Pelvic Organ Prolapse
What you must know
Prolapse is described by compartment (anterior, apical, posterior) and by POP-Q stage. Understand the pathophysiology: levator ani injury, connective-tissue failure, and denervation, with parity, aging, obesity, and chronic straining as risk factors. Know that anterior and posterior vaginal wall prolapse often coexist with apical descent, so apical support must be evaluated and addressed.
Treatment ladder: observation, pelvic floor muscle training, pessary (ring, Gellhorn, cube; support vs space-filling), and surgery. Surgical categories: obliterative (colpocleisis) for frail patients; restorative (native-tissue anterior/posterior repair, sacrospinous or uterosacral suspension, abdominal sacrocolpopexy); and the role of hysterectomy. Understand mesh controversy: transvaginal mesh for prolapse carries regulatory restriction and specific complication risks (erosion, pain, dyspareunia).
Know complications: recurrence, dyspareunia, mesh erosion, ureteral/k bowel injury, and de novo urinary symptoms.
Traps
Questions claim "anterior repair is definitive" - but if apical descent is unaddressed, recurrence is common. Another trap: assuming colpocleisis is inappropriate because of age - it is often ideal for the medically frail who do not desire coitus. Don't confuse sacrospinous fixation (vaginal, to ischial spine) with sacrocolpopexy (abdominal/robotic, to sacral promontory).
Rule of thumb
Treat the apex first. If point C is descended, plan apical support; the anterior and posterior walls follow the apex.
Worked example: A 78-year-old with comorbidities and complete procidentia, not sexually active, wants a durable single procedure. Colpocleisis offers high success with low morbidity; sacrocolpopexy carries greater anesthetic and mesh risk.