Pelvic organ prolapse in women: Choosing a primary surgical procedure

INTRODUCTION — Pelvic organ prolapse (POP) affects millions of females; approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States [1,2]. Eleven to 19 percent of females will undergo surgery for prolapse or incontinence by age 80 to 85 years, and 30 percent of these individuals will require an additional prolapse repair procedure [3-5].

Patients with symptomatic POP experience daily discomfort, and may also experience interference with sexual function and exercise. Reconstructive surgery for those with POP consists of some combination of resuspension of the vaginal apex and anterior and posterior vaginal walls. The choice of a primary surgical procedure for people with POP depends upon a variety of considerations, including the anatomic site(s) of prolapse, presence of concomitant urinary or fecal incontinence, health status, and patient preferences.

The process of choosing a surgical procedure for patients with POP who have not undergone a prior prolapse repair will be reviewed here. The clinical presentation, evaluation, and management options for patients with POP are discussed separately.

●(See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)

●(See "Pelvic organ prolapse in women: Diagnostic evaluation".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

CANDIDATES FOR SURGICAL TREATMENT — Candidates for surgical repair of POP are women with symptomatic prolapse who have unsuccessful or who have declined conservative management.

Symptomatic prolapse — Reconstructive surgery for POP should be performed only in women who have symptomatic prolapse, with rare exceptions. Surgical correction of asymptomatic POP or non-bothersome POP poses risk without known health benefits.

POP symptoms include pelvic pressure, sensation of a vaginal bulge, urinary retention, and/or difficult defecation; some women need to reduce the prolapse using a finger in the vagina (also referred to as splinting) to urinate or defecate. Prolapsed vaginal tissue may protrude, leading to chronic discharge and bleeding from ulceration. Such symptoms may interfere with daily activities, sexual function, or exercise. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

Many women are asymptomatic despite demonstrable loss of vaginal support; approximately 40 percent of women have stage 2 or greater prolapse upon routine pelvic examination [6-9]. There is no indication for repair of asymptomatic POP as an isolated procedure.

When women undergo other pelvic procedures (eg, vaginal hysterectomy, stress urinary incontinence [SUI] surgery), some surgeons repair asymptomatic support loss to prevent the need for subsequent surgery. This practice is based upon the assumption that prolapse will progress. While this approach makes sense to patients and surgeons, the practice is not evidence-based and may increase surgical morbidity. Interestingly, the natural history of prolapse does not follow a progressive course in all women. Data suggest that the course is progressive until menopause, after which the degree of prolapse may follow a course of alternating progression and regression [10-12]. On the other hand, in addition to premenopausal status, risk factors for the progression of POP include obesity and hysterectomy [13,14]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Risk factors'.)

Given the paucity of data regarding repair of asymptomatic support loss, for most women with asymptomatic stages 0 to 2 support who are undergoing other pelvic floor procedures (eg, SUI surgery), we suggest not performing prolapse repair. Prolapse repair for asymptomatic women at the time of other pelvic surgery is a reasonable option in women with advanced prolapse (stages 3 or 4) or risk factors for prolapse progression (eg, concomitant hysterectomy, premenopausal status, obesity).

Combined surgical treatment of POP and SUI is discussed separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'SUI with asymptomatic POP'.)

Patients who decline or have persistent symptoms despite conservative therapy — First line management of POP is conservative therapy. The mainstay of nonsurgical treatment for POP is the vaginal pessary. Pessaries are silicone devices that are inserted into the vagina and support the pelvic organs. Pelvic floor muscle exercise is another conservative treatment option. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Conservative management'.)

Prolapse is typically a chronic problem, and many women ultimately prefer surgery to conservative therapy since successful surgery does not require ongoing maintenance. In the patients who can be fit with a pessary, approximately 50 percent of women discontinue pessary use within one to two years of use [15]. It is difficult to estimate how many women who choose to have a pessary go on to have surgery. (See "Vaginal pessaries: Indications, devices, and approach to selection", section on 'Symptom resolution'.)

Patients finished with childbearing — Pelvic support may be disrupted during pregnancy or birth, particularly vaginal birth. Most surgeons recommend delaying surgical management of symptomatic POP until childbearing is complete. Small case studies have reported successful pregnancy after uterus-sparing surgery, but no study has specifically investigated the risk of developing recurrent POP after delivery.

