Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is the descent of one or more pelvic structures (anterior vaginal wall, posterior vaginal wall, uterus/cervix, or vaginal vault) below their normal anatomical level into or through the vaginal canal. It results from failure of pelvic floor support and is one of the most consistently tested topics in NEET PG gynaecology — particularly the grading systems and the operation of choice at each grade.

Definition & basic anatomy of support

The pelvic organs are held in place by a dynamic combination of muscles, fascia and ligaments. Loss of any of these leads to herniation of the vaginal wall and the organ behind it.

The classic framework is DeLancey's three levels of support, which is high-yield because it links each defect to a specific clinical prolapse:

Level	Structure	Supports	Defect produces
Level I (apical/suspension)	Uterosacral & cardinal (Mackenrodt's) ligaments	Cervix + upper vagina	Uterovaginal prolapse / vault prolapse
Level II (lateral attachment)	Arcus tendineus + endopelvic fascia	Mid-vagina	Cystocele (anterior) & rectocele (posterior)
Level III (fusion)	Perineal body, levator ani, urogenital diaphragm	Lower vagina + introitus	Deficient perineum, gaping introitus

High-yield: Level I support (uterosacral/cardinal ligaments) is the most important support of the uterus. Loss of Level I → uterine descent or, post-hysterectomy, vault prolapse.

The levator ani (pubococcygeus, puborectalis, iliococcygeus) forms the muscular pelvic floor and provides the main constant tone. The perineal body is the central tendinous point — a torn perineal body underlies most rectoceles and deficient perineums.

Classification of prolapse

Prolapse is named for the compartment and the organ herniating into the vagina:

Compartment	Name	Herniating organ	Symptom clue
Anterior wall, upper ⅔	Cystocele	Urinary bladder	Stress incontinence, incomplete voiding, "splinting" to void
Anterior wall, lower ⅓	Urethrocele	Urethra	Stress incontinence
Posterior wall, upper ⅓	Enterocele	Loops of small bowel (peritoneal sac)	Often after hysterectomy; only true hernia
Posterior wall, lower ⅔	Rectocele	Rectum	Difficulty in defecation, digitation/splinting per vaginum
Apical / middle	Uterovaginal prolapse	Uterus + cervix	"Something coming down", mass at introitus
Apical (post-hysterectomy)	Vault prolapse	Vaginal apex	Mass after previous hysterectomy

High-yield: The enterocele is the only true hernia in pelvic organ prolapse, as it contains a peritoneal sac with bowel. It is the commonest prolapse to follow hysterectomy if the vault is not adequately suspended.

Decubitus ulcer: a trophic ulcer that develops on the most dependent, exposed part of a long-standing procidentia due to venous stasis and friction. It is not malignant and usually heals with rest/pessary; biopsy only if it fails to heal.

Grading systems

Two grading systems are tested. Know both — but examiners increasingly favour POP-Q.

Baden–Walker Halfway System (clinical, bedside)

Graded relative to the hymen during straining:

Grade	Descent
0	Normal position, no descent
1	Descent halfway to the hymen
2	Descent up to the hymen
3	Descent halfway past/beyond the hymen
4	Maximum descent / complete eversion (procidentia)

For uterine descent specifically, the older first/second/third degree scheme is still asked:

• First degree: cervix descends but remains within the vagina.
• Second degree: cervix reaches up to or protrudes through the introitus.
• Third degree (procidentia / complete prolapse): entire uterus lies outside the introitus, with complete inversion of the vagina.

High-yield mnemonic for uterine descent: "In-At-Out" → 1° cervix in vagina, 2° at introitus, 3° out of introitus (procidentia).

POP-Q (Pelvic Organ Prolapse Quantification) — the gold standard

POP-Q is the internationally accepted, objective, reproducible system and the "investigation/staging of choice" answer. The fixed reference point is the hymen (value 0). Points above the hymen are recorded as negative, points below as positive.

Six points + three landmarks are measured (in cm):

Point	Location
Aa	Anterior wall, 3 cm proximal to hymen (urethrovesical crease)
Ba	Most dependent point of remaining upper anterior wall
C	Cervix or vaginal cuff
D	Posterior fornix (omitted post-hysterectomy)
Ap	Posterior wall, 3 cm proximal to hymen
Bp	Most dependent point of remaining upper posterior wall
gh	Genital hiatus
pb	Perineal body
TVL	Total vaginal length

POP-Q staging:

• Stage 0: No prolapse (Aa, Ba, Ap, Bp all at −3; C/D within 2 cm of TVL).
• Stage I: Most distal portion >1 cm above the hymen (< −1 cm).
• Stage II: Most distal portion within 1 cm of the hymen (−1 to +1 cm).
• Stage III: Most distal portion >1 cm below hymen but < (TVL − 2) cm.
• Stage IV: Complete eversion (most distal ≥ TVL − 2 cm).

High-yield: In POP-Q the hymen = 0 is the reference; above = negative, below = positive. Stage II straddles the hymen (−1 to +1 cm). This single fact is repeatedly asked.

