Assess (POP-Q) and manage pelvic organ prolapse, including native-tissue repair, pessary and the transvaginal-mesh position

In one line

Pelvic organ prolapse is failure of the pelvic-floor support system — the levator ani and the endopelvic fascial attachments — that lets a vaginal wall descend; the consultant task is to localise the defect by compartment and POP-Q, match the treatment to the woman's symptoms and goals rather than to the stage on paper, and offer native-tissue repair, pessary or apical suspension within a transvaginal-mesh landscape now restricted to research and to abdominal sacrocolpopexy.

The support anatomy, the POP-Q points and the basic distinction between conservative and surgical care are assumed here — those foundations are at genital prolapse. What follows is the level above: choosing between competing operations, defending the route and the use of mesh from the trial data, and managing the woman whose prolapse coexists with incontinence, who has failed a previous repair, or who is too frail for reconstruction.

Mechanism & pathophysiology

Prolapse is a disorder of support, not of the organ. The bladder behind a cystocele is structurally normal; what has failed is the anterior vaginal wall and its lateral attachments. The suffix "-cele" therefore names the prolapsing vaginal segment, not a herniated viscus — cystocele (anterior wall), rectocele (posterior wall), enterocele (peritoneal sac, usually apical/posterior), and apical descent of uterus or vault. Naming the compartment drives the operation; naming the organ does not.

DeLancey's three levels of vaginal support are the framework that converts an examination finding into a surgical plan:

• Level I — apical suspension. The cardinal–uterosacral ligament complex suspends the cervix and upper vagina to the sacrum and lateral pelvic sidewall. Level I failure produces uterine or vault prolapse and is the level most often under-treated: an anterior repair that ignores a detached apex fails, because much of what looks like a "cystocele" is apical descent dragging the anterior wall down with it.
• Level II — lateral attachment. The mid-vagina is attached laterally to the arcus tendineus fascia pelvis (the "white line") and to the levator ani. Level II failure gives the classic anterior (cystocele) and posterior (rectocele) wall prolapse, either as a midline fascial break or a paravaginal (lateral) detachment.
• Level III — distal fusion. The distal vagina and urethra are fused to the perineal body, perineal membrane and levator. Level III failure underlies a deficient perineum, gaping introitus and distal anterior-wall descent, and is where obstetric perineal trauma writes itself into later prolapse.

Two tissue systems fail together. The levator ani — principally the puborectalis/pubococcygeus — provides the active, constant tonic floor that keeps the urogenital hiatus closed and takes the load off the ligaments; the endopelvic connective tissue (the cardinal and uterosacral ligaments, the pubocervical and rectovaginal fascia) provides the passive suspensory backup. The boat-and-mooring analogy holds: the levator is the water level holding the boat up, the ligaments are the ropes that only take strain when the water drops. Levator avulsion — detachment of the puborectalis from its pubic insertion, the commonest major obstetric levator injury, seen in roughly 15–30% of women after a first vaginal birth and far more after forceps — drops the "water level", enlarges the hiatus, transfers chronic load onto the ligaments, and is the single strongest anatomical predictor of prolapse and of recurrence after repair. This is why a repair in a woman with bilateral avulsion is biomechanically swimming upstream.

The risk-factor list maps onto these mechanisms rather than sitting beside them: vaginal parity and instrumental/operative vaginal delivery (levator and fascial injury), age and oestrogen withdrawal (collagen quality and quantity fall, the connective tissue weakens), chronically raised intra-abdominal pressure (obesity, chronic cough, constipation and straining, heavy lifting), connective-tissue disorders (Ehlers–Danlos, Marfan), and previous prolapse or hysterectomy (the apex is now unsupported). A genetic/collagen contribution is real — prolapse clusters in families and presents in nulliparous women — which is why the operation alone never fully "cures" the underlying tissue tendency.

