Pelvic organ prolapse


Pelvic anatomy.
  • Definition: herniation of pelvic organs to or beyond vaginal walls
  • First Degree: Lowering of cervix into lower 1/3 of vagina
  • Second Degree: Protrusion of cervix through the vaginal introitus
  • Third Degree: Complete externalization of the uterus and inversion of the vagina (also called descensus or procidentia)

Risk Factors


  • Cystocele
    • Most common form of pelvic organ prolapse
    • Hernia of anterior vaginal wall + descent of bladder
  • Rectocele
    • Hernia of posterior vaginal segment + descent of rectum
  • Enterocele
    • Hernia of intestines to or through vaginal wall
  • Uterine/vaginal vault prolapse
    • Descent of apex of vagina to lower vagina, hymen, or beyond introitus
    • Apex= uterus and cervix, cervix, or vaginal vault
    • Apical prolapse often associated with enterocele
  • Urethral Prolapse
    • Postmenopausal and prepubescent females

Clinical Features

Total uterine prolapse.
Uterine prolapse.
  • Severity may be related to position
    • Less noticeable in AM and supine
    • Worse as day progresses, upright, and active
  • Vaginal bulge/fullness, pressure
  • Urinary dysfunction
  • Defecatory dysfunction
    • Constipation
    • Incomplete emptying
    • Fecal urgency
    • Fecal incontinence
    • Obstructive symptoms- straining or need for digital pressure to vagina in order to completely evacuate
  • Sexual dysfunction
    • Reports of adverse effects or orgasm and sexual satisfaction
    • Dyspareunia
    • Avoidance of sexual activity due to fear of discomfort or embarrassment
  • Urethral prolapse
    • pain with unination
    • blood in diaper or underwear
    • tenderness while wiping

Differential Diagnosis

Postmenopausal Pelvic Pain




Prepubescent-Urethral prolapse


  • Sarcoma botryoides
  • sarcoma botryoides


  • Clinical diagnosis


Emergency Department

  • Look for signs of infection or skin breakdown if prolonged prolapse
  • Reduction may be as simple as pushing organ back inside
  • If difficult reduction due to edema:
    • Provide analgesia, and place copious granulated sugar
    • Wait 15 minutes for edema to subside and re-attempt reduction
    • If reduction fails, consult gynecology
    • Saline-soaked gauze applied to prolapsed organs could provide both comfort and protection of exposed mucosa
  • For urethral prolapse:
    • Topical estrogen twice daily (0.01%)
    • Sitz baths
    • Consult urology if concern for necrosis of tissue


Treatment includes:

  • Expectant management
  • Conservative (vaginal pessary, pelvic floor muscle exercises)
  • Estrogen creams and Sitz baths (Urethral Prolapse)
  • Surgical


  • Discharge with outpatient Gynecology or Urology referral

See Also


  • Rogers, RG, Fashokun, TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. In: Post T, ed. UpToDate; Waltham, MA.: UpToDate; 2020. Accessed June 16, 2020