Young or older adult patients — Patients at a young age are at higher risk of prolapse recurrence but lower overall risk of complications from surgery compared with older women (table 1) [16-18]. However, procedures with longer efficacy (eg, abdominal sacral colpopexy rather than vaginal sacrospinous ligament suspension) have higher surgical risk. Thus, it is recommended, especially for younger patients, to understand that choosing procedures with higher efficacy may come at the expense of higher risk.

POP repair can be safely performed in many older adult women, although patients ages 80 years or older appear to have higher surgical risk [19]. Older women are at lower risk of recurrence and higher risk of complications from surgery compared with younger women [16-18]. In a retrospective cohort study of women who underwent a primary procedure for incontinence or prolapse, cumulative incidence of a repeat surgery (not just risk of recurrence) for either POP or SUI was greater for women ages 65 or older compared with those under age 65 (9.9 versus 7.8 percent) [5]. Analysis of a United States national database reported double (4.5 versus 9 percent) the risk of surgical complications for patients 80 years or older undergoing POP surgery, regardless of frailty index [19]. Compared with individuals ages 45 to 64 years, those 80 or older had greater risks of cardiac complications, stroke, and mortality. However, there did not appear to be increased risk in individuals ages 65 to 79 compared with individuals ages 45 to 64.

Individuals with obesity — Although obesity is a risk factor for new onset and recurrent POP [16,17], individuals with obesity appear to have no difference in outcome of surgical correction of apical prolapse compared with those without [20]. Many surgeons feel that patients with obesity are good candidates for the most durable repair, abdominal sacral colpopexy. Unfortunately, the open abdominal approach in the patient with obesity increases the risk usually in the form of wound complications [21].

GENERAL APPROACH TO THE CHOICE OF PROCEDURE — The choice of a primary procedure for POP includes a variety of factors:

●Reconstructive or obliterative – Most women with symptomatic POP are treated with a reconstructive procedure. Obliterative procedures (eg, colpocleisis) are reserved for women with medical comorbidities that increase risk for more extensive surgery or who are not planning future vaginal intercourse.

●Concomitant hysterectomy – When apical prolapse is repaired, an intentional decision to perform or avoid concomitant hysterectomy is needed.

●Surgical route for repair of multiple sites of prolapse – Reconstructive surgery for POP often involves repair of multiple anatomic sites of prolapse (apical, anterior, posterior). The choice of surgical route depends upon the optimal approach for the combination of prolapse sites.

●Concomitant anti-incontinence surgery – Symptomatic POP often coexists with stress urinary incontinence and, in some women, anal incontinence. POP repair should be coordinated with treatment of incontinence.

●Use of surgical mesh – Surgical mesh is used in abdominal POP repair. Use in transvaginal procedures is based on the indication and risks and benefits for the individual woman.

A summary of all major decisions involved in choosing a primary surgical procedure to repair POP is presented in the figure (algorithm 1).

RECONSTRUCTIVE VERSUS OBLITERATIVE PROCEDURES — The choice of a reconstructive or obliterative procedure depends upon the medical status and sexual activity of the patient.

Reconstructive surgery surgically corrects the prolapsed vagina and aims to restore normal anatomy, while obliterative surgery corrects prolapse by removing and/or closing off all or a portion of the vaginal canal (ie, colpocleisis or colpectomy) to reduce the pelvic viscera back into the pelvis [22]. Another difference between the two types of procedures is that reconstructive surgery can be performed using a vaginal or abdominal approach, while all obliterative surgeries are performed using the vaginal approach.

Most women with symptomatic POP are treated with a reconstructive procedure. Obliterative procedures are reserved for women with medical comorbidities that increase risk for more extensive surgery or who are not planning future vaginal intercourse [23]. The advantages of obliterative procedures in this population are that such procedures typically have a short operative duration, low risk of perioperative morbidity, and an extremely low risk of prolapse recurrence. The obvious disadvantages are the elimination of the potential for vaginal intercourse. If the uterus or cervix are left in situ, there is also an inability to evaluate the cervix or uterus via a vaginal route (eg, cervical cytology or endometrial biopsy).

Obliterative procedures for POP are discussed in detail separately. (See "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)".)

CONCOMITANT HYSTERECTOMY — Hysterectomy is often performed at the time of POP repair. This practice is dependent upon the surgical technique used for pelvic reconstruction and other potential benefits. On the other hand, there is concern that concomitant hysterectomy may increase the risk of some perioperative complications (eg, mesh erosion) and, additionally, an increasing number of women wish to conserve their uterus as an important component of their body image.

