Genital Prolapse — Pelvic Supports, POP-Q Staging and Surgical Options

Pelvic organ prolapse (POP) is the descent of the anterior or posterior vaginal wall, the uterus, cervix or vaginal apex into or beyond the vaginal canal, caused by weakness of the muscles, fascia and ligaments of the pelvic floor. Adjacent organs — bladder, rectum or small bowel — herniate into the vagina, producing a cystocele, rectocele, enterocele or uterine prolapse. Mild prolapse can be asymptomatic; it becomes clinically significant when the woman has pelvic pressure, a vaginal bulge, voiding or defecation difficulty, incontinence or sexual dysfunction.

Vaginal support is described in three DeLancey levels: Level I — the apex, held by the cardinal-uterosacral ligament complex; Level II — the mid-vagina, held by the endopelvic fascia (attachment to the pelvic wall); Level III — the distal vagina, supported by the perineal body.

• Vaginal childbirth is the most significant risk factor — especially high parity, large birthweight, forceps delivery, prolonged labour and the first vaginal delivery.
• Age, obesity, genetic predisposition and connective-tissue disorders.
• Chronically raised intra-abdominal pressure — chronic cough, constipation, heavy lifting.
• Previous pelvic surgery or hysterectomy.
• Menopause alone is not directly associated with prolapse once age is accounted for; age is the consistent factor.

The Pelvic Organ Prolapse Quantification (POP-Q) system was published by Bump and colleagues in 1996 (International Continence Society standardisation). It uses the hymen as a fixed reference point (0). Measurements are in centimetres; positions above (proximal to) the hymen are negative and below (distal to) the hymen are positive. The examination is performed in the dorsal lithotomy position with the patient straining (Valsalva). It records nine measurements in a tic-tac-toe grid, which improves inter-observer agreement.

The stage is determined by the most distal portion of the prolapse relative to the hymen. Using the thresholds below (as applied in a 2026 study that staged anterior prolapse using point Ba):

• Strengths: objective, site-specific and reproducible; the standard for research and outcome reporting since 1996.
• Limitations: harder to learn, only about 40% of specialists used it routinely in one survey; the patient's position affects results; it does not identify unilateral or asymmetrical defects.
• A simplified POP-Q measuring only four points (Aa, Ba, C, D) correlates well with the full system.

Start with a thorough history: vaginal bulge, pressure, urinary symptoms (stress or urge incontinence, voiding difficulty, manual splinting), bowel symptoms (straining, incomplete evacuation, faecal incontinence) and sexual function. Examination begins with inspection of the vulva and vaginal mucosa (atrophy, ulceration), then a split-speculum or single-blade Sims speculum examination during Valsalva or cough to bring out the maximum prolapse, checking all three compartments. If prolapse is not fully seen supine, examine again standing. Pelvic floor muscle strength is graded absent, weak, normal or strong.

The clinical pelvic examination remains the cornerstone. Dynamic MRI or defecography is for complex or multicompartment cases; post-void residual, urodynamics or stress testing with the prolapse reduced assess coexisting urinary dysfunction. Management is guided by both the symptoms and the POP-Q stage.

• Observation for mild, asymptomatic prolapse. Among symptomatic women who defer treatment, about 78% had no significant anatomical progression over about 16 months, while about 29% progressed to prolapse beyond the hymen within a year.
• Pelvic floor muscle training (Kegel exercises) strengthens the levator ani and improves symptoms in women with mild prolapse.
• Vaginal pessary — medical-grade silicone devices suitable for all stages. About two-thirds of women with symptomatic prolapse choose a pessary and up to 77% still use it at one year; roughly 85% are fitted successfully.

The usual first choice is a ring pessary, folded for insertion and placed between the pubic symphysis and the posterior vaginal fornix. A proper fit remains at least one fingerbreadth above the introitus when the woman bears down. After fitting she should sit, walk and void to check comfort and avoid urinary retention, and she must be taught to remove and clean it (nightly to monthly). Fitting is harder with a short vagina, wide introitus or after hysterectomy.

Surgical choice depends on the compartment affected, uterine status, desire for future fertility and sexual function, age and comorbidity. The principle is that adequate apical support is critical for successful repair of advanced prolapse.

• POP-Q numerical stems: Aa, Ba, C, tvl values given — assign the stage (remember −1 to +1 = stage II; ≥ tvl − 2 = stage IV).
• 'Which point is 3 cm above the hymen?' → Aa / Ap; point D is omitted after hysterectomy.
• Reference point of POP-Q → hymen.
• Procedure for uterine prolapse with elongated cervix in a woman who wants children → Manchester operation.
• Complication of sacrospinous fixation → pudendal vessel injury, new anterior wall defect.
• Prolapse in a woman who is not sexually active and wants a definitive obliterative procedure → colpocleisis; first-line non-surgical option → ring pessary.