Etiology & risk factors

Prolapse is multifactorial — anything that raises intra-abdominal pressure or weakens supports contributes.

Obstetric (most important):

• Multiparity — the single biggest risk factor; vaginal deliveries stretch and tear fascia and pudendal nerve.
• Prolonged second stage, instrumental delivery, big baby, bearing down before full dilatation.
• Inadequate perineal repair, early resumption of work in the puerperium.

Constitutional / acquired:

• Menopause / oestrogen deficiency → atrophy and loss of collagen support.
• Obesity, chronic cough (COPD), chronic constipation, heavy weight-lifting, pelvic tumours, ascites — all raise intra-abdominal pressure.
• Previous pelvic surgery (especially hysterectomy → vault prolapse/enterocele).

Congenital:

• Nulliparous / congenital prolapse due to inherent connective-tissue weakness (e.g., Ehlers–Danlos, Marfan) or spina bifida; often presents with an elongated cervix (supravaginal elongation), little cystocele/rectocele.

High-yield: Nulliparous prolapse classically shows supravaginal elongation of the cervix with minimal anterior/posterior wall descent — the operation of choice is Manchester (Fothergill) repair if fertility is desired.

Clinical features

Symptoms correlate with severity and compartment:

• "Something coming down per vaginum" — the cardinal symptom; worse on standing/straining, relieved on lying down.
• Dragging sensation / backache (relieved by lying down — differentiates from orthopaedic backache).
• Cystocele: stress incontinence, frequency, incomplete emptying, recurrent UTI, need to reduce the bulge to void.
• Rectocele: constipation, incomplete evacuation, digitation (need to push posterior wall to defecate).
• Enterocele: deep pelvic discomfort, worse at end of day.
• Decubitus ulcer → bleeding/discharge in long-standing procidentia.
• Occult stress incontinence: a large cystocele may kink the urethra and mask incontinence, which then appears after repair — important to test pre-operatively.

Diagnosis & investigations

Diagnosis is clinical. Examine in lithotomy and standing/left-lateral (Sims') position with a Sims' speculum, asking the patient to strain (Valsalva).

Steps of examination → Inspect introitus at rest → ask patient to bear down/cough → assess descent of each wall with a Sims' speculum retracting the opposite wall → grade by POP-Q/Baden-Walker → assess cervical length → reduce prolapse and perform stress test for occult incontinence.

Investigations:

• POP-Q charting — staging of choice.
• Urodynamics — if incontinence/voiding dysfunction, especially before surgery.
• Urine culture (recurrent UTI), residual urine.
• Pap smear / cervical assessment, ultrasound if pelvic mass suspected.
• Pre-operative fitness workup (these are often elderly women).

Management

Conservative / non-surgical

Indicated in mild prolapse, women desiring future fertility, pregnancy, or those unfit/unwilling for surgery.

• Pelvic floor muscle training (Kegel exercises) — useful for Stage I–II.
• Pessaries — first-line non-surgical device; the ring pessary is most commonly used, the Gellhorn/shelf pessary for advanced prolapse. Needs topical oestrogen and periodic change to avoid ulceration/erosion.
• Treat reversible factors: weight loss, treat cough/constipation, local/systemic oestrogen in post-menopausal women.

High-yield: Ring pessary is the device of choice for conservative management and for prolapse during pregnancy (surgery is contraindicated antenatally; definitive repair is deferred to ~3 months postpartum).

Surgical management — the high-yield core

The operation depends on age, parity, desire to preserve fertility/menstruation, and the predominant defect.

Clinical situation	Operation of choice
Cystocele	Anterior colporrhaphy (anterior repair)
Rectocele	Posterior colporrhaphy (posterior repair)
Cysto + rectocele	Anterior + posterior colpoperineorrhaphy
Young woman, wants to preserve uterus/fertility, prolapse with elongated cervix	Manchester (Fothergill) operation
Multiparous, family complete, no need to conserve uterus	Vaginal hysterectomy + pelvic floor repair (with McCall culdoplasty)
Elderly, frail, not sexually active, procidentia	Le Fort partial colpocleisis (colpectomy)
Vault prolapse, abdominal/fit patient	Abdominal sacrocolpopexy (mesh to sacral promontory) — gold standard
Vault prolapse, vaginal route/unfit	Sacrospinous fixation of vault
Enterocele	Excise sac + Moschcowitz / McCall culdoplasty

Manchester (Fothergill) operation — know it cold

A uterus-preserving procedure for prolapse with cervical elongation in women wanting to retain menstruation/fertility. It has three components:

1. Amputation of the elongated cervix.
2. Plication of the cardinal (Mackenrodt's) ligaments anterior to the cervix — the key step that elevates the uterus.
3. Anterior colporrhaphy ± posterior repair (Fothergill's stitch / Sturmdorf suture to cover the cervical stump).

High-yield: The essential / most important step of the Manchester operation is plication of the cardinal ligaments in front of the amputated cervix. Cervical amputation can cause cervical stenosis, cervical incompetence, infertility and mid-trimester abortion — hence counsel before use in women desiring pregnancy.

