Literature review

Post Reproductive Health

2020, Vol. 26(2) 79–85
Pelvic organ prolapse management ! The Author(s) 2020
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DOI: 10.1177/2053369120937594
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K Fleischer and G Thiagamoorthy

Abstract
Pelvic organ prolapse describes the loss of support and subsequent descent of pelvic organs into the vagina. It is
common, affecting up to 50% of parous women, and can be accompanied by a number of burdening symptoms.
Prolapse has been thrown into the spotlight secondary to mesh-related complications. There are a number of effective
treatment options to consider when managing pelvic organ prolapse and most do not require mesh. Patients’ choice,
comorbidities and likelihood of treatment success should be considered when making decisions about their care. Vaginal
mesh surgery is currently on hold in the UK and even prior to this there has been a reduction both in the number of all
prolapse surgeries and the number of women seeking surgery to manage their symptoms. This article reviews the
current evidence for the management of pelvic organ prolapse, providing an update on the current state of mesh in
prolapse surgery and summarises the key evidence points derived from the literature.

Keywords
Mesh, pelvic organ prolapse, prolapse, prolapse management

Introduction
quality of life, comorbidities, previous treatment and
Pelvic organ prolapse (POP) is defined by the loss of likelihood of ‘treatment success’.5
support and subsequent prolapse of viscera (including
the bladder, rectum, colon, uterus and vaginal vault)
situated within the pelvis into the vagina.1 The overall Conservative
prevalence of POP from epidemiological studies varies
widely from 3% to 50% depending on age and means Observation
of identification.2 For example, there was a higher Observation is a reasonable treatment option to con-
prevalence in studies that used pelvic examination sider, especially if symptoms described do not have a
(30–50%) instead of self-reporting to identify POP significant impact on quality of life.1 Between 19% and
(3–10%).1 48% of stage 1 or 2 prolapse spontaneously resolved
This review article focuses on the current suggested without any intervention over three to eight years.6
management options as well as provides an update on Another study found that with mild prolapse
the use of mesh as an option for POP. (Stage 1), regression rates for cystocoele, rectocoele
This article uses the pelvic organ prolapse– and uterine prolapse were 24%, 22% and 48%, how-
quantification (POP-Q) system. The stages are defined ever, remission rates in participants presenting with
in Table 1. stage 2/3 POP were 9%, 3% and 0% respectively.7
Overall, when considering observation as a manage-
Management of POP ment option for POP, it can be suitable for managing
mild POP especially where the risks of more invasive
Management should be individualised and guided by
what the patient wishes to achieve.3 Since severity and
degree of symptoms can vary widely, it may be difficult Ashford and St Peter’s NHS Foundation Trust, London, UK
to determine and define ‘treatment success’.2,4 It is the
Corresponding author:
responsibility of the clinician to offer the most appro- G Thiagamoorthy, King’s College Hospital, Golden Jubilee Wing, Suite 8,
priate management options for the patient taking into 3rd Floor, London SE5 9RS, UK.
account the severity of symptoms, the impact on her Email: gans.t@nhs.net
80 Post Reproductive Health 26(2)

Table 1. Pelvic organ prolapse–quantification (POP-Q) classifi- practice for many surgeons and more studies are
cation system. required to investigate this.
Stage Description

