Practice Bulletin No. 176 Summary: Pelvic Organ Prolapse

Abstract

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (1). Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70–79 years (2). Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50% (3). The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

Clinical Management Questions

• What is the recommended initial evaluation for a woman with suspected pelvic organ prolapse?
• Is additional testing beyond history and physical examination needed to evaluate women with pelvic organ prolapse?
• Is the pelvic organ prolapse quantification examination necessary before treatment of pelvic organ prolapse?
• Are effective nonsurgical treatments available for women with pelvic organ prolapse?
• When is surgery indicated for the management of pelvic organ prolapse, and what are the primary approaches?
• Are vaginal surgical approaches effective for the management of pelvic organ prolapse?
• When is abdominal sacrocolpopexy indicated for the management of pelvic organ prolapse?
• Do patients benefit from a minimally invasive approach to pelvic organ prolapse surgery?
• Is posterior vaginal wall prolapse repair more effective with a transanal or transvaginal incision?
• Are surgical approaches available to treat pelvic organ prolapse in women with medical comorbidities?
• What can be recommended regarding currently available synthetic mesh and biologic graft materials for use in vaginal pelvic organ prolapse surgery?
• Is special training required to perform pelvic organ prolapse procedures that use mesh or biologic grafts?
• Is it necessary to perform intraoperative cystoscopy during pelvic organ prolapse surgery?
• Are there effective pelvic organ prolapse surgical treatment methods available for women who prefer to avoid hysterectomy?
• Can the occurrence of stress urinary incontinence after surgery for pelvic organ prolapse be anticipated and avoided?
• What are the complications of pelvic organ prolapse surgery, and how are they managed?
• How should recurrent pelvic organ prolapse be managed?

Summary of Recommendations and Conclusions

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

• Uterosacral and sacrospinous ligament suspension for apical POP with native tissue are equally effective surgical treatments of POP, with comparable anatomic, functional, and adverse outcomes.
• The use of synthetic mesh or biologic grafts in transvaginal repair of posterior vaginal wall prolapse does not improve outcomes.
• Polypropylene mesh augmentation of anterior vaginal wall prolapse repair improves anatomic and some subjective outcomes but does not affect reoperation rates for recurrent prolapse and is associated with a higher rate of complications compared with native tissue vaginal prolapse repair.

The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):

• Many women with POP on physical examination do not report symptoms of POP. Treatment is indicated only if prolapse is causing bothersome bulge and pressure symptoms, sexual dysfunction, lower urinary tract dysfunction, or defecatory dysfunction.
• Women considering treatment of POP should be offered a vaginal pessary as an alternative to surgery.
• Vaginal apex suspension should be performed at the time of hysterectomy for uterine prolapse to reduce the risk of recurrent POP.
• Abdominal sacrocolpopexy with synthetic mesh has a lower risk of recurrent POP but is associated with more complications than vaginal apex repair with native tissue.
• Obliterative procedures––which narrow, shorten, or completely close the vagina––are effective for the treatment of POP and should be considered a first-line surgical treatment for women with significant medical comorbidities who do not desire future vaginal intercourse or vaginal preservation.
• The use of synthetic mesh or biologic grafts in POP surgery is associated with unique complications not seen in POP repair with native tissue.
• Hysteropexy is a viable alternative to hysterectomy in women with uterine prolapse, although there is less available evidence on safety and efficacy compared with hysterectomy.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• A POP-Q examination is recommended before treatment for the objective evaluation and documentation of the extent of prolapse.
• A pessary should be considered for a woman with symptomatic POP who wishes to become pregnant in the future.
• Pelvic organ prolapse vaginal mesh repair should be limited to high-risk individuals in whom the benefit of mesh placement may justify the risk, such as individuals with recurrent prolapse (particularly of the anterior or apical compartments) or with medical comorbidities that preclude more invasive and lengthier open and endoscopic procedures. Before placement of synthetic mesh grafts in the anterior vaginal wall, patients should provide their informed consent after reviewing the benefits and risks of the procedure and discussing alternative repairs.
• Surgeons who perform POP surgery with biologic grafts or synthetic mesh grafts should have training specifically for these procedures and should be able to counsel patients regarding the risk–benefit ratio for the use of mesh compared with native tissue repair.
• Routine intraoperative cystoscopy during POP surgery is recommended when the surgical procedure performed is associated with a significant risk of injury to the bladder or ureter. These procedures include suspension of the vaginal apex to the uterosacral ligaments, sacrocolpopexy, and anterior colporrhaphy and the placement of mesh in the anterior and apical compartments.
• All women with significant apical prolapse, anterior prolapse, or both should have a preoperative evaluation for occult stress urinary incontinence, with cough stress testing or urodynamic testing with the prolapse reduced.
• Patients with POP but without stress urinary incontinence who are undergoing either abdominal or vaginal prolapse repair should be counseled that postoperative stress urinary incontinence is more likely without a concomitant continence procedure but that the risk of adverse effects is increased with an additional procedure.

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A—Recommendations are based on good and consistent scientific evidence.

Level B—Recommendations are based on limited or inconsistent scientific evidence.

Level C—Recommendations are based primarily on consensus and expert opinion.