PassFinals
Women's Health

Pelvic Organ Prolapse

Pelvic organ prolapse is descent of the bladder, uterus, rectum or vaginal vault into or through the vagina because the pelvic floor muscles and fascia that support them have weakened; it is common after childbirth and around the menopause, and management runs from pelvic floor training and pessaries to surgery.

In a nutshell

Pelvic organ prolapse is descent of an anterior, posterior or apical vaginal compartment, causing a vaginal bulge or functional symptoms. Assess symptoms and POP-Q findings together; offer shared choices ranging from no treatment and supervised pelvic floor muscle training to a pessary or specialist surgery. Pessary care and mesh safety-netting are essential.

Classic presentation

A parous postmenopausal woman with a dragging sensation and a feeling of something coming down in the vagina, worse by the end of the day.

Key points

  • Support comes from the levator ani and the uterosacral and cardinal ligaments; prolapse is their failure.
  • Main risk factors are vaginal childbirth, the menopause and raised intra-abdominal pressure.
  • Compartment determines symptoms: cystocele (bladder), rectocele (rectum), apical (uterus or vault).
  • First-line treatment for symptomatic POP-Q stage 1 or 2 includes supervised pelvic floor muscle training for at least 16 weeks.
  • A pessary is a shared non-surgical option for symptomatic prolapse at any stage, with fitting and removal/follow-up safety requirements.
  • Surgery is offered when symptoms persist despite or the woman declines non-surgical treatment, with recurrence and functional risks discussed.
  • Vaginal oestrogen is for associated menopausal genitourinary symptoms, not a treatment that mechanically reverses prolapse.

First-line investigation

History and vaginal examination with POP-Q assessment of the anterior, central/apical and posterior compartments; repeat standing or squatting examination if symptoms are not explained.

Management

Confirm the compartment and symptom burden

  • Examine and record anterior, central/apical and posterior prolapse using POP-Q, assess pelvic floor activity and ask directly about urinary, bowel, pain and sexual symptoms; no routine imaging is needed when examination explains the symptoms.1,2

Start conservative care

  • Address constipation, weight and heavy lifting, and offer supervised pelvic floor muscle training for at least 16 weeks for symptomatic stage 1 or 2 prolapse.1,3

Offer a safe pessary trial

  • Offer a pessary according to preference, sexual function, fit and ability to self-manage; explain discharge, bleeding, expulsion and tissue-injury risks and ensure it is removed at least every 6 months or managed under an appropriate specialist plan.1,2

Refer for shared surgical decision making

  • Offer specialist surgery when symptoms persist despite or the woman declines non-surgical treatment; discuss native-tissue and other options, mesh restrictions, urinary/bowel/sexual effects and recurrence.1,3

Safety-net pessary and exposed prolapse

  • Review fit, vaginal tissue, voiding and bowel function; promptly assess bleeding, pain, malodorous discharge, retention or an embedded pessary, and reassess recurrent symptoms after surgery.1,2

Exam traps

  • Cystocele is anterior wall (bladder), rectocele is posterior wall (rectum): do not swap them.
  • Investigate postmenopausal bleeding separately; do not attribute it to the prolapse.
  • Pelvic floor muscle training is first-line for stage 1 to 2, not straight to surgery.
  • Complete uterine prolapse (procidentia) can cause ureteric kinking and hydronephrosis.
  • Vaginal mesh use is highly restricted in the NHS; discuss long-term uncertainty and use the appropriate specialist mesh pathway for complications.

Illustrations

Uterine prolapse on clinical examinationClinical examination showing descent of the cervix and uterus through the vaginal introitus, demonstrating apical pelvic organ prolapse.Mikael Häggström, Wikimedia Commons · CC0

Key sources

  1. NICE NG123, Urinary incontinence and pelvic organ prolapse in women: management (Current NICE guidance for assessment, pelvic floor muscle training, lifestyle, vaginal oestrogen for associated menopausal genitourinary symptoms, pessaries, surgery and mesh complications; page last reviewed 26 March 2025.)Published 2 Apr 2019
  2. UK Clinical Guideline for Best Practice in the Use of Vaginal Pessaries for Pelvic Organ Prolapse (Multidisciplinary UK consensus guideline first published 22 June 2026, supported by UK professional organisations including BSUG, RCOG, POGP and UKCS; due for review 2028.)Published 22 Jun 2026
  3. NHS, Pelvic organ prolapse (Current NHS patient information cross-check for symptoms, conservative treatment, pessaries and the current restriction on vaginal mesh surgery in the NHS; accessed 4 August 2026.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.