The type of therapy depends on the extent of prolapse and associated symptoms, impact on the patient’s quality of life, the patient’s age, and her desire for menstruation, pregnancy, and coitus.
Supportive measures include a high-fiber diet and laxatives to improve constipation. Weight reduction in obese patients and limitation of straining and lifting are helpful. Pelvic muscle training (Kegel exercises) is a simple, noninvasive intervention that may improve pelvic function; it has demonstrated clear benefit for women with urinary or fecal symptoms, especially incontinence. Pessaries may reduce a cystocele, rectocele, or enterocele and are helpful in women who do not wish to undergo surgery or who are poor surgical candidates (eFigure 18–11 and 18–12).
The most common surgical procedure is vaginal or abdominal hysterectomy with additional attention to restoring apical support after the uterus is removed, by suspension either by vaginal uterosacral or sacrospinous fixation or by abdominal sacral colpopexy. Since stress incontinence is common after vault suspension procedures, an anti-incontinence procedure should be considered. Surgical mesh placed transvaginally for pelvic organ prolapse repair was introduced into clinical practice in 2002, but in 2011 the FDA issued warnings about concerns for serious complications associated with this practice (including mesh erosion and pain). Use of these methods subsequently declined significantly. In April 2019, the US FDA withdrew its previous (2016) class III (high risk) approval of surgical mesh intended for transvaginal repair of anterior compartment prolapse. Patients planning to have surgical repair of pelvic organ prolapse should discuss all treatment options, including the risks and benefits of using surgical mesh, with their clinician. If the patient desires pregnancy, the same procedures for vaginal suspension can be performed without hysterectomy, though limited data on pregnancy outcomes or prolapse outcomes are available. Generally, surgical repair of pelvic organ prolapse is reserved until after completion of childbearing. For elderly women who do not desire coitus, colpocleisis, the partial obliteration of the vagina, is surgically simple and effective. Uterine suspension with sacrospinous cervicocolpopexy may be an effective approach in older women who wish to avoid hysterectomy but preserve coital function. Women who have received transvaginal mesh for the surgical repair of pelvic organ prolapse but who are having no symptoms or complications related to it should continue with their annual check-ups and other routine follow-up care. They should let their clinician know that they have a surgical mesh implant, especially if they plan to have another pelvic surgery or related medical procedure. In addition, they should notify their clinician if they develop symptoms such as persistent vaginal bleeding or discharge, pelvic or groin pain, or dyspareunia.