The same biomechanics explain why repairs recur. A native-tissue colporrhaphy re-approximates attenuated fascia; it does not regenerate strong collagen or reattach an avulsed levator. So the woman with a wide hiatus and a dropped "water level" is asking a plicated, already-weak tissue layer to hold a load the muscle should be carrying — and over time it stretches again. Two corollaries follow for the consultant: first, the apex is load-bearing, so a repair that restores the anterior or posterior wall but leaves a descended apex unsupported simply transfers the strain back onto the weakest segment and fails; second, a durable apical operation works at a different anatomical level — sacrocolpopexy re-suspends the vault to the sacrum with a permanent bridge, sidestepping the reliance on the woman's own attenuated ligaments, which is precisely why it outlasts native-tissue suspension in the long-term data.

Assessment

The history establishes whether the anatomy is actually the problem. A POP-Q stage II that the woman cannot feel needs no operation; a stage II at the introitus that dominates her life may. Separate the symptoms by system because each maps to a compartment and to a different repair:

• Bulge symptoms — "something coming down", a visible/palpable lump, vaginal pressure or dragging that worsens through the day and on standing and eases on lying. The bulge symptom (seeing or feeling the prolapse) is the one most reliably cured by surgery; vague pelvic discomfort is not.
• Voiding/urinary — incomplete emptying, hesitancy, a weak or positional stream, the need to splint (push the bulge back to void) or digitate. Occult stress incontinence matters disproportionately: a large anterior or apical prolapse can kink the urethra and mask stress leakage that surgery then unmasks — reduce the prolapse on examination and re-test for stress leakage before operating, and counsel accordingly.
• Defecatory — incomplete evacuation, the need to splint the perineum or posterior wall, post-defecatory soiling; these point to a posterior-compartment/rectocele or perineal problem and frequently to constipation that must be treated before and after any repair.
• Sexual — dyspareunia, awareness of laxity, body-image distress, or simple avoidance; ask directly, because sexual outcome is a primary reason to choose (or avoid) a particular operation and is routinely neglected.

On examination, inspect at rest and on Valsalva, in the dorsal position and, if findings do not match the symptoms, standing — the prolapse a woman complains of may only appear when she is upright at the end of the day. A Sims (single-bladed) speculum retracts one wall so the opposite compartment can be graded in isolation; you cannot stage an anterior wall while a bivalve speculum is holding it up. Assess each compartment separately, look specifically for the apex (reduce the anterior and posterior walls and ask the cervix/vault to descend — apical support is the most missed defect), test the levator (ask for a voluntary contraction; feel for, and grade, avulsion and the resting hiatal size), and do a stress test with the prolapse reduced.

The POP-Q (the standardised system from Bump's 1996 terminology report, adopted by IUGA/ICS) replaces the vague "first/second/third-degree" language with reproducible measurement against a fixed reference, the hymen (0 by definition; points above/inside are negative centimetres, points below/outside are positive). Six vaginal points and three landmarks are recorded, all on maximal Valsalva:

• Aa — anterior wall, 3 cm proximal to the external urethral meatus (range −3 to +3).
• Ba — the most dependent point of the remaining upper anterior wall.
• C — the cervix or vaginal vault (the leading edge of the apex).
• D — the posterior fornix (the level of the uterosacral attachment); omitted after hysterectomy, and a large C–D gap suggests cervical elongation rather than true apical descent.
• Ap — posterior wall, 3 cm proximal to the hymen (−3 to +3).
• Bp — the most dependent point of the remaining upper posterior wall.
• gh (genital hiatus, mid-urethra to posterior midline hymen), pb (perineal body, posterior hymen to mid-anus), tvl (total vaginal length, the only measurement at rest).

