Pelvic Organ Prolapse

❍ At a glance

• Approximately 50% of parous women have some degree of prolapse on examination, but only 10-20% are symptomatic. POP is underreported - many women consider it a normal consequence of childbirth or ageing. Treatment is guided by symptoms, not examination findings alone.
• The first-line treatment for all symptomatic prolapse is pelvic floor muscle training (PFMT) - supervised physiotherapy. Evidence from RCTs shows significant improvement in prolapse symptoms and quality of life at 6-12 months.¹ Refer to a pelvic floor physiotherapist before considering surgical referral. At least 3-6 months of consistent practice is needed before assessing benefit.
• Vaginal pessaries are effective long-term management for women unsuitable for or not wishing surgery. Ring pessaries suit most cystocele and uterine prolapse. Most women self-manage after initial fitting; 3-6 monthly removal and cleaning is required.
• Mesh for vaginal repair has been restricted in NZ following TGA and Medsafe review. Non-mesh native tissue repairs are the preferred approach for vaginal access surgery.

❍ Presentation, assessment, and conservative management

Presentation: dragging sensation or feeling of something coming down, typically worse at end of day or after prolonged standing. Women may see or feel a lump at the vaginal opening. Anterior prolapse (cystocele): stress urinary incontinence, urinary frequency, incomplete bladder emptying, need to reduce the prolapse to void. Posterior prolapse (rectocele): incomplete bowel emptying, straining, splinting (applying digital pressure to perineum to defecate). Uterine or vault prolapse: pelvic pressure and low back pain. Symptoms fluctuate - worse with standing, coughing, straining, and better lying down.

Assessment: Sims' speculum in left lateral position or supine with Valsalva. Grading: Grade I - more than 1 cm above introitus; Grade II - to within 1 cm of introitus; Grade III - beyond introitus; Grade IV - complete eversion. Include urinalysis, post-void residual if incomplete emptying is suspected, and urodynamic assessment if mixed incontinence is prominent or surgical planning is underway.

Conservative management: lifestyle modification (weight reduction reduces intra-abdominal pressure; treat chronic cough; avoid constipation and heavy lifting). PFMT: supervised pelvic floor physiotherapy is first-line - refer to a physiotherapist specialising in pelvic floor before surgical referral.¹ In NZ, ACC covers physiotherapy for obstetric injury. Topical vaginal oestrogen in postmenopausal women improves vaginal tissue quality and response to pessary use (does not directly treat prolapse). Vaginal pessaries: silicone devices providing mechanical support - ring pessaries for anterior/uterine prolapse, shelf or Gelhorn for severe posterior prolapse. Fitting by experienced clinician; 3-6 monthly review and cleaning.

❍ Surgical options and referral criteria

Surgical management is indicated for symptomatic prolapse that has not responded to or is declined by conservative management, in women who are fit and wish surgery. Options include anterior and posterior colporrhaphy (native tissue repair), sacrospinous ligament fixation (vault prolapse), and laparoscopic sacrocolpopexy (mesh-based, superior durability). Mesh for vaginal access surgery has been restricted in NZ following TGA and Medsafe review - non-mesh native tissue repairs are preferred.

Refer to urogynaecology or gynaecology for: Grade III-IV prolapse; prolapse significantly impairing quality of life after conservative treatment; prolapse causing urinary retention or renal impairment; patient wishing surgical assessment; or complex mixed symptoms requiring urodynamic assessment. Continence nurse specialist referral is appropriate for pessary fitting support and pelvic floor physiotherapy coordination.