Treatment Options for Pelvic Organ Prolapse

Solutions to Help You Feel Like Yourself Again

Pelvic organ prolapse (POP) is a common condition caused by weakening of the pelvic floor muscles and connective tissue, leading to the descent of pelvic organs. Pressure, bulging, incontinence, and pain are common symptoms. Management of POP includes pelvic floor physical therapy, pessary use, and, in more advanced cases, surgical options such as reconstructive or obliterative procedures.

Pelvic organ prolapse (POP) is a condition that occurs when the muscles and connective tissue that support the pelvic organs can no longer hold them in place. If the pelvic floor is weak, the vagina, uterus, bladder, urethra, or rectum may slip down.

There are several types of prolapse depending on the organ involved:

  • Cystocele – the bladder drops into the vagina
  • Enterocele – the small intestine bulges into the vagina
  • Rectocele – the rectum bulges into the vagina
  • Uterine prolapse – the uterus drops into the vagina
  • Vaginal vault prolapse – the top of the vagina loses support and drops

Pregnancy and vaginal childbirth are typically the main causes of POP. Other contributing factors include menopause, aging, repeated heavy lifting, being overweight, chronic coughing, and straining during bowel movements.

Symptoms sometimes come on gradually, and can include:

  • a feeling of pressure or fullness
  • a bulge in the vagina and/or organs protruding from the vagina
  • urinary leakage or stress incontinence
  • difficulty emptying the bladder
  • bowel movement problems
  • lower back pain
  • trouble inserting tampons
  • pain

Regularly doing pelvic floor exercises or using vaginal pessaries can improve POP problems and support the organs in the pelvis. Many women find that doing pelvic floor exercises or using a vaginal pessary is enough to improve the symptoms. However, their effects are limited if the organs have already slipped down too far. If that’s the case, surgery may be considered.

Pelvic PT

Pelvic floor exercises (aka., Kegels) are designed to strengthen the muscles in the lower pelvis. Learning to contract and relax the pelvic floor muscles in a controlled way with physical therapy (PT) is the most effective way to go about it. Physical therapists provide guidance on performing the exercises correctly, after which women can continue them independently at home. Doing pelvic floor exercises carelessly or incompletely can actually exacerbate symptoms. Once patients understand proper technique, at-home sessions typically last a few minutes and are repeated one to three times per day.

When done effectively and regularly, pelvic floor exercises can improve symptoms in cases of mild to moderate prolapse and may prevent further descent of the organs. They also tend to be most effective when the prolapsed organs are located toward the front of the pelvis.

The benefits of pelvic PT appear within a few weeks of consistent practice for most patients with mild symptoms, though exercises may not fully reverse prolapse if the organs have already descended significantly. Performing the exercises properly shouldn’t cause side effects, but incorrect technique can lead to tension or discomfort.

Pessaries

Vaginal pessaries are removable soft silicone or rubber devices that are inserted into the vagina and pushed up to the cervix to help hold the uterus, bladder, urethra, and rectum in their normal positions, reducing symptoms of prolapse and stress incontinence. They are often considered when women want to avoid or delay surgery or when pelvic floor exercises alone do not provide enough relief, though they do not correct the underlying weakness of the pelvic floor muscles. Some women also choose pessaries if they have medical problems that make surgery too risky.

A pessary is a first-line nonsurgical option for supporting the pelvic organs. Ring pessaries are used for mild to moderate prolapse and stress incontinence, while Gellhorn pessaries, which are disk-shaped with a central knob, are used for more advanced prolapse. Other types include Shaatz, Gehrung, donut, and cube pessaries, with each providing slightly different support.

Fitting a pessary is done in-office with a physician, who performs a pelvic exam to evaluate vaginal anatomy and prolapse severity. The appropriate type and size is determined, inserted, and tested to make sure it stays in place during movement, coughing, and urination. Patients might try several pessaries before finding one that works. Doctors may prescribe pessaries that women can insert, remove, and clean themselves every day. Other types of pessaries can stay in the vagina for weeks or months, but then have to be changed at the doctor’s office.

Pessaries do require ongoing care, including regular cleaning and follow-up visits to look for signs of complications; they have potential to cause irritation or pressure sores if not positioned correctly, and regular check-ins will help prevent damaged skin or infections. After menopause, hormone creams are often recommended for added protection of the vaginal lining. Signs of issues include pain, discomfort, pink or bloody discharge, or foul-smelling discharge, which may indicate infection or improper fit.

Pessaries generally have no negative effects on your sex life, and can even have a positive effect by reducing prolapse-related problems such as pain during sex and feelings of pressure. Some types must be removed before sexual activity, while others allow intercourse without removal.

Pessaries are generally inexpensive and safe to use. Most women who use a pessary get by with it so well that they use it for several years.

