Pelvic Organ Prolapse (POP)

What is Pelvic Organ Prolapse (POP) in Women?

Pelvic organ prolapse (POP) is a condition that commonly affects women, particularly those over the age of 50. It involves the descent of pelvic organs, such as the bladder, rectum, or uterus, into or outside the vaginal canal. In some cases, these organs may protrude to the extent that a bulge is felt or seen outside the vagina.

POP occurs when the supportive structures of the pelvis—such as muscles, connective tissue, and fascia—become weakened or damaged. Normally, these structures hold the pelvic organs securely in place. However, when this support system fails, the organs can shift downward due to gravity. This condition is more frequently seen in women who have undergone vaginal childbirth, have had multiple deliveries, or are older in age.

What Causes Pelvic Organ Prolapse?

The most common cause of pelvic organ prolapse is the weakening of the pelvic floor muscles and connective tissues. This weakening is often the result of stress placed on the pelvic region during childbirth.

Prolonged or difficult vaginal deliveries, delivering a large baby, or using instruments like vacuum or forceps can all damage the pelvic support structures. With aging, declining estrogen levels can also reduce tissue elasticity, further contributing to prolapse.

Other contributing factors include chronic constipation, obesity, heavy lifting, persistent coughing, and genetic predisposition. Additionally, some women may experience pelvic organ prolapse following a hysterectomy (removal of the uterus).

What Are the Symptoms of Pelvic Organ Prolapse (POP)?

In pelvic organ prolapse, the most noticeable symptom is often a bulging mass protruding from the vagina, which can be alarming to the patient. If the protruding organ is the bladder, this is referred to as a cystocele (see Figure 1). It may cause incomplete bladder emptying, requiring the patient to press on the bulge manually to urinate.

Because the bladder does not fully empty, symptoms such as frequent urination, urgency, and recurrent urinary tract infections can occur.

If the protruding structure is the rectum, it may lead to bowel symptoms such as constipation and the need to apply manual pressure to evacuate the bowels.

In some cases, the uterus itself protrudes outside the vaginal opening, a condition known as apical prolapse. If the uterus has previously been surgically removed, the vaginal wall may evert and protrude instead.

Often, all three pelvic compartments may be involved to varying degrees. Patients may also experience stress urinary incontinence, especially during activities that increase intra-abdominal pressure, such as coughing. In some cases, this type of incontinence becomes noticeable only after the prolapsed organ is pushed back inside—a condition called occult stress incontinence. Sexual dysfunction and lower back pain are also commonly reported by patients.

Symptoms of Pelvic Organ Prolapse

Individuals with pelvic organ prolapse may experience a variety of symptoms. One of the most common complaints is a sensation of pressure or fullness in the vaginal area.

Some patients report feeling a bulge protruding from the vaginal opening. Urinary symptoms such as incontinence, difficulty urinating, frequent urination, or incomplete bladder emptying are also common. If the rectum is involved, symptoms may include difficulty with bowel movements, a sensation of incomplete evacuation, or fecal incontinence. Pain during sexual intercourse (dyspareunia) is also frequently reported. Symptoms often worsen throughout the day, especially after prolonged standing or physical activity.

Who Is at Risk for Pelvic Organ Prolapse?

Patients at risk for pelvic organ prolapse are generally those exposed to factors that weaken the pelvic floor muscles or cause laxity in the connective tissue. Women who have had multiple vaginal deliveries, especially those with a history of difficult or instrumental births, are at the highest risk. As women age, the support structures of the pelvic floor weaken, so the incidence increases in older women. Menopause is also a significant risk factor due to decreased estrogen levels. Additionally, conditions that increase intra-abdominal pressure such as chronic constipation, heavy lifting, chronic cough, and obesity raise the risk of prolapse. Individuals with a genetic predisposition to weak connective tissue may experience prolapse earlier and more severely. Furthermore, previous pelvic surgeries, smoking, and certain neurological diseases can negatively affect the pelvic support system and increase the risk of organ prolapse.

How Is Pelvic Organ Prolapse Treated?

When starting treatment for pelvic organ prolapse, it is essential to understand the patient’s expectations regarding sexual activity (desire for coitus) and fertility. Reducing risk factors (obesity, smoking, chronic cough, constipation, heavy lifting) and performing pelvic floor exercises can prevent progression of the prolapse.

For patients, especially elderly ones, who do not want surgery, pessaries (rings or supports) can be an option to prevent prolapse; however, long-term patient compliance tends to be low. If the patient has advanced prolapse, surgery is usually the only solution. Anterior repair is done for bladder prolapse, while posterior repair is performed for rectal prolapse. Although synthetic meshes have been used to achieve more durable results during these repairs, due to complications, their use has become less common. Repairs are generally performed using the patient’s own tissues.

In apical prolapse, meaning uterine prolapse, there are two main approaches: vaginal hysterectomy or sacrocolpopexy. The uterus protrudes because the pelvic floor is lax; therefore, surgical removal of the uterus is not always necessary.

In sacrocolpopexy, the uterus is suspended with mesh attached to the sacral promontory (part of the sacrum bone) (see Figure 2).

If the uterus has already been removed, the vaginal cuff is fixed to the bone to prevent prolapse. These surgeries are very successful, with long-term success rates exceeding 90%.

For very elderly patients with no sexual activity expectations and who have anesthesia risks, the vagina can be closed using a procedure called Le Fort colpocleisis. Patient satisfaction rates are very high in selected groups undergoing this operation.

Pelvic Organ Prolapse Surgery

Treatment of pelvic organ prolapse includes both surgical and non-surgical options, but surgery is generally required for advanced prolapse. The type of surgery depends on the prolapsed organ, patient’s age, overall health, and childbearing plans.

Common surgical approaches include prolapse repair through vaginal or laparoscopic methods. Procedures like sacrocolpopexy use synthetic mesh to support the organs. For patients wishing to preserve the uterus, uterus-sparing techniques such as uterosacral ligament suspension are available.

Recovery After Pelvic Organ Prolapse Surgery

Recovery time after pelvic organ prolapse surgery varies between individuals but usually allows a return to daily activities within a few weeks. However, patients are advised to avoid heavy lifting and excessive physical exertion during recovery.