Assess patient preferences — We perform shared decision-making with the patient to determine the role of hysterectomy at the time of surgery for POP. We find both discussion and written patient-education materials helpful. Patient decision aids are effective in facilitating shared decision-making and may be helpful in supporting patient-centered decisions at the time of POP surgery. A meta-analysis of 35 trials demonstrated that the use of patient decision aids reduced decisional conflict and improved patient knowledge but did not significantly reduce patient anxiety or impact satisfaction [24]. While a question-based instrument that measures patients' preferences for uterine preservation during POP surgery is available and may help clarify preferences or facilitate discussion with the surgeon, it has not been sufficiently evaluated to determine effectiveness as a patient decision aid [25].

Evidence for hysterectomy — During POP repair, surgeons have generally performed hysterectomy rather than uterus-sparing procedures based upon several assertions:

●Role in apical prolapse repair – Apical prolapse is often present in women with symptomatic prolapse, and the most commonly performed techniques for apical prolapse repair require hysterectomy. In sacral colpopexy and transvaginal native tissue repairs, such as uterosacral vaginal vault suspension and sacrospinous ligament suspension, hysterectomy is required because the apex is elevated by affixing the vaginal cuff or remaining cervix to a support structure (eg, the sacrospinous ligament or the anterior longitudinal ligament of the sacrum).

Discussion of the various vaginal approaches for surgical treatment of apical prolapse, with or without a uterus, are presented in detail in related topics. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Vaginal surgical approach'.)

●Concern for increased recurrence risk with uterus retention – The common wisdom has been that retaining the uterus increases the risk of recurrent prolapse, although there are limited data to support this. There are three underpowered studies that describe uterine preservation at the time of surgery for POP and uterine preservation did not affect the risk of POP recurrence [26-28]. Another study compared 421 women who underwent vaginal vault prolapse with 601 women who underwent uterovaginal prolapse apical repair reported no significant differences in success rates, changes in prolapse related symptoms, or serious adverse events one to two years postoperatively [29].

●Exclusion of pathology – Hysterectomy eliminates current or future risk of cervical or intrauterine pathology. However, such benefits are less relevant with current advances in minimally invasive treatment of abnormal uterine bleeding and in cervical cancer screening. Uterine cancer typically presents at an early stage with uterine bleeding, and thus, preventive measures are not routinely recommended for patients at average risk.

In a retrospective analysis of pathology findings at reconstructive pelvic surgery with hysterectomy, over a 3.5-year period, 17 of 644 patients (2.6 percent) had unanticipated premalignant or malignant uterine pathology. Two (0.3 percent) had endometrial carcinoma. All cases of unanticipated disease were identified in postmenopausal women [30].

Potential disadvantages of hysterectomy and the associated pelvic floor dissection are an increased risk of pelvic neuropathy and disruption of natural support structures such as the uterosacral cardinal ligament complex [31].

Evidence for uterus-sparing procedures — Uterus-sparing procedures correct apical prolapse by attaching the lower uterus or cervix to a support structure [32]. Advantages of uterus-sparing techniques are a shorter operative duration and less blood loss; however, the evaluation of uterus-sparing procedures is in early phases [26,27,33-37]. There is conflicting evidence that uterus-sparing procedures are inferior to procedures that include hysterectomy in the short term.

●Two randomized trials in women with stage 2 or higher POP that compared transvaginal sacrospinous hysteropexy with vaginal hysterectomy (with uterosacral or sacrospinous ligament suspension of the vaginal vault) yielded consistent results: the rate of prolapse recurrence after 9 to 12 months was higher in women who underwent hysteropexy in both trials but reached statistical significance in one trial (27 versus 3 percent [35]) and not the other (25 versus 13 percent [34]). Operative duration (59 versus 120 minutes in one trial [34]) and blood loss (20 versus 120 mL in one trial [34]) were decreased for sacrospinous hysteropexy compared with vaginal hysterectomy; complication rates were similar for the two groups.