Surgery

Surgery is considered when POP symptoms are severe and when nonsurgical treatments are not effective. Surgery aims to restore the pelvic organs to a more normal position and reduce symptoms of pressure, urinary issues, or bowel dysfunction.

There are two main types of surgery for pelvic organ prolapse: reconstructive and obliterative.

Reconstructive procedures vary depending on which organs are affected. For vaginal prolapse, anterior and posterior colporrhaphy are commonly performed to fix defects in the wall of the vagina. Anterior colporrhaphy repairs the connective tissue between the bladder and vagina to lift the bladder back into place (cystocele), while posterior colporrhaphy strengthens the tissue between the rectum and vagina to correct rectocele (the rectum bulging into the vagina).

For uterine prolapse, procedures such as sacrohysteropexy (mesh connects cervix to sacrum to lift uterus), sacrospinous fixation (suspends vaginal apex to the sacrospinous ligament to treat vaginal vault or uterine prolapse), and pectopexy (for more complex pelvic anatomy, attaches the vaginal apex or cervix to the iliopectineal ligaments with mesh) are used to lift and support the uterus. Sacrocolpopexy may be decided upon to treat vaginal vault prolapse and enterocele by attaching surgical mesh between the walls of the vagina and the sacrum. In some cases, a hysterectomy (removal of the uterus) may be performed.

Frail and older women who cannot tolerate the duration of restorative surgery may be better candidates for obliterative surgery. Obliterative surgery narrows or closes off the vagina to provide support for prolapsed organs. It’s important for patients to understand that this particular procedure either partially or completely eliminates the vaginal canal and that vaginal sex is not possible afterward. In women over 70, this procedure has been shown to not only be highly effective but also comes with less surgical risk.1 Reconstructive surgery is more commonly performed in younger women and those who still plan to have vaginal sex, and focuses on restoring the organs to their original position while preserving vaginal function.

The materials used in POP surgeries are either mesh or native tissue repair (NTR), and implants are used in some repairs. Mesh can improve structural support but lead to additional surgery. NTR avoids complications associated with synthetic mesh but may not be appropriate for individuals at risk of prolapse recurrence.2 Because each option depends on surgical choice as well as patient health history and future reproductive plans, use of either is carefully considered on a case-by-case basis.

Female slings are also an option when stress urinary incontinence is a manifestation of pelvic organ prolapse. These procedures support the urethra to help prevent urine leakage and are often performed alongside prolapse repair when both conditions are present.

Depending on the complexity of the surgery, procedures might be performed through the vagina, through small incisions in the abdomen (laparoscopy), or through a larger abdominal incision. In some cases, robotic assistance is used. The approach is based on the type of prolapse, the procedure being performed, and patient-specific factors. These operations are usually done under general anesthesia, and some patients may stay in the hospital for several days following the procedure.

Recovery times vary, but most patients need several weeks of rest before returning to normal activities. Women are advised to avoid heavy lifting, strenuous exercise, sexual intercourse, and tasks that increase abdominal pressure for the first 6 to 8 weeks. Adequate fiber and fluid intake is also recommended to encourage softer bowel movements during the healing process, as straining can affect the surgical site. Pelvic floor exercises are not recommended right away, but can be resumed once cleared by the surgical team.

When considering surgery, factors such as age, overall health, severity of symptoms, and future pregnancy plans are important. For individuals who plan to have children, surgery is delayed when possible, as pregnancy can increase the risk of recurrence. Decisions about surgery should be made in consultation with a healthcare provider, with a clear understanding of the risks, benefits, and expected outcomes.

In some cases, approaches may be combined. For example, using pelvic floor therapy alongside a pessary or continuing pelvic exercises after surgery to help support long-term outcomes. If you are experiencing symptoms such as urinary leakage, difficulty emptying your bladder, pelvic pressure, or other urologic concerns, evaluation by a specialist can help determine the most appropriate treatment plan.

The urologists at Georgia Urology provide comprehensive care for conditions including pelvic organ prolapse, urinary incontinence, and bladder dysfunction, and can guide you through both nonsurgical and surgical options based on your specific needs.

References:

  1. Jeon M. J. (2019). Surgical decision making for symptomatic pelvic organ prolapse: evidence-based approach. Obstetrics & gynecology science, 62(5), 307–312. https://doi.org/10.5468/ogs.2019.62.5.307.
  2. Sokol, E. R., Tu, L. M., Thomas, S. L., Erickson, T. B., & Roovers, J.-P. W. R. (2024). Transvaginal Mesh Versus Native Tissue Repair for Anterior and Apical Pelvic Organ Prolapse. Journal of Obstetrics and Gynaecology Canada, 46(11), 102658. https://doi.org/10.1016/j.jogc.2024.102658.
Find Atlanta’s Top Urologists