Pelvic Organ Prolapse: Evaluation and Surgical Management
Evaluation
Use the POP-Q system: point Aa and Ba anterior, Ap and Bp posterior, C cervix/cuff, D posterior fornix, gh, pb, tvl. Stage 0 = no prolapse; Stage I = leading edge >1 cm above hymen; Stage II = within 1 cm of hymen; Stage III = >1 cm beyond hymen but not complete; Stage IV = complete eversion. Document compartment-specific defects, posterior compartment (rectovaginal exam), and assess for occult stress incontinence with reduction.
Surgical principles
Restore apical support (sacrospinous, uterosacral, or sacrocolpopexy). Native tissue repair is appropriate for many; mesh augments durability but adds erosion risk. Sacrocolpopexy has lower recurrent apical prolapse than vaginal native tissue but more mesh complications. Obliterative procedures (colpocleisis) suit frail patients who do not desire vaginal intercourse.
Traps
- POP-Q stage misclassification: Stage II is within 1 cm of hymen, not "at the hymen" only.
- Forgetting to reduce prolapse to test for occult SUI before repair.
- Assuming mesh is always superior; weigh reoperation for prolapse vs mesh erosion.
- Overlooking posterior compartment or enterocele in a patient with prior hysterectomy.
Worked example
A patient with point C at +3 and Ba at +2 has Stage III apical-predominant prolapse. Plan apical suspension; counsel that correcting the apex may unmask stress incontinence, so consider a concomitant continence assessment.