●In a multicenter, noninferiority trial, 208 women were randomized to either sacrospinous hysteropexy or vaginal hysterectomy with suspension of the uterosacral ligaments [37]. The predefined noninferiority margin was an increase in surgical failure rate of 7 percent. At 12 months, sacrospinous hysteropexy was noninferior for anatomical recurrence of the apical compartment with bothersome bulge symptoms or repeat surgery (n = 0) compared with vaginal hysterectomy with suspension of the uterosacral ligaments (n = 4, 4 percent, difference -3.9 percent, 95% CI -8.6-0.7).

An aspirational goal of uterus-sparing surgery is a decreased impact on sexual function; however, there is no evidence supporting this outcome. Two studies of this issue reported no difference in effect on sexual function in women who underwent sacrospinous hysteropexy compared with vaginal hysterectomy or vaginal hysterectomy with suspension of the uterosacral ligaments [37,38]. Also, studies of hysterectomy for POP and other indications have generally not demonstrated any clear impact on sexual function.

Uterus-sparing techniques offer the potential for preserving fertility. There are few data, however, regarding the risk of intrapartum complication and postpartum recurrence of prolapse following these procedures [27,39].

While uterus-sparing techniques may offer benefits of decreased operative duration and blood loss, their noninferiority to hysterectomy techniques and decreased risk remains unproven. Given the current data, for women undergoing apical prolapse repair, we suggest performing concomitant hysterectomy rather than uterine preservation. A uterus-sparing procedure performed by a surgeon familiar with the necessary techniques is a reasonable alternative for women who strongly prefer to retain their uterus and are aware of the potential risk of recurrent prolapse requiring need for future hysterectomy and the uncertainty regarding the impact of future pregnancy on the durability of the repair.

CONCOMITANT REPAIR OF APICAL AND ANTERIOR OR POSTERIOR PROLAPSE — Reconstructive surgery for POP often involves repair of multiple anatomic sites of prolapse (apical, anterior, and/or posterior). Repair of each prolapse site and how to best perform a combined reconstruction must be considered when choosing an overall surgical approach. The common teaching is that all procedures should be performed using one route (vaginal or abdominal), since it is generally preferred to avoid both abdominal and vaginal incisions. In some instances, however, surgeons may combine the two surgical approaches.

Choice of surgical route is mainly of concern in women who require repair of apical prolapse, since isolated repair of anterior or posterior vaginal wall prolapse is typically performed transvaginally (posterior prolapse can also be repaired endoanally). Repair of apical prolapse abdominally with sacral colpopexy results in a lower rate of recurrence, while transvaginal repair (eg, sacrospinous ligament fixation, uterosacral ligament fixation) has a shorter recovery and less morbidity. The choice of surgical technique for specific anatomic sites of prolapse is discussed separately. (See "Surgical management of posterior vaginal defects", section on 'Surgical approaches' and "Pelvic organ prolapse in women: Surgical repair of anterior vaginal wall prolapse".)

Patients with apical prolapse are more likely to have anterior prolapse and less likely to experience posterior prolapse [40]. It is controversial whether repair of apical prolapse is sufficient to support the anterior and posterior vaginal walls or if additional procedures are required to address anterior and/or posterior prolapse. If the vaginal muscularis is well suspended at the apex, many anterior defects (55 percent in one study) [41] and some posterior defects will resolve. On the other hand, correction of anterior or posterior prolapse does not repair apical descent. The approach to concomitant repair of multiple sites of prolapse varies by surgical route and by site of prolapse.

Repair of anterior or posterior prolapse alone appears to have a higher failure rate than when these procedures are combined with apical prolapse repair. This was illustrated in United States national study of 2756 women and found the following 10-year reoperation rates: anterior repair versus combined anterior and apical repair (20.2 versus 11.6 percent); anterior and posterior repair versus combined anterior, posterior, and apical repair (14.7 versus 10.2 percent); and posterior repair versus combined posterior and apical repair (14.6 versus 12.9 percent) [42]. Hysterectomy for prolapse and the omission of appropriate prolapse repairs are risk factors for reoperation of prolapse [43,44]. The incidence of reoperation within 10 years of surgery is 7.4 percent when vaginal hysterectomy is done alone for prolapse and just 2 percent when concomitant pelvic floor repairs are undertaken at the time of hysterectomy [43]. The long-recognized importance of apical vaginal support has also been quantified in biomechanical studies. Support of the vaginal apex eliminates anterior vaginal wall laxity in 63 percent of women with stage 3 or 4 apical prolapse [41] and these analyses reveal that >70 percent of anterior wall prolapse is accounted for by loss of uterine or apical vaginal prolapse [45,46].

