Pelvic Organ Prolapse

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. (A)

The use of synthetic mesh or biologic grafts in transvaginal repair of posterior vaginal wall prolapse does not improve outcomes. (A)

Compared with native tissue anterior repair, polypropylene mesh augmentation of anterior vaginal wall prolapse repair improves anatomic and some subjective outcomes but is associated with increased morbidity. (A)

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. (B)

Women considering treatment of POP should be offered a vaginal pessary as an alternative to surgery. (B)

Vaginal apex suspension should be performed at the time of hysterectomy for uterine prolapse to reduce the risk of recurrent POP. (B)

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. (B)

Obliterative procedures––which narrow, shorten, or completely close the vagina––are effective for the treatment of POP and should be considered a firstline surgical treatment for women with significant medical comorbidities who do not desire future vaginal intercourse or vaginal preservation. (B)

The use of synthetic mesh or biologic grafts in POP surgery is associated with unique complications not seen in POP repair with native tissue. (B)

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. (B)

A POP-Q examination is recommended before treatment for the objective evaluation and documentation of the extent of prolapse. (C)

A pessary should be considered for a woman with symptomatic POP who wishes to become pregnant in the future. (C)

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. (C)

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. (C)

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. (C)

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. (C)

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. (C)