Pelvic organ prolapse happens when weak pelvic floor support lets the bladder, uterus or rectum drop into the vagina; a bladder prolapse (cystocele) bulges through the front wall. Risk factors include vaginal birth, aging, menopause, obesity, chronic cough and constipation.
Key symptoms
- Pressure, heaviness or a bulge in the vagina, worse at the end of the day
- Slow stream, incomplete emptying or pushing the bulge back to urinate
- Urine leakage, urgency or repeated bladder infections
- Discomfort with sex or a low backache
What you find on exam
- Pelvic exam with a split speculum at rest and while straining
- Bulge of the front vaginal wall in a cystocele
- Grade how far it descends (POP-Q staging)
- Look for ulcers and vaginal atrophy; check for stress leakage
Tests
- Urinalysis and urine culture if there are urinary symptoms
- Post-void residual to check for retention
- Kidney function and renal ultrasound if severe prolapse may block the ureters
- Urodynamic testing before surgery in selected women
Treatment basics
- Watchful waiting if mild and not bothersome
- Pelvic floor muscle training, ideally with a physical therapist
- Vaginal pessary fitted in the office
- Vaginal estrogen for atrophy and to protect the tissue
- Surgery: anterior repair, apical suspension or a closing procedure
Red flags
- Urinary retention or blocked kidneys (hydronephrosis)
- Ulcer or bleeding on the prolapsed tissue
- Prolapse that is stuck and cannot be pushed back
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.