Abdominal route — The abdominal route has been used for the repair of both anterior and posterior prolapse.

Anterior prolapse — Among women undergoing sacral colpopexy who also have symptomatic anterior prolapse, anterior vaginal wall support can be achieved transabdominally either by sacral colpopexy alone or by a combined procedure with paravaginal repair. Data are limited on the efficacy and comparative efficacy of these procedures:

●A systematic review of 62 studies of sacral colpopexy found few data regarding the efficacy of sacral colpopexy alone for anterior prolapse [47].

●A literature review of five observational studies reported that combined sacral colpopexy and paravaginal repair successfully treated anterior prolapse in 76 to 97 percent of women [48].

●The only comparative study was a retrospective cohort study of 170 women in which a conclusion could not be reached since only six patients required reoperation for anterior prolapse recurrence [49].

Unfortunately, inter- and intra-examiner reliability of the clinical examination for central, superior, and right and left paravaginal defects is poor [50]. Since it is difficult for examiners to agree on whether a paravaginal defect is present, in our practice, we do not routinely perform paravaginal defect repairs for anterior wall support and feel that a good apical suspension obviates the need for a separate repair of the anterior wall. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Inspection for paravaginal defects'.)

Posterior prolapse — Repair of posterior vaginal wall prolapse at the time of abdominal surgery can be performed in one of three ways:

●Modifying the sacral colpopexy to extend the posterior mesh down the rectovaginal septum. Some data suggest that extending the mesh to the perineal body using a combined abdominal and vaginal approach (sometimes referred to as sacral colpoperineopexy) increases the risk of mesh erosion [51].

●Posterior colporrhaphy, which is a vaginal procedure.

●Endoanal or endorectal posterior repair; however, the transvaginal approach appears to be superior to these approaches. (See "Surgical management of posterior vaginal defects", section on 'Vaginal versus transanal approach'.)

In the Colpopexy and Urinary Reduction Efforts (CARE) trial, which evaluated the role of Burch colposuspension in women undergoing sacral colpopexy, 87 of 298 women (29 percent) underwent posterior vaginal wall repair in which colporrhaphy, perineorrhaphy, or sacral colpoperineopexy was used according to surgeon discretion [52]. Women who did or did not undergo posterior repair had a similar rate of improvement in bowel symptoms, including obstructive symptoms (constipation, incomplete emptying and of pain and/or irritation with defecation); posterior anatomic outcomes were also similar for the two groups.

Observational studies of sacral colpopexy with posterior mesh extension, but without posterior colporrhaphy, have had widely variable results. In two prospective studies, the rate of recurrence of posterior prolapse varied from 8 percent at one year [53] to 57 percent at two years [54].

The decision to perform a posterior colporrhaphy is dependent upon whether the patient has patient’s posterior prolapse-related and/or defecatory symptoms and the degree of prolapse of the posterior wall. In our practice, in patients with posterior wall prolapse, we extend the mesh down the posterior vaginal wall to the lower half of the vagina. When symptoms are bothersome and/or the prolapse of the posterior wall extends to or beyond the hymen, we generally perform a posterior colporrhaphy.

Vaginal route — In women undergoing a transvaginal apical suspension, the optimal management of separately addressing anterior and posterior wall prolapse is unclear. Many surgeons perform a simultaneous anterior or posterior colporrhaphy, while others think that an effective vaginal apical suspension obviates for a separate anterior or posterior procedure.

Recurrence rates are higher following vaginal compared with open abdominal prolapse repairs despite maintenance of improved prolapse symptoms and low retreatment rates. A two-by-two trial comparing the outcomes of two vaginal procedures (uterosacral ligament suspension [ULS] or sacrospinous ligament fixation [SSLF]) and two perioperative treatments (behavioral therapy and pelvic floor muscle training compared with usual care) reported a nonsignificant difference in surgical failure rates at five years of follow-up regardless of perioperative treatment (61.5 percent for ULS and 70.3 percent for SSLF) [55]. The estimated proportions of women with anatomic failure were 47.5 and 61.8 percent and with bothersome bulge symptoms were 37.4 and 41.8 percent, respectively. The proportion of women undergoing retreatment for prolapse by five years was also similar (11.9 percent for ULS and 8.1 percent for SSLF). Repeat treatments included pessary (6.0 and 4.5 percent), repeat surgery (8.5 and 4.6 percent); and both pessary and surgery (2.5 and 1.0 percent).