Staging is then driven by the leading edge: stage 0 (no prolapse, points at their normal apical/distal extremes), stage I (leading edge >1 cm above the hymen), stage II (leading edge within 1 cm of the hymen, i.e. −1 to +1 cm), stage III (leading edge >1 cm below the hymen but not complete eversion), stage IV (complete eversion/procidentia, ≥ tvl −2 cm). The clinical value is that POP-Q forces you to record the apex (C/D) and the hiatus (gh) — the two measurements that an organ-based "cystocele/rectocele" description hides, and the two that most often dictate whether a repair will hold.

Investigations are symptom-directed, not routine. A post-void residual (catheter or bladder scan) where voiding is incomplete. Urodynamics is not needed for the prolapse itself but is indicated when surgery is planned in a woman with significant or mixed urinary symptoms, when occult stress incontinence is demonstrated on prolapse reduction, or before a continence procedure is added. Renal tract imaging in long-standing procidentia, because complete eversion can kink the ureters and cause hydronephrosis. Examine the exposed epithelium in a large, chronically prolapsed vagina for decubitus ulceration (treat with pessary reduction and topical oestrogen, biopsy anything that does not heal).

Reading the host and the failure risk

Two patients with the same POP-Q stage can need opposite plans, and the discriminators are the levator, the apex and the connective-tissue reserve. Levator integrity is the dominant one: a palpable bilateral avulsion, or a resting genital hiatus that stays wide on examination, predicts both a more advanced prolapse and a higher recurrence after any reconstructive repair — a finding that should lower your threshold for a durable apical operation (sacrocolpopexy) and raise your honesty in counselling about recurrence. A large, undiagnosed apical defect masquerading as an anterior wall problem is the second: reduce the anterior and posterior walls and look specifically for how far C and D descend before committing to an "anterior repair". Connective-tissue reserve — youth, nulliparity-with-prolapse, a family history, or a recognised syndrome (Ehlers–Danlos, Marfan) — flags tissue that will not hold a plication well and warrants a frank conversation about recurrence and about non-surgical options. And in the postmenopausal woman, epithelial quality (atrophy, a decubitus ulcer) is part of the assessment because it determines pessary tolerance and the timing of surgery: an ulcerated vault is pre-treated with reduction and topical oestrogen before any operation. Quantifying these — the hiatus, the apex, the levator, the tissue — is what turns a stage into a plan.

Management

Order the response immediate → ongoing → long-term, but the first decision is whether to treat at all: asymptomatic prolapse, whatever the stage, is observed, not operated. The woman's symptoms and goals — not the POP-Q number — set the plan. Within that, the three live arms are conservative care, pessary and surgery, and the surgical choice is then made by compartment and by apex.

Immediate / conservative. Address the reversible load on the floor: weight reduction, treat chronic cough and constipation, avoid heavy lifting, and topical vaginal oestrogen in the postmenopausal woman (it improves epithelial quality, eases pessary tolerance and treats decubitus ulceration — it does not reduce the prolapse). Pelvic-floor muscle training, supervised by a physiotherapist over at least three to four months, improves symptoms and is the reasonable first step for mild-to-moderate prolapse, though its anatomical effect is modest and it is more a symptom and progression strategy than a cure.

Pessary — the workhorse, not the consolation prize. A vaginal pessary is appropriate at any stage, for a woman who wants to avoid or defer surgery, who is pregnant or has not completed her family, who is unfit for surgery, or who simply prefers it; in a resource-constrained service it is the single most cost-effective intervention and frequently the definitive one. The two functional classes are support pessaries (ring ± support, for stage I–II, retained behind the pubic symphysis — the woman or clinician can often manage these herself and intercourse is usually possible) and space-filling pessaries (Gellhorn, donut, cube, for advanced stage III–IV where a ring will not stay in). Fit by trial; the correct size is the largest the woman cannot feel and that stays in on Valsalva and walking. Care is the safety issue: a neglected pessary erodes, ulcerates, fistulates and rarely becomes incarcerated, so every pessary needs a removal/cleaning schedule (self-management where possible, otherwise clinic review every few months) and topical oestrogen. Red flags on follow-up are bleeding, discharge, pain or difficulty removing it. Self-management is safe and effective and should be the default offer where the woman can be taught it, reserving clinic-based care for those who cannot.