0 No demonstrable prolapse
Pessary
1 The most distal portion of the prolapse is greater Pessaries for prolapse are relatively commonplace but
than 1 cm above the level of the hymen data to support their use are limited.1 There is a role for
2 The most distal portion of the prolapse is less pessary use in women complaining of symptomatic
than 1cm proximal or distal to the level of the
prolapse especially if they are not suitable candidates
hymenal plane
for surgery or do not wish to have a surgical interven-
3 The most distal portion of the prolapse is greater
than 1 cm from the hymen but no farther than tion.9 There are many different types of pessaries avail-
2 cm less than the total vaginal length able. The most commonly used being ring pessaries,
4 Vaginal eversion is essentially complete which are frequently the ‘first-line’ pessary and often
changed every six months at a GP practice. Other often
Adapted from Bump et al. (1996).8
used pessaries include gelhorn, shelf and cube pessaries.
Complications of pessary treatment, including localised
treatment might outweigh the benefits. Ideally conser- devascularisation, can be mitigated with concomitant
vative management with lifestyle modification and topical estrogens and appropriately timed replacement
pelvic floor muscle training is preferred. – serious adverse complications are rare.14 The PESSRI
study highlighted that ring pessaries may be more effec-
Lifestyle modification tive in treating less severe degrees of prolapse and gel-
horn pessaries at more severe grades.15
Evidence for lifestyle modification is mixed and there
A study comparing surgery and pessaries as primary
are limited studies looking at specific interventions.1 treatment for POP found surgery to be more effective
Anecdotal evidence supports adapting one’s lifestyle in alleviating POP symptoms in women with Stage 2 or
such as maintaining a healthy weight/body mass higher POP.16
index (BMI) and stopping smoking.9 It is considered
that activities which increase intra-abdominal straining
such as high-impact training, carrying heavy weights, Medical
for example at work or even at home such as gardening Estrogens may be of benefit in treating POP but data
will exert pressure on the weak pelvic floor and stretch are limited. In postmenopausal women, there is a
the connective tissue worsening one’s prolapse. reduction in circulating estrogen and an increase in
estrogen receptors in the uterosacral ligament.17
Topical estrogens may also be useful in preventing
Physiotherapy – Pelvic floor muscle post-POP surgery cystitis but more research is required
training to investigate if they can improve POP stage.18 A sys-
tematic review of oral raloxifene identified that it does
This is a detailed programme of exercises designed to
not increase pelvic floor relaxation in menopausal
improve the strength and function of the pelvic floor.10
women, and therefore, can potentially decrease the
Women with prolapse (stages 1–3) randomised to
requirement for surgery in this population.19 This,
supervised pelvic floor muscle training (PFMT) in a
however, should be balanced against the increased
study comparing supervised PFMT versus lifestyle
risk of venous thromboembolism as participants
advice, at two years, were less likely to develop symp-
taking raloxifene were 1.54 and 1.91 times more likely
toms and less likely to have sought treatment for to develop a DVT or PE respectively.20
POP.11 Multiple studies used in systematic reviews
have underlined the benefits of PFMT in treating the
symptoms of POP12 and as such this is first line in Surgical
NICE guidance.10 Surgical management remains a common treatment
There may be a role in negative pressure exercises, option for POP and can broadly be divided into
where the intention is to reduce intra-abdominal pres- native tissue repair and mesh repair (biological/absorb-
sure, in improving the effectiveness of PFMT.1 able/non-absorbable). It can be difficult to assess ‘suc-
PFMT has not been found to be useful in the pre- cessful treatment’,4 most studies will assess for
vention of POP in immediately postpartum women.13 anatomical success (reduction to POP-Q stage 0–1)
The evidence to support PFMT as an adjunct to and review symptoms through validated patient
POP surgery is lacking despite this being routine reported outcome measures.
Fleischer and Thiagamoorthy 81

