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Pelvic Organ Prolapse (POP)

NICE guideline [NG123] Urinary incontinence and pelvic organ prolapse in women: management. Last updated: Jun 2019. NICE guideline [NG210] Pelvic floor dysfunction: prevention and non-surgical management. Published: Dec 2021.

Background Information

NICE recommends using the Pelvic Organ Prolapse Quantification (POP-Q) system
 
Stage Description (location of most distal part of prolapse)
0 No prolapse 
1 >1 cm above the hymen
2 Within +/-1 cm of the hymen (1cm above or 1cm below)
3 >1 cm below the hymen but NOT fully ouside the vagina
4 Complete eversion - visible outside the vagina

Compartment Type of Prolapse Description / Structure Involved
Anterior Cystocele Herniation of the bladder into the anterior vaginal wall
Urethrocele Herniation of the urethra into the anterior vaginal wall. Often occurs with cystocele (cystourethrocele)
Apical Uterine prolapse Descent of the uterus and cervix down into the vaginal canal
Vaginal vault prolapse Prolapse of the vaginal apex after hysterectomy
Posterior Rectocele Herniation of the rectum into the posterior vaginal wall
Enterocele Herniation of the small bowel into the upper posterior vaginal wall, typically through the pouch of Douglas.
 

Guidelines

Perform a physical examination
  • Examination with the women standing / squatting can unmask the findings
 

Do not routinely perform imaging if prolapse detected by physical examination.

Advise the women:
  • Lose weight if BMI >30 kg/m2
  • Minimise heavy lifting
  • Prevent / treating constipation

Supervised pelvic floor muscle training (at least 16 weeks of a supervised programme)
  • 1st line in symptomatic stage 1/2 pelvic organ prolapse

Consider vaginal pessary alone or together with supervised pelvic floor muscle training
  • Can be inserted in the clinic
  • Advise to remove once every 6 months (to prevent and monitor for complications like ulceration, infection or displacement)

Offer surgery if symptoms persist despite non-surgical options, or declined non-surgical options.
 

Type of Prolapse Surgical Options Notes
Uterine prolapse Take women's preference in preserving the uterus or not:
  • Vaginal hysterectomy +/- vaginal sacrospinous fixation with sutures
  • Vaginal sacrospinous hysteropexy with sutures
  • Manchester repair
  • Sacrohysteropexy (laparoscopic / abdominal with mesh)
 If fertility is desired:
  • Do not perform Manchester repair
  • Refer to MDT
Vault (vaginal) prolapse
  • Vaginal sacrospinous fixation with sutures
  • Sacrohysteropexy (laparoscopic / abdominal with mesh)
 n/a
Anterior wall prolapse Anterior colporrhaphy (repair without mesh) Do not use mesh
Posterior wall prolapse Posterior colporrhaphy (repair without mesh) Do not use mesh

Consider colpocleisis in:
  • Uterine / vault prolapse, and
  • Frail for surgery, or vaginal sex not intended

Follow up 6 months after any surgeries.

References

Author: Adams Lau
Reviewer:
Last edited: 12/07/25