Surgery — choose by compartment, and never ignore the apex. Reconstructive surgery aims to restore anatomy and function; obliterative surgery sacrifices the vagina for durability in a woman who has finished with penetrative intercourse.

• Native-tissue anterior/posterior repair (colporrhaphy) is the default first-line reconstructive operation in South African practice. The dominant error is treating an apical defect as an anterior one: an isolated anterior colporrhaphy in a woman whose anterior-wall descent is actually being pulled down by a detached apex has a high recurrence — the apex must be supported at the same operation whenever it has descended.
• Apical suspension, vaginal route. Sacrospinous fixation anchors the vault/cervix to the sacrospinous ligament (usually unilateral, right side) — watch for buttock/gluteal and pudendal-territory pain and the small risk to pudendal vessels. Uterosacral ligament suspension re-suspends the apex to the uterosacral ligaments intraperitoneally — the characteristic hazard is ureteric kinking/injury, so intra-operative cystoscopy to confirm ureteric patency is mandatory. The two are equivalent in durability (OPTIMAL).
• Vaginal hysterectomy vs uterine preservation. Vaginal hysterectomy with concurrent apical suspension (the apex must still be suspended — removing the uterus does not fix the support) remains standard for uterine prolapse where the woman is content to lose the uterus. Hysteropexy (sacrospinous hysteropexy, abdominal/laparoscopic sacrohysteropexy, or the Manchester repair for cervical elongation with preserved apical ligaments) is a legitimate choice for women wanting uterine preservation for personal, cultural or fertility reasons; counsel that long-term comparative data are thinner and that the cervix still needs screening.
• Abdominal/laparoscopic sacrocolpopexy suspends the vault to the anterior longitudinal ligament of the sacrum with a permanent (polypropylene) mesh bridge. It is the most durable apical repair, the reference operation for vault prolapse and for recurrence after failed vaginal repair, and the one remaining accepted indication for synthetic mesh because the mesh sits abdominally, not transvaginally. The trade-off is greater operative magnitude and a real, time-dependent mesh-exposure risk (≈10% at seven years in extended CARE). The laparoscopic/robotic route lowers morbidity versus open. In a stress-continent woman undergoing sacrocolpopexy, a concomitant continence procedure (Burch in CARE) reduces post-operative stress incontinence — but this must be a counselled, individualised decision, not automatic.
• Obliterative colpocleisis (LeFort partial, or total after hysterectomy) closes the vaginal canal. In a frail, elderly woman who does not desire penetrative intercourse it gives very high anatomical success and satisfaction with low morbidity and low regret — a genuinely good operation that is under-offered because it feels radical; the counselling point is irreversible loss of coitus and the (small) need for future bleeding to be investigable.

Ongoing. Cystoscopy after any apical or extensive vaginal repair where ureteric or bladder injury is possible. Catheter/voiding trial post-operatively (prolapse surgery and concomitant slings cause transient voiding difficulty). Treat constipation aggressively after posterior repair — straining onto a fresh repair is how it fails. Continue topical oestrogen.

Long-term. Counsel every woman that prolapse is a tissue disorder, not a single mechanical fault: recurrence and reoperation are realities, quoted around a 1-in-9 to 1-in-12 lifetime risk of surgery for prolapse or incontinence, with reoperation after a first repair in the order of 10–30% depending on compartment, apical support and levator integrity. Address the modifiable load (weight, constipation, cough) for life, keep cervical screening going where the uterus or cervix is preserved, and set realistic expectations: the aim is a woman without a troublesome bulge and with acceptable bladder, bowel and sexual function — not a perfect POP-Q.