Clinicians should ensure patients are fully aware of potentially healthy uterus.28 Vaginal hysterectomy
success, recurrence and complication rates when decid- alone does not address this issue and recurrent prolapse
ing on suitable treatment options (5). The 30% re- rates are between 10% and 40%.29,30 Current review of
operation reoperation rate for POP initially quoted in all evidence suggests that if there is no indication for
1997 has been updated to closer to 15–17%.21,22 uterine preservation, vaginal hysterectomy with simul-
taneous apical fixation is the most appropriate treat-
ment of uterovaginal prolapse.24
Anterior and posterior repairs
Uterine preservation may be a consideration for
Vaginal surgery example, if there is an intention to preserve fertility.
Vaginal hysteropexy performed by securing the cervix
Colporrhaphy is the most commonly performed surgi- to the sacrospinous ligaments with sutures or with
cal treatment for POP and can be use in the treatment mesh,9 has a success rate considered ‘non-inferior to
of anterior/posterior compartment prolapse. It is a vaginal hysterectomy’.31 However, with increased
native tissue repair involving a midline incision into rates of recurrent prolapse and 21% mesh exposure
the anterior/posterior vaginal wall, with plication of rates the procedure is less preferred.9,32
underlying fascia and subsequent reduction of the pro-
lapse.23 A ‘site-specific repair’, where localised tissue Abdominal surgery. Abdominal hysteropexy can be per-
defects are closed individually with sutures, can also formed by securing the uterus to a fixation point within
be considered.24 the pelvis. Most commonly the cervix is fixed to the
When performing a posterior repair, a transvaginal anterior longitudinal ligament of the sacrum via a
incision, is superior to a transanal one.25 Posterior mesh, a sacrohysteropexy. Laparoscopic sacrohystero-
repairs may include perineorrhaphy, reattachment of pexy has similar cure rates and patient satisfaction at
the pelvic floor to the rectovaginal septum if a perineal one-year to vaginal hysteropexy.33
defect is noted.9
Colporrhaphy could include vaginal paravaginal Vaginal vault prolapse
repair (VPVR) simultaneously depending location
Vaginal surgery. Vaginal vault prolapse can occur follow-
and degree of the abnormality. Studies investigating
ing hysterectomy. Uterosacral ligament suspension
VPVR have shown comparable rates of success but (ULS) and sacrospinous ligament fixation (SSLF) are
more recent studies have identified increased rates of native tissue repairs used for apical prolapse and have
significant complications without improved outcomes.1 comparable outcomes, surgical success rate (64.5% vs.
63.1%) and adverse event rates at two years post inter-
Abdominal surgery vention.34 Vaginal sacrocolpopexy with mesh has been
An abdominal approach either open or laparoscopi- considered for the treatment of apical prolapse.
cally for the treatment of anterior compartment pro- A Cochrane systematic review of vaginal surgery for
lapse secondary to a lateral wall defect has been shown apical prolapse found there was no significant benefit
to have good rates of anatomical success.1 However, between native tissue and mesh repair and those with
due to increased operating time, rates of complication mesh repair were at high risk of complications includ-
and morbidity compared to an anterior colporrhaphy it ing mesh exposure 18%.33
is less commonly undertaken.
Abdominal surgery. Multiple studies have shown sacro-
colpopexy, where the vaginal apex is secured to the
Apical prolapse sacral promontory typically with synthetic mesh as
safe and effective35 with success rates between 78%
Uterine prolapse
and 100%.32 Alternatives to synthetic mesh have been
Vaginal surgery. A significant proportion of women with studied but the data are inconclusive. Data suggest por-
anterior compartment prolapse will also have a degree cine dermal xenograft was comparable to synthetic
of apical descent. Identification and concomitant repair mesh36 whilst cadaveric fascia lata was inferior.37
of apical prolapse during anterior/posterior compart- Long-term outcomes for sacrocolpopexy compared
ment prolapse is recommended and can significantly to native tissue vaginal apex (SSLF/ULS) repair
reduce the rates of POP recurrence and subsequent showed a significantly higher anatomical success rate
POP surgery.26 and a lower risk of POP recurrence but a higher pro-
The appropriateness of hysterectomy in uterovagi- portion of complications (10.5% mesh related).35 ULS,
nal prolapse has been debated27 as the underlying path- via a vaginal (described above), open or laparoscopic
ophysiology is related to connective tissue rather than a approach, can be considered as a treatment for vault
82 Post Reproductive Health 26(2)

prolapse. Following an open procedure, recurrence Table 2. Summary of mesh/graft materials used in gynaecolog-
rates range between 5% and 12%.38 There is a paucity ical surgery.
of data specifically looking at laparoscopic ULS, how- Device Example
ever, the vault prolapse recurrence rates are between
0% and 10%.9 Biological graft
Minimally invasive procedures have been shown to Autograft Rectus sheath, fascia lata
be superior to open procedures with improved blood Allograft Cadaveric fascia specimen
Xenograft Acellular porcine/bovine collagen
loss and length of hospital stay.9
Synthetic mesh
Absorbable Polyglactin
Obliterative surgery Non-absorbable Polypropylene