Le Fort colpocleisis

Partial obliteration of the vagina by suturing the denuded anterior and posterior walls together, leaving lateral channels for drainage. Reserved for elderly, frail, sexually inactive women with procidentia. Renders the vagina unusable for intercourse and precludes future cervical screening — hence patient selection is critical.

Vault prolapse

After hysterectomy. Abdominal sacrocolpopexy (suspension of vault to the anterior longitudinal ligament over the sacral promontory using mesh) gives the best durability and is the gold standard; sacrospinous ligament fixation is the vaginal alternative for unfit patients (risk: injury to pudendal vessels/nerve, sciatic pain).

High-yield exam pairing: Procidentia in a young woman wanting children → Manchester repair. Procidentia in a multipara, family complete → vaginal hysterectomy + repair. Procidentia in a frail, sexually inactive elderly woman → Le Fort colpocleisis.

Prevention

• Adequate spacing and limiting parity.
• Avoid bearing down before full cervical dilatation; judicious second-stage management.
• Proper repair of perineal tears; avoid early heavy work in the puerperium.
• Postnatal pelvic floor (Kegel) exercises.
• Treat chronic cough, constipation; manage obesity; local oestrogen at menopause.

Complications

• Decubitus ulcer, bleeding, infection of exposed mucosa.
• Urinary: incomplete voiding, recurrent UTI, hydroureter/hydronephrosis from kinking of ureters in long-standing procidentia (rarely renal failure).
• Occult / de novo stress incontinence after anterior repair.
• Keratinisation of exposed vaginal epithelium.
• Surgical: recurrence, dyspareunia, vault prolapse/enterocele after hysterectomy, mesh erosion (sacrocolpopexy), cervical stenosis & pregnancy loss (Manchester).
• Rarely, malignant change in a chronic decubitus ulcer (uncommon — biopsy non-healing ulcers).

Key differentials

A prolapse mass at the introitus must be distinguished from other causes of a "mass coming down":

Condition	Distinguishing feature
Chronic uterine inversion	Mass is the inverted fundus; no cervix felt around it; bimanual shows absent fundus
Cervical / endometrial polyp	Pedicle traceable to cervix; uterus normally placed
Congenital cervical elongation	Long cervix but body of uterus well supported
Gartner's duct / vaginal cyst	Cystic, anterolateral wall, mobile, intact overlying mucosa
Fibroid polyp / chronic inversion	Firm mass, may bleed; ultrasound clarifies
Urethral diverticulum / caruncle	Tender anterior swelling, urethral origin

High-yield: A protruding mass with no palpable cervix and an absent uterine fundus on bimanual suggests chronic uterine inversion, not prolapse — a classic distractor.

Recently asked / exam angle

• Operation of choice at each grade is the single most repeated theme: cystocele → anterior colporrhaphy; rectocele → posterior colporrhaphy; young woman with cervical elongation → Manchester; multipara complete family → vaginal hysterectomy + repair; frail elderly → Le Fort colpocleisis.
• Essential step of Manchester operation → plication of cardinal ligaments (not cervical amputation).
• POP-Q reference point = hymen (0); Stage II = within ±1 cm of hymen.
• Enterocele = only true hernia; commonest prolapse after hysterectomy.
• DeLancey Level I = uterosacral/cardinal ligaments = apical support; its loss causes vault prolapse.
• Gold standard for vault prolapse = abdominal sacrocolpopexy.
• Decubitus ulcer is benign/trophic, not malignant; manage with pessary/rest, biopsy if non-healing.
• Ring pessary for conservative management and for prolapse in pregnancy.
• Image/clinical: differentiate chronic inversion (no cervix, absent fundus) from procidentia.
• Nulliparous prolapse = supravaginal cervical elongation.

Rapid revision

1. Multiparity is the single most important risk factor for prolapse.
2. DeLancey Level I (uterosacral + cardinal ligaments) is the main apical support; loss → uterovaginal/vault prolapse.
3. Enterocele is the only true hernia and the commonest prolapse after hysterectomy.
4. POP-Q hymen = 0; above negative, below positive; Stage II = −1 to +1 cm.
5. Baden-Walker: Grade 4 = complete eversion = procidentia.
6. Uterine descent: 1° in vagina, 2° at introitus, 3° (procidentia) outside introitus.
7. Manchester (Fothergill) operation = cervical amputation + cardinal ligament plication + anterior repair; preserves uterus.
8. Vaginal hysterectomy + pelvic floor repair for multipara with completed family.
9. Le Fort colpocleisis for frail, sexually inactive elderly — vagina becomes unusable.
10. Abdominal sacrocolpopexy is the gold standard for vault prolapse.
11. Ring pessary = first-line conservative device and treatment in pregnancy (defer surgery).
12. Decubitus ulcer is a benign trophic ulcer; chronic uterine inversion (no cervix, absent fundus) is the key mimic of procidentia.