Guidelines compared

The substantive points of agreement and divergence: every body now places native-tissue repair and conservative care first and treats transvaginal mesh for prolapse as withdrawn or research-restricted — the convergence dates to 2019, when NICE NG123 limited it to research and, the same year, the US FDA ordered the last manufacturers to stop selling transvaginal POP mesh. Where they differ is tone and scope: NICE/RCOG operate inside a formal national pause with mandated registries and consent processes after the Cumberlege "First Do No Harm" review; IUGA/ICS, speaking internationally, never imposed an outright ban and continue to permit mesh in trained hands with proper consent. None of these positions touches abdominal sacrocolpopexy mesh, which sits abdominally and remains accepted everywhere.

The evidence & the controversy

The defining controversy of the last decade is mesh, and the consultant must hold the distinction the public conversation usually loses: transvaginal mesh for prolapse is the problem, not mesh per se. The case against transvaginal POP mesh is that it never bought the durability it promised at an acceptable cost. PROSPECT — the largest randomised comparison — found prolapse symptom scores at one year essentially identical between native-tissue repair and mesh/graft augmentation (mean difference 0.00), while around one in eight mesh-exposed women had a mesh complication over two years. Augmenting a vaginal repair with mesh added harm without adding benefit, and that, combined with the safety signals (chronic pain, dyspareunia, mesh exposure/erosion, fistula and difficult revision surgery), drove the 2019 NICE research-only restriction and the FDA withdrawal. The defensible position is that transvaginal mesh for primary prolapse is not standard care; native-tissue repair is the default; and the few remaining indications for any vaginal graft belong to subspecialist hands inside a consented, registry-tracked pathway.

The flip side is the risk of over-correction. The same pause that protected women from a poorly-evidenced device must not be read as "all mesh is dangerous", because abdominal sacrocolpopexy mesh remains the most durable apical repair we have — extended CARE shows it holds, with anatomic success persisting at seven years and a mesh-exposure risk around 10% that is real but manageable and far lower-stakes than transvaginal exposure. Throwing out sacrocolpopexy along with transvaginal kits would be the wrong lesson.

The second live debate is how to support the apex vaginally, and here the honest answer is "either, well-counselled". OPTIMAL randomised uterosacral against sacrospinous suspension and found them equivalent at two years (≈59–61% success), and the five-year e-OPTIMAL follow-up confirmed no significant difference — but with sobering recurrence in both arms (61.5% vs 70.3% failure by the composite definition), a reminder that vaginal apical repair is durable-ish, not durable, and that the choice between SSF and USLS turns on the surgeon's skill and the complication profile (gluteal/pudendal pain with SSF, ureteric risk with USLS) rather than on superiority. OPTIMAL also closed the door on routine perioperative pelvic-floor muscle training improving surgical outcomes.

A genuinely current thread worth weighing is the shift towards pessary self-management and away from clinic dependence. TOPSY showed that teaching women to manage their own pessaries is as effective as clinic-based care on quality of life, which matters enormously for an over-stretched South African service: it converts the pessary from a recurring clinic burden into a self-care intervention, widening access to the cheapest effective treatment. The broader controversy this sits inside — whether prolapse care has been too quick to operate — is reframed by it: for many women a well-fitted, self-managed pessary, weight and bowel optimisation, and physiotherapy is not second-best to surgery but a legitimate definitive choice.

Landmark trials & key evidence

A quick arithmetic on CARE makes the counselling concrete: prophylactic Burch reduced 3-month stress incontinence from 57.4% to 33.6%, an absolute reduction of about 23.8 percentage points, so the number needed to treat is roughly 1/0.238 ≈ 4 stress-continent women given a concomitant Burch at sacrocolpopexy to prevent one case of post-operative stress incontinence — a strong number, tempered by the fact that adding a continence procedure carries its own voiding-dysfunction cost, which is why it is a counselled choice rather than a default. The mirror-image number from extended CARE is the mesh-erosion risk of about 1 in 10 at seven years, the figure to quote when consenting a woman for sacrocolpopexy.

