal lumen with the expectation that they willdissolve over time.

Comparison of Vaginal Approaches to Apical RepairIn a review by Sze and Karram42 of vaginal surgeriesfor apical prolapse, recurrent prolapse was reportedin 8–18%, with variable follow-up in mostly retro-spective case series. Until controlled trials are avail-able, clinicians should counsel patients that the vagi-nal approaches to apical suspension are probablysimilar in outcomes related to prolapse repair. Inchoosing which procedure to recommend for individ-ual patients, clinicians should consider their owntraining and experience, as well as technical aspectsand risks of complications specific to each procedure.

Sacrospinous ligament suspension may leave theanterior vagina at greater risk for subsequent failure,61

because of the pronounced posterior deviation of thevaginal axis, although the risk of recurrent anteriorvaginal prolapse seems high regardless of which vaginalsuspension procedure is used. Because the procedureis extraperitoneal, there should be little if any risk ofureteral injury; rectal injury is a rare complication ofposterior dissection. Because sutures are passedthrough the sacrospinous ligament, risks unique tothis procedure include pudendal or inferior glutealvessel injury with intraoperative hemorrhage, or sci-atic or pudendal nerve injury, manifested as severebuttocks pain (that may radiate down the back of thethigh) postoperatively. The pain may resolve sponta-neously when absorbable sutures are used, but sutureremoval may be necessary for permanent sutures.The sacrospinous ligament may be atrophied and less

surgically useful in patients of advanced age anddebility. In addition, sacrospinous ligament suspen-sion may be more difficult to teach, a factor toconsider for those involved in resident education.

The iliococcygeal suspension is a straightforwardprocedure to learn and teach. It carries virtually norisk of ureteral or small bowel injury, and in contrastto sacrospinous ligament fixation, there are no vitalstructures nearby at risk for surgical injury. In addi-tion, the iliococcygeus muscle and fascia are uni-formly present regardless of patient age, prolapsestatus, or general debility. Some surgeons are con-cerned that the iliococcygeal suspension leaves thevagina shorter than other procedures, although thishas not been described in the literature. It is possiblethat the iliococcygeal suspension has been underusedas a vaginal apical suspension procedure.

Uterosacral ligament suspension traditionallyrequires peritoneal entry, which may be challeng-ing in posthysterectomy prolapse, especially in thesetting of bowel adhesions, engendering the rareoccurrence of bowel injury. Bowel packing maydelay the return of bowel function in occasionalpatients. Uterosacral ligament suspension carries arisk of ureteral injury (usually kinking due to medialdisplacement or suture ligation that impedes urinaryflow, rather than transection) as high as 11%.68 Aslong as ureteral injury is recognized and addressedintraoperatively, most patients will not incur morbid-ity. However, if ureteral injury is not identified at theindex surgery and recognition is delayed, a secondsurgery is usually necessary and subsequent morbid-

Fig. 8. A modification of the highuterosacral vaginal suspension de-scribed by Shull, whereby singlemonofilament permanent suturesare placed through the residualuterosacral remnants cephalad toand at the same posterior level ofthe ischial spines, then secured inlocking fashion to the paravaginalconnective tissue of the anteriorand posterior vaginal cuff. Afterthe beginning of closure fromeach lateral angle, the suspensionsuture is tied to “pulley” the vagi-nal apex to a more physiologicposition.Weber. Pelvic Organ Prolapse.Obstet Gynecol 2005.


ity can be severe, at worst irretrievable loss of kidneyfunction on the affected side. Cystoscopy shouldalways be performed after the uterosacral sutures aretied to confirm ureteral patency. Some surgeonsquestion whether the uterosacral ligaments are appro-priate sources of support in women with advancedprolapse, although other surgeons maintain that theligaments can virtually always be identified as surgicallyuseful structures. No trials compare outcomes afterdifferent procedures for vaginal apical suspension.