High rates of anterior wall prolapse have been reported for sacrospinous ligament suspension or uterosacral ligament suspension in combination with anterior colporrhaphy (29 percent), and even higher for anterior colporrhaphy alone (30 to 40 percent) [56]. However, most of these studies used a definition of failure defined as recurrence of stage 2 or higher; new evidence suggests that this definition is too strict and has been based on expert opinion only and not data. Current evidence supports a definition of success as a patient’s perception of bother, which typically corresponds to prolapse beyond the hymen [57]. Using this definition, most studies investigating the efficacy of anterior colporrhaphy show high success rates and low reoperation rates. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Outcome' and "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Outcome' and "Pelvic organ prolapse in women: Surgical repair of anterior vaginal wall prolapse".)

In our practice, when apical prolapse, as well as stage 2 anterior or posterior vaginal wall prolapse, are present during the preoperative examination, we perform an anterior or posterior colporrhaphy in addition to a transvaginal apical suspension.

CONCOMITANT INCONTINENCE SURGERY

Urinary incontinence — Symptomatic POP often coexists with stress urinary incontinence (SUI). Women with symptoms of both POP and SUI are treated with a combined prolapse repair and continence procedure.

Another important patient population consists of women with stage 2 or higher apical prolapse who remain continent despite loss of anterior vaginal and bladder/urethral support. Unfortunately, 13 to 65 percent of continent women develop symptoms of SUI after surgical correction of prolapse. This likely occurs because the prolapse kinks the urethra, obstructing urine outflow; this obstruction is alleviated when the prolapse is repaired. This is referred to as "occult" or "potential" stress incontinence.

Women without symptoms of SUI who are planning surgery for apical prolapse should have a preoperative evaluation for occult SUI with clinical or urodynamic urinary stress testing with and without reduction of prolapse. However, preoperative prolapse reduction testing alone does not accurately predict postoperative stress incontinence (approximately 40 percent of women with negative testing will develop postoperative stress incontinence).

A prediction model exists for calculating a woman's individual risk of postoperative SUI after surgery for prolapse in women who do not have SUI before surgery [58]. The calculator, which has been tested in an independent, international cohort, can inform the patient and surgeon's decision regarding performance of a concomitant continence procedure at the time of prolapse surgery [59].

For women with stage 2 or greater POP who are undergoing abdominal sacral colpopexy, regardless of the results of preoperative testing for occult SUI, high-quality data support a concomitant Burch colposuspension rather than sacral colpopexy alone. Similarly, for women with stage 2 or greater POP who are undergoing vaginal vault suspension, regardless of the results of preoperative testing for occult SUI, a concomitant midurethral sling rather than vaginal vault suspension alone significantly decreases the risk of postoperative SUI, but is accompanied by an increase in postoperative complications [60]. Concomitant surgery for POP and SUI is discussed in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)

Anal incontinence — Repair of POP may improve symptoms in women who have bothersome symptoms of both POP and anal incontinence. When POP is the patient's primary symptom, some surgeons choose to repair POP prior to recommending surgery for anal incontinence.

Data are mixed regarding the impact of POP repair, specifically rectocele repair, on anal incontinence [61-64]. A prospective study of 101 women undergoing rectocele repair reported that 63 percent who had anal incontinence preoperatively reported resolution or improvement in these symptoms at one year after surgery [61]. In contrast, in a retrospective series of 231 women who underwent posterior colporrhaphy, the prevalence of fecal incontinence increased postoperatively from 4 to 11 percent, and 19 percent of patients developed incontinence of flatus [62]. Further study is needed to evaluate this issue.

Anal incontinence is discussed in detail separately. (See "Fecal incontinence in adults: Etiology and evaluation".)

MESH AUGMENTATION — Surgical mesh use is standard in abdominal sacral colpopexy. The use of surgical mesh for transvaginal POP repair has been introduced with the goal of reducing the risk of recurrent prolapse, but this approach is controversial. At present, potentially higher success rates resulting from the use of some mesh products for the anterior, and possibly the apex, of the vagina are accompanied by a higher complication rate than traditional vaginal surgery.