Colpocleisis procedures close the vaginal introitus, sup- Adapted from Campbell et al. (2018).43
port the pelvic organs and thus relieve POP symptoms
with subjective cure rates as high as 99%.39 With a number of different products became widely available
relatively low complication rate, ease of conducting through the ‘FDA 510(k)’ clearance based on similar-
under regional local or regional anaesthesia and ities to already available products. Usage increased
shorter operative time, colpocleisis can be considered rapidly; in 2010, a third of all POP surgeries in the
in women who have any form of POP and wish to USA used mesh.44
undergo surgery but no longer require to be sexually Graft/mesh devices are summarised in Table 2.
active and/or have other comorbidities.
Partial colpocleisis, initially described by Le Fort
Current evidence against the use of
and typically preserves the uterus/cervix, involves dis-
section of the vaginal epithelium, suturing of the ante- vaginal biological grafts and mesh devices
rior/posterior walls whilst preserving lateral channels A Cochrane systematic review in 2016, compared 37
for the drainage of cervical secretions – perineorrhaphy RCTs and concluded that, on balance, vaginal mesh
is typically performed simultaneously. and biological graft repairs offered no significant ben-
Complete colpocleisis involves a similar technique, efit over native tissue repair. Women undergoing vag-
however, following reduction of the prolapse via purse inal mesh repairs suffered increased rates of intra and
string sutures into the vaginal muscularis, the vaginal postoperative morbidity with the overall mesh expo-
epithelium completely closed at the level of the sure rate was 12%.45 These conclusions were seconded
introitus.39 by further Cochrane reviews of anterior/posterior pro-
Considerations should be made for potential com- lapse surgery25,45 and an apical prolapse meta-analysis,
plications following colpocleisis including pyometra where the mesh exposure rate was 18%.32 Cost analysis
and de-novo urinary incontinence.39 Assessment to also found that vaginal mesh repair was not cost-
rule out the presence of gynaecological cancers effective compared to native tissue repair.47 Data
should be made prior to performing the procedure regarding absorbable mesh and biological graft repairs
but routine concomitant hysterectomy is not recom- were insufficient to draw conclusions. With this back-
mended due to increased rates of morbidity.40 ground in mind, the current NICE guidance recom-
mends native tissue colporrhaphy as the first-line
surgical treatment for anterior/posterior prolapse.10
History of biological grafts and mesh
devices in POP surgery
The current state and future of mesh
Following concerns of high surgical failure rates devi-
ces to reduce this were sought. Based upon the success devices in POP surgery
of abdominal hernia meshes vaginal meshes were The UK Government’s current period of ‘high vigi-
investigated.41 lance restriction’ on the use of mesh products for the
Most non-absorbable synthetic mesh used in gynae- treatment of POP and stress urinary incontinence
cological surgery is Type 1 (completely macroporous (SUI)48 states the use of mesh for research purposes
and monofilametous; all pore sizes greater than and abdominal mesh for POP is still acceptable. Even
75 lm) as this is thought to reduce rates of infection prior to these recent restrictions placed on the use of
and allows better incorporation into surrounding tissue vaginal mesh, there had been a reduction in the pro-
by allowing infiltration of macrophages, blood vessels, portion of mesh procedures being performed. The pro-
fibroblasts and collagen.42 Mesh products were widely portion of mesh repairs for anterior prolapse fell from
adopted after initial positive results to suggest their 11% to 1% and for posterior prolapse fell from 12 to
improved efficacy over native tissue repair1 and a 3% between 2011 and 2016.49 There has also been a
Fleischer and Thiagamoorthy 83

Table 3. Summary of key evidence points.

Summary of evidence
PFMT should be considered as first line treatment for symptomatic POP. More research is required to determine if it can actually
reverse POP.
There is a paucity of data to make recommendations on medical treatment for POP.
Native tissue repair is the recommended primary surgery for anterior/compartment prolapse.
Utilising abdominal mesh appears to be safe, however, the routine use of vaginal mesh is not recommended.
Uterine preservation should be considered for women with apical prolapse where hysterectomy is not indicated but balanced
against whether the same result could be achieved with pessary devices.
More research is required to make recommendations on comparisons between different modes of uterine preservation surgery as
well as uterine preservation against hysterectomy with apical fixation.
PFMT: pelvic floor muscle training; POP: pelvic organ prolapse.

32% decline in the overall number of prolapse and uri- Funding

nary continence surgeries performed.50 As such, it is The author(s) received no financial support for the research,
possible a larger proportion of women are not seeking authorship, and/or publication of this article.
treatment for their urogynaecological symptoms or are
persevering with conservative management alone. This Ethical approval
may also be related to clinicians changing their practice N/A.
in response to new research but also to mesh-related
complications being a high profile medical issue. Guarantor
There needs to be further research in POP surgery to GT.
identify best techniques to not require other grafts/
meshes to augment POP repair and where materials Contributorship
maybe required, innovation is required to identify KF and GT researched literature and conceived the review
potential materials which reduce adverse outcomes article. KF wrote the first draft of the manuscript. Both
and improve host response.51 authors reviewed, edited and approved the final edit of the
article prior to submission.

Conclusion ORCID iD
POP is common and with an ageing population it is K Fleischer https://orcid.org/0000-0002-8865-5356
likely that the burden of disease will increase further.
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