Exam traps & red flags

• Treating the "-cele" as a herniated organ. A cystocele is anterior vaginal wall prolapse, not a bladder hernia; the operation addresses the wall and its support, and the bladder behind it is normal. Describing prolapse by organ instead of compartment hides the apex.
• Ignoring the apex. The commonest reason an anterior repair recurs is an unsupported, descended apex pulling the anterior wall down. Always assess C/D on POP-Q and support the apex at the same operation when it has prolapsed; an isolated anterior colporrhaphy over an apical defect is set up to fail.
• Missing occult stress incontinence. A large prolapse can kink the urethra and mask stress leakage. Reduce the prolapse and re-test before surgery, and counsel that a continence procedure may be needed — otherwise the "dry" woman becomes incontinent the day you fix her bulge.
• Offering transvaginal mesh for primary prolapse. Post-NICE NG123 and the 2019 FDA withdrawal, transvaginal mesh for POP is research-restricted; PROSPECT showed no symptom benefit over native tissue with added harm. Reaching for a transvaginal mesh kit as a first-line repair is a clear error.
• Confusing the two mesh stories. The pause is on transvaginal mesh for prolapse. Abdominal sacrocolpopexy mesh is still accepted and is the most durable apical repair — "all mesh is banned" is wrong and would deny a woman the best vault operation.
• Over-narrowing the posterior repair. Aggressive levator plication at posterior colporrhaphy produces a ridge and dyspareunia; do a site-specific fascial repair and ask about sexual function before and after.
• Ureter at uterosacral suspension. Uterosacral ligament suspension kinks/injures the ureter; intra-operative cystoscopy to confirm ureteric patency is mandatory, not optional.
• Operating on an asymptomatic prolapse. Stage is not an indication. Treat the woman, not the POP-Q; an asymptomatic stage II or even III is observed.
• Forgetting the pessary (and its dangers). A pessary is a definitive option, not a holding measure — but a neglected one ulcerates, fistulates and can incarcerate. Every pessary needs a cleaning schedule, topical oestrogen, and review for bleeding/discharge/pain.
• Procidentia with hydronephrosis. Complete eversion can obstruct the ureters; image the renal tract in long-standing procidentia and reduce the prolapse (pessary) while planning definitive care.
• Under-offering colpocleisis. In the frail elderly woman who does not want intercourse, obliterative surgery is high-satisfaction, low-morbidity and low-regret; dismissing it as too radical denies a good operation.

Evidence anchors

• PROSPECT — Glazener et al., Lancet 2017 (mesh/graft vs native-tissue repair)
• OPTIMAL — Barber et al., JAMA 2014 (uterosacral vs sacrospinous, 2-year)
• e-OPTIMAL — Jelovsek et al., JAMA 2018 (5-year durability)
• SUPeR — Nager et al., JAMA 2019 (mesh hysteropexy vs vaginal hysterectomy + uterosacral suspension)
• CARE — Brubaker et al., N Engl J Med 2006 (Burch at sacrocolpopexy)
• Extended CARE — Nygaard et al., JAMA 2013 (long-term sacrocolpopexy outcomes)
• TOPSY — Hagen et al., eClinicalMedicine 2023 (pessary self-management)
• POP-Q standardised terminology — Bump et al., Am J Obstet Gynecol 1996
• DeLancey — anatomic levels of vaginal support, Am J Obstet Gynecol 1992
• IUGA/ICS joint report on POP terminology — Haylen et al., Int Urogynecol J 2016
• NICE NG123 — Urinary incontinence and pelvic organ prolapse in women: management (2019)
• US FDA — urogynaecologic surgical mesh implants (2019 transvaginal POP mesh withdrawal)
• South Africa NDoH / SAMF context — native-tissue repair and pessary first-line; transvaginal POP mesh not in routine public-sector use; sacrocolpopexy mesh retained at tertiary centres; physiotherapy, urodynamics and laparoscopic sacrocolpopexy tertiary-concentrated.