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.
Article Last Updated: 12 July 2025
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Pelvic Organ Prolapse (POP)
Pelvic organ prolapse (POP) occurs when one or more pelvic organs descend from their normal position into or through the vagina because the pelvic floor support structures become weakened. It may involve the bladder, uterus, vaginal vault, rectum, or bowel.
This updated UKMLA guide to POP is based on NICE NG123 and NG 210, which covers types, staging, risk factors, symptoms, diagnosis, and management.
Definition
POP refers to the descent or herniation of pelvic organ(s) from their normal anatomical position into or through the vagina due to weakness of the pelvic floor support structures.
Classification
Classification by Anatomy
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
Classification by Severity
NICE recommends using the Pelvic Organ Prolapse Quantification (POP-Q) system:
Stage
Description(location of the 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 outside the vagina
4
Complete eversion – visible outside the vagina
Causes and Risk Factors
POP results from weakening of the pelvic floor support structures (muscles, fascia and ligaments) that maintain pelvic organ position.
Supervised pelvic floor muscle training programme (at least 16 weeks) is 1st line for symptomatic stage 1 and 2 POP
Vaginal pessary
Consider a pessary in all stages of POP
Can be inserted in a clinic
Advise to remove once every 6 months (to prevent and monitor for complications like ulceration, infection or displacement)
All symptomatic POP patients should be offered nonsurgical management first, which includes pelvic floor muscle training and/or a pessary trial. [Ref]
2nd Line: Surgical Management
Offer surgery if symptoms persist despite non-surgical options or declined non-surgical options.
Type of prolapse
Surgical options
Uterine prolapse
Vaginal hysterectomyRemoval of the uterus through the vaginal route +/- vaginal sacrospinous fixationAnchors the apex of the vagina to a pelvic ligament
Vaginal sacrospinous hysteropexyUterus suspended by suturing it to the sacrospinous ligament
Manchester repairInvolves - Removal part of the cervix - Shortening and repositioning of the uterosacral and cardinal ligaments to lift the uterus
SacrohysteropexyMesh used to suspend the prolapse uterus
Vault (vaginal) prolapse
Vaginal sacrospinous fixationAnchors the apex of the vagina to a pelvic ligament
SacrohysteropexyMesh used to suspend the prolapse uterus
Anterior wall prolapse
Anterior colporrhaphyTightening and reinforcing the weakened anterior vaginal walls with sutures
Posterior wall prolapse
Posterior colporrhaphyTightening and reinforcing the weakened posterior vaginal walls with sutures
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