Abdominal Apical RepairAbdominal Sacral Colpopexy. Abdominal sacralcolpopexy uses graft material attached to the anteriorand posterior vaginal apex and suspended to theanterior longitudinal ligament of the sacrum for repairof apical prolapse.69 Surgical variations are legion,including graft configurations on the vagina, the ex-tent to which the anterior and posterior vagina areattached to the graft, different graft and suture mate-rials, peritoneal closure over the graft, and oblitera-tion of the cul-de-sac for treatment or prevention ofenterocele. In case series, cure rates range from 78%to 100% for apical prolapse. When cure is defined asno postoperative prolapse, the range widens, from56% to 100%, although subsequent anterior or poste-rior vaginal prolapse has not been as consistentlyreported as apical prolapse.70

We recommend the use of 2 permanent sutures inthe anterior sacral ligament. The peritoneum overly-ing the vaginal apex is removed and polypropylenemesh, fashioned in a Y configuration, is affixed to thevaginal apex posteriorly from the rectovaginal junc-tion to the bladder reflection anteriorly. No overttension is placed on the vagina while attaching thethird arm of the mesh to the anterior sacral ligament.We reperitonealize over the mesh. In the setting of adeep cul-de-sac, we place Halban culdoplasty sutureswith No. 1 polydioxanone (PDS). We perform cystos-copy at the end of the procedure.

When abdominal sacral colpopexy is planned forapical prolapse and concomitant high rectocele ispresent, some advocate extending the graft down theposterior vagina to address this.69 Cundiff et al71

described the technique of sacral colpoperineopexyto reconstruct the normal vaginal suspensory liga-ments and “fascial sheet” that runs from the sacrum tothe perineal body. Because mesh erosion occurredfrequently when the vagina was opened (16% forvaginally placed sutures and 40% for vaginally placedmesh72), we recommend avoiding opening the vaginawhenever possible.

Complications associated with to abdominal sa-cral colpopexy fall into 3 major categories: 1) intra-operative hemorrhage, 2) laparotomy, and 3) graft

infection or erosion. Intraoperative hemorrhage thatoccurs when lacerated sacral veins retract into thesacrum can be difficult to control. The consequencescan be as severe as intraoperative death from exsan-guination. Complications due to laparotomy are usu-ally related to adhesions and small bowel obstruction.Although the risk seems highest in the immediatepostoperative period, the risk is lifelong. Syntheticgraft material holds the highest risk of infection orerosion, although these complications have been re-ported with all types of graft material. As with smallbowel obstruction, mesh erosion or infection has beenreported years after the index surgery. Althoughmesh erosion can usually be successfully treated witha relatively minor excision of the exposed mesh,occasionally the entire graft must be removed, withhigh levels of surgical morbidity.

Laparoscopic Approach to Apical ProlapseRepair. Virtually all procedures for apical prolapserepair have been approached by the laparoscopicroute, although it is sacral colpopexy that seems mostlikely to offer patient benefit, provided effectiveness isequivalent.73 The potential applicability of these pro-cedures is limited by the relatively high level oftechnical skill required for advanced laparoscopictechniques.

Comparison of Abdominal and Vaginal Approachesto Apical RepairFew randomized trials compare abdominal and vag-inal approaches for the treatment of apical prolapse(Table 2).74–77 Success rates appear to favor the ab-dominal approach to apical vaginal prolapse. Ran-domized trials are important to compare outcomes inan unbiased rigorous fashion, but the data obtainedmay not always be generalizable. In the Bensonstudy,74 the external validity is reduced because nee-dle urethropexy is no longer regarded as effectivetreatment for stress incontinence. In the trial byRoovers et al76 the 2 treatment groups were unequalas to the performance of hysterectomy. Again, use ofthe needle suspension technique for subjects withurinary incontinence predisposed to increased failure.In the trial of Maher et al,77 the colposuspension forstress incontinence in the sacrospinous group mayhave protected the anterior vaginal compartment. Inaddition, open colposuspension combined with avaginal approach for prolapse would be less general-izable today with the increased use of midurethralsling procedures. Furthermore, history of previoushysterectomy type was not equal between groups,introducing bias, and the vaginal group had more lossto follow-up.

