Categorized according to the affected compartment (3):
Anterior compartment prolapse: weakness of the anterior vaginal wall often associated with the descent of the bladder (cystocele)
Posterior compartment prolapse: weakness of the posterior vaginal segment often associated with bulging of the rectum into the vagina (rectocele) but can include the small intestine (enterocele).
Apical prolapse: descent of the uterus, cervix, (or in the posthysterectomy patient, the vaginal cuff), vaginal vault, and/or the bowel (enterocele) at the top of the vagina
Enterocele is a true hernia of the intestines into the vaginal wall.
Prolapse occurs most frequently in the anterior compartment, followed by the posterior compartment, and least commonly in the apex
Complete uterine prolapse (procidentia) can cause bilateral ureteral obstruction.
Correction of the prolapse causes relief of the ureteral obstruction.
Level I: suspends the uterus and upper vagina to the sacrum and lateral pelvic sidewall.
[Loss of level I support contributes to apical prolapse]
Level II: includes the paravaginal attachments of the middle third of the vagina laterally to the superior fascia of the levator ani muscle and the arcus tendineus fascia pelvis.
Loss of level II support contributes to anterior vaginal wall prolapse/cystocele
Level III: includes the vagina’s lower third attachments with the perineal membrane, levator ani muscles (superficial and deep perineal muscles), and perineal body.
Loss of level III support anteriorly contributes to urethral mobility
Loss of level III support posteriorly results in a distal rectocele or perineal descent
Increasing number of childbirths increases the risk of POP, although the rate of increase slows after the first two deliveries
Less well-established risk factors (7):
Smoking
Chronic constipation
Menopause/hormonal effects
Hysterectomy and other pelvic surgery
Hysterectomy performed for POP is a strong predictor of the need for repeat pelvic floor surgery
Increasing weight of the vaginally delivered fetus
Genetic predisposition
Race/ethnicity
More common in Caucasian and Hispanic women when compared with African-American women
Urinary incontinence and Pelvic Organ Prolapseedit
Pelvic organ prolapse can exacerbate storage lower urinary tract symptoms
Important to identify and manage symptomatic prolapse when evaluating patients with UI
> 40% of women with SUI will have a significant cystocele
Procedures for UI [without correction of POP] can exacerbate certain types of POP
Improvement of storage symptoms can be expected after POP surgery in a significant proportion of patients
Occult SUI is stress urinary incontinence that develops after prolapse reduction, due to urethral sphincteric incompetence that was previously masked by the presence of high-stage anterior POP.
Failure to address occult SUI at the time of surgery for POP may lead to more severely symptomatic SUI postoperatively.
Although POP is generally considered a QoL condition with few medical sequelae, untreated prolapse can become advanced to a point when a woman can develop urinary retention from urethral compression and, rarely, renal failure from ureteral compression.
Whether the patient is aware of any prolapse and what, if any, symptomatology and bother the prolapse may be causing.
Sensation of a vaginal bulge remains the only symptom that is strongly associated with prolapse at or below the hymenal ring
Other symptoms, including UI and fecal incontinence, voiding and defecation difficulty, and sexual dysfunction, frequently coexist with pelvic organ prolapse, but they correlate weakly with the severity or site of pelvic organ prolapse.
Disorders of defecation, including fecal incontinence and urgency, should be carefully evaluated before considering POP surgery.
Risk factors
Gynecologic and obstetric history, including gravity, parity, and hormonal status.
Determination of whether the patient is premenopausal, perimenopausal, or post-menopausal and whether she has used any exogenous hormones such as oral contraceptives or local or systemic hormone replacement therapy
Treatment expectations and an understanding of the balance between benefits and risks/burden of available treatment options.
Treatment of POP may ameliorate symptoms of sexual dysfunction. Still, dyspareunia has been associated with some types of POP repair, and, as such, changes in sexual function are an important aspect of preoperative counseling.
External genitalia: general appearance, estrogen status, lesions, and labial size, and adhesions.
Attention to the overall tissue appearance and color is important. Hormonally deficient vaginal tissue has a pale, flat, dry appearance with no rugae, as opposed to the healthy, pink rugated tissue of well-estrogenized tissue
Signs of estrogen deficiency (3):
Urethral caruncle
Urethral prolapse
Labial adhesions
Assessment of pelvic organ prolapse ideally should be performed in both the lithotomy and standing position
Anal sphincter tone
Reflection of the function at S2-4
Particularly important in neurologic patients with pelvic floor dysfunction.
Radiologic studies play a relatively small role in the evaluation of pelvic organ prolapse
Pelvic Organ Prolapse Quantification (POP-Q) systemedit
Several classification systems are used to quantify pelvic organ prolapse, the most widely used of which are the Baden-Walker classification and the Pelvic Organ Prolapse-Quantification (POP-Q) system.
What organs are involved with anterior, apical, and posterior prolapse? Which is most common? Least common? Which level of support is lost with each prolapse?
List risk factors for pelvic organ prolapse
What do the Aa, Ba, Ap, Bp, C, and D points on the POP-Q system signify?
What organs are involved with anterior, apical, and posterior prolapse? Which is most common? Least common? Which level of support is lost with each prolapse?
List risk factors for pelvic organ prolapse
What do the Aa, Ba, Ap, Bp, C, and D points on the POP-Q system signify?
Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 71
Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging. J Med Life. 2011;4(1):75-81.