●A trial comparing transvaginal mesh hysteropexy with vaginal hysterectomy/suture apical suspension reported similar 36-month recurrence outcomes for both groups (adjusted hazard ratio 0.61, 95% CI 0.37-1.02) [32]. Compared with suture suspension, the mesh hysteropexy group had higher rates of mesh exposure (8 versus 0 percent) but lower rates of ureteral kinking managed intraoperatively (0 versus 7 percent), granulation tissue at 12 weeks (1 versus 11 percent), and suture exposure after 12 weeks (3 versus 21 percent). The product used in this trial is no longer available in many countries, including the United States.

Use of surgical mesh in pelvic reconstructive surgery is discussed in detail separately. (See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse" and "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Pelvic organ prolapse (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Candidates for surgery – Surgical candidates for pelvic organ prolapse (POP) repair are women with symptomatic prolapse who decline or have persistent symptoms despite conservative therapy (eg, vaginal pessaries). (See 'Candidates for surgical treatment' above.)

●Asymptomatic POP – For patients with asymptomatic POP, we suggest not performing prolapse repair, either as an isolated procedure or in conjunction with other pelvic surgery (eg, stress urinary incontinence [SUI] surgery) (Grade 2C). Prolapse repair at the time of other pelvic surgery is a reasonable option in women with advanced prolapse or women with risk factors for developing prolapse progression (eg, concomitant hysterectomy, premenopausal status, obesity).

●Obliterative surgery – Individuals who are older, do not plan future vaginal intercourse, and/or have excessive medical risks for extensive surgery are candidates for obliterative POP surgery. (See 'Reconstructive versus obliterative procedures' above.)

●Hysterectomy with apical prolapse repair – For women undergoing apical prolapse repair, we suggest performing concomitant hysterectomy rather than uterine preservation (Grade 2B). A uterus-sparing procedure performed by a surgeon familiar with the necessary techniques is a reasonable alternative for women who strongly prefer to preserve their uterus and are aware of the potential risk of recurrent prolapse and the uncertainty regarding obstetric outcomes. (See 'Concomitant hysterectomy' above.)

•Abdominal apical suspension – For women who are undergoing an abdominal apical suspension procedure who require repair of anterior and/or posterior vaginal wall prolapse (see 'Abdominal route' above):

-For women with anterior vaginal wall prolapse, we suggest apical suspension alone rather than combined with abdominal paravaginal repair (Grade 2C).

-For most women with posterior vaginal wall prolapse who are planning an abdominal sacral colpopexy, we suggest extending the vaginal mesh from the apical suspension down the posterior vaginal wall to the lower half of the vagina (Grade 2C). When symptoms are bothersome and/or the prolapse of the posterior wall extends to or beyond the hymen, we suggest performing a posterior colporrhaphy (Grade 2C).

•Vaginal apical suspension – Uterosacral ligament suspension and sacrospinous ligament suspension are two commonly performed vaginal surgical procedures. Recurrence rates are similar and higher than open sacral colpopexy, despite maintenance of improved prolapse symptoms, fewer adverse events, and low retreatment rates. (See 'Vaginal route' above.)

●Role of colporrhaphy – For patients who are undergoing a transvaginal apical suspension procedure who require repair of anterior and/or posterior vaginal wall prolapse, we suggest concomitant anterior and/or posterior colporrhaphy (Grade 2C). (See 'Vaginal route' above.)

●Evaluate for urinary incontinence – POP often coexists with SUI. All women planning repair of apical prolapse should have a preoperative evaluation for SUI, which may involve clinical or urodynamic urinary stress testing, both with and without reduction of prolapse. However, preoperative prolapse reduction testing alone does not accurately predict postoperative stress incontinence (approximately 40 percent of women with negative testing will develop postoperative SUI). This testing may impact surgical decision making, particularly for women undergoing transvaginal apical prolapse repair. (See 'Urinary incontinence' above.)

●Prophylactic surgery for SUI – Patients with symptomatic apical POP and no SUI symptoms may have occult SUI and may benefit from a prophylactic continence procedure at the time of POP repair. A patient's individual risk can be calculated using a de novo SUI risk calculator. (See 'Urinary incontinence' above and "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)

●Use of transvaginal synthetic mesh – Use of surgical mesh for transvaginal POP repair has potentially higher anatomic success rates than repair without mesh, but also appears to result in similar subjective success rates and a higher complication rate than traditional vaginal surgery.

•(See 'Mesh augmentation' above.)

•(See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)

•(See "Transvaginal synthetic mesh: Complications and risk factors".)