Pelvic organ prolapse
Pelvic organ prolapse is descent of the anterior or posterior vaginal wall, the uterus, or the vaginal cuff into or beyond the vaginal introitus from loss of pelvic floor support. It is a clinical diagnosis made on Valsalva examination; treatment is a vaginal pessary for most patients and compartment-specific reconstructive or obliterative surgery for those who fail or decline conservative care.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: pelvic organ prolapse is descent of one or more vaginal compartments, the anterior vaginal wall (cystocele), the posterior vaginal wall (rectocele or enterocele), the uterus/cervix, or…
- Epidemiology
Age association: prevalence rises with advancing age, and symptomatic presentations cluster in postmenopausal women.
- Risk factors
Multiple vaginal deliveries: the strongest and most modifiable obstetric risk factor; each additional vaginal delivery further stretches pelvic floor support.
- Pathophysiology
Loss of levator and fascial support: vaginal delivery, aging, and chronically elevated intra-abdominal pressure progressively injure the levator ani muscles and the endopelvic (pubocervical and…
- Clinical features
Vaginal or pelvic pressure and bulge sensation: the hallmark symptom is the feeling of a bulge, protrusion, or something "falling out" of the vagina, often worse with standing, straining, or by the end of the day.
- Differential diagnosis
Vaginal cancer: presents with abnormal vaginal bleeding, discharge, and a fixed or irregular mass, most often in the upper third of the vagina; biopsy differentiates it from the soft, reducible bulge…
- Diagnosis
This is a clinical diagnosis: pelvic organ prolapse is established by a comprehensive gynecologic, urologic, and defecatory history combined with pelvic examination; no laboratory or imaging test is required to confirm it.
- Management
Only treat if the prolapse is bothersome: asymptomatic mild descent found incidentally on exam does not require intervention.
- Complications
Voiding dysfunction: an advanced anterior prolapse can obstruct the urethra enough to cause urinary retention or the need to manually reduce the prolapse to void.
- Prognosis
Pessary success is high for appropriately selected patients: pessaries effectively reduce the prolapse and relieve symptoms in patients who are fitted and followed regularly, making them a durable…
- Prevention
Limit vaginal deliveries' cumulative pelvic floor trauma where feasible: counsel on pelvic floor muscle training during and after pregnancy, since each additional vaginal delivery independently increases risk.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Urinary incontinence
Urinary incontinence is involuntary urine loss classified as stress, urge, mixed, or overflow by history and simple office testing. Stress incontinence is treated with pelvic floor muscle training then a midurethral sling, and urge incontinence/overactive bladder with bladder training then an antimuscarinic or beta-3 agonist, after a postvoid residual and urinalysis exclude overflow and infection.
- Vesicovaginal fistula
Vesicovaginal fistula is an abnormal epithelialized tract between the bladder and vagina that produces continuous, painless leakage of urine from the vagina, most often after pelvic surgery (especially hysterectomy) in resource-rich settings or prolonged obstructed labor in resource-limited settings. Small fistulas found early may heal with prolonged bladder (Foley) catheter drainage; established fistulas require surgical closure, timed to let inflammation resolve.
- Rectovaginal fistula
An abnormal epithelialized communication between the rectum and vagina that presents with passage of flatus or stool through the vagina, most often from breakdown of an inadequately repaired fourth-degree obstetric laceration or from fistulizing Crohn disease, confirmed on exam and treated according to the underlying cause.
- Uterine fibroids
Uterine leiomyomas are benign monoclonal smooth-muscle tumors of the myometrium that cause heavy menstrual bleeding, bulk symptoms, and reproductive dysfunction; management ranges from expectant care to hormonal bleeding control to fertility-sparing or definitive surgery.
- Genitourinary syndrome of menopause
Genitourinary syndrome of menopause is the chronic, progressive constellation of vulvovaginal and lower urinary tract symptoms caused by estrogen deficiency, presenting with vaginal dryness, dyspareunia, and recurrent urinary symptoms in menopausal women. It is a clinical diagnosis treated first with nonhormonal moisturizers and lubricants, then low-dose vaginal estrogen, with ospemifene or vaginal prasterone reserved as second-line options.
- Constipation
Constipation is infrequent, difficult, or incomplete defecation that is secondary to an identifiable cause, most often a medication, or functional once secondary causes are excluded. Diagnosis rests on alarm-feature screening and Rome IV criteria for the functional subtype, and treatment proceeds stepwise from fiber and osmotic laxatives through secretagogues, prokinetics, biofeedback, or peripheral opioid antagonists.
- Obesity
Obesity is a chronic disease of excess adiposity, defined by a body mass index of 30 or greater, that raises risk for type 2 diabetes, cardiovascular disease, sleep apnea, liver disease, and several cancers. Management is staged: lifestyle intervention for all patients, pharmacotherapy after 3 to 6 months of unmet lifestyle goals, and bariatric surgery for a body mass index of 40 or greater or 35 or greater with a comorbidity.
- Vaginal cancer
Primary vaginal cancer is a rare gynecologic malignancy, usually squamous cell carcinoma linked to HPV, that must be distinguished from the far more common metastatic or direct extension of cervical, endometrial, or vulvar cancer into the vagina. Diagnosis rests on biopsy of a visualized lesion with clinical FIGO staging, and treatment is predominantly radiation with concurrent platinum-based chemosensitization.