Despite the shortcomings of uncontrolled seriesand the few randomized trials, clinicians can be


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guided by the literature and their own clinical expe-rience in offering abdominal versus vaginal surgery topatients with apical prolapse. It seems likely thatabdominal sacral colpopexy is more durable in pro-viding apical support, but at the cost of increasedcomplications, both immediate and long term. There-fore, patients for abdominal sacral colpopexy shouldbe those most likely to benefit from its durability andat lowest risk for complications or those most likely torecover from complications that might occur. Age isoften used as an important determining factor; forexample, we usually recommend abdominal sacralcolpopexy to younger women with prolapse for 2reasons. Younger women benefit more from durabil-ity, with the reduced chance they will need prolapsesurgery in the future. Younger women are also likelyto be more active and subject their prolapse repair togreater stress than older women who may be moresedentary. Women who develop prolapse requiringsurgery at a young age may be intrinsically at higherrisk for prolapse recurrence.78 Therefore, they mayhave better outcomes with abdominal sacral col-popexy that provides extrinsic apical support throughsynthetic graft material, compared with vaginal apicalrepairs that rely on the patient’s own tissues forsupport. (Vaginal colporrhaphies augmented withgrafts would not and should not be expected to haveany effect on apical support unless the graft is incor-porated into the uterosacral ligaments. No data existregarding outcomes in this clinical situation.)

We do not use an upper age limit for recom-mending abdominal sacral colpopexy. For olderwomen who are medically healthy and physicallyactive, an abdominal approach to apical repair maybe appropriate with careful counseling. Chronologicalage is not always the most important determinant ofbenefit versus risk. Health status, ie, the presence ofcomorbid conditions, is often a better predictor of riskthan age. A clinical dilemma often arises as a womanwith prolapse ages—when is the best time to intervenesurgically, if ever? Say a woman has chosen pessarymanagement for her prolapse and this has workedwell for her from ages 65 to 70. But now her cognitivefunction is declining and she may not be able toprovide ongoing care for her pessary as she has in thepast. Or she has developed hypertension, and al-though it is well controlled currently, she worries thather risk of surgery will increase with time. Perhaps herprolapse is progressing despite pessary use, and onlya cube pessary effectively relieves her symptoms now.It seems likely that there is a window of time, inchoosing between nonsurgical and surgical manage-ment of prolapse as a woman ages, that favors sur-gery. In cases such as these, we recommend vaginalapical repairs or colpocleisis, when minimizing mor-

bidity, rather than enhancing durability, is the mostimportant goal.

These are not absolute indications for the differ-ent apical procedures and every woman’s manage-ment should be individualized, based in large part onher own preferences once she has been informed ofthe choices. Ideally, surgeons would be equally skilledand experienced in both abdominal and vaginalapproaches to apical prolapse to provide care that istruly individualized, rather than emphasizing oneapproach to the exclusion of the other.

ColpocleisisReconstructive procedures may last several hours andare associated with potentially higher blood loss andincreasing morbidity with longer anesthesia. For olderpatients who do not desire vaginal function, colpoclei-sis may be an appropriate choice.79 Many variationsexist, from partial colpocleisis (where some portion ofthe vaginal epithelium is left, providing drainagetracts for cervical or other upper genital discharge) tototal colpectomy (where all the vaginal epithelium isremoved from the hymen posteriorly to within 0.5–2.0 cm of the external urethral meatus anteriorly). Ifhysterectomy is performed, blood loss is greater andoperative time is longer than procedures withouthysterectomy.80 The technique often includes a leva-tor plication and high perineorrhaphy to reinforceposterior support and reduce the genital hiatus, withthe goal of reducing the chance of recurrent prolapse.Case series have reported success rates ranging from91% to 100%, although the patient population, by itsnature of relatively short life expectancy and limitedactivity level, is probably at low risk for recurrence.We typically perform a partial LeForte-type colpoclei-sis with the use of delayed absorbable suture. Thisleaves the potential for egress of blood associated withthe procedure and cervicovaginal secretions postop-eratively. We recommend levator plication usingpermanent sutures and high perineorrhaphy to fur-ther reinforce vaginal closure.

The prevention or treatment of stress inconti-nence in the context of colpocleisis is problematic.Some surgeons treat stress incontinence with slingprocedures, although elderly patients are at high riskfor postoperative urinary retention requiring slingtakedown.81 Other surgeons minimize the risk ofretention by performing suburethral Kelly plication toprovide differential support to the urethra and thentreat persistent or recurrent postoperative stress in-continence with periurethral injection. The impact ofcolpocleisis on bowel function is unknown, as well asits overall impact on quality of life. The issue of regretafter colpocleisis has not been well studied.82 A cohortstudy is currently underway through the Pelvic Floor


Disorders Network to collect data prospectively onincontinence, other pelvic symptoms, and life impactafter colpocleisis.

Diagnosis and Treatment of Stress Incontinencewith Pelvic Organ ProlapseIn patients with stress incontinence symptoms con-firmed by stress testing, it seems straightforward torecommend anti-incontinence surgery in the settingof prolapse repair. However, as discussed previously,how to treat the finding of latent stress incontinence insymptomatically continent women with prolapse isless clear. Positive stress testing with prolapse reduc-tion is not the equivalent of confirming stress incon-tinence in a symptomatic woman. The false positiverate of such testing is unknown. Postoperative stressincontinence develops in up to one quarter of previ-ously stress-continent women who did not receive acontinence procedure with prolapse repair.82,83 How-ever, concern has been raised that “prophylactic”continence procedures in women with latent stressincontinence may represent overtreatment and resultin new voiding dysfunction, including urgency, urgeincontinence, and urinary retention.84 Nevertheless,some studies report that patients benefit when anti-incontinence procedures are added to prolapse repairto treat latent incontinence, with low rates of bothstress incontinence (8–10% at one year) and new urgeincontinence (8–16%).85–87 Tension-free vaginal tapeprocedure is more effective in preventing stress incon-tinence than suburethral plication.87

The Pelvic Floor Disorders Network is currentlyconducting a randomized trial88 for symptomaticallystress-continent women with advanced prolapse whoare undergoing abdominal sacral colpopexy, withrandomization to the addition of Burch colposuspen-sion versus no Burch. The objectives are to determinewhether a trade-off exists in reducing stress inconti-nence versus worsening voiding dysfunction, andwhether preoperative prolapse reduction testing accu-rately predicts who benefits from the Burch proce-dure. Enrollment in the trial was halted early (atapproximately 350 subjects) based on interim resultsshowing less stress incontinence in the Burch group,with no significant difference in voiding dysfunction,at 3 months after surgery. The data will be analyzed todetermine whether the results of prolapse reductiontesting (or any aspect of urodynamic testing, theresults of which were masked to the surgeons) pre-dicted outcomes. Follow-up is planned for at least 2years after surgery.

Adjunctive MaterialsThe use of adjunctive materials in prolapse surgery isan attempt to improve outcomes obtained by using

the patient’s own tissue. Surgeons, frustrated by recur-rent prolapse, actively seek means to reduce the riskof recurrence, but in their enthusiasm, they maymisjudge the risk presented by new materials thathave not been well studied in the vaginal environ-ment. Currently, the most common prolapse proce-dures using adjunctive materials are abdominal sacralcolpopexy and anterior and posterior vaginal repairs.The ideal adjunctive material should be biocompat-ible yet inert, nonallergenic and noninflammatory,noninfectious, resistant to mechanical stress or shrink-age, and conveniently available. Several reviews haveevaluated the various types of synthetic and biologicmaterials used in prolapse surgery,89–90 although theirwidespread use has leapfrogged ahead of scientificevidence of their safety and effectiveness.91 The im-pact of adjunctive materials on sexual function andlong-term outcomes is unknown. Different grafts havedifferent complication rates, depending on where andhow they are used. Unlike graft material used inabdominal sacral colpopexy, typical graft use in vag-inal repairs involves a much greater area of contactbetween the graft and the vagina after the vaginal wallhas been split by surgical dissection. It is criticallyimportant for surgeons to discuss the use of adjunctivematerials with their patients before surgery so patientsare well-informed of the unknown risks and benefitsand can participate in the decision to use such mate-rials. It cannot be assumed that graft use is automat-ically the same or better than existing procedures.The likelihood that outcomes will actually be worsemust be considered by the clinician and the patientconsidering the use of graft materials. Until we haveevidence that graft materials are beneficial, we recom-mend that their use be restricted to subjects in re-search protocols. This will ensure that evidence sup-porting or refuting their use actually becomesavailable over the next several years.

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