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Surgical management of pelvic organ prolapse in women

Maher C, Feiner B, Baessler K, Schmid C
Published Online: 
30 April 2013

Pelvic organs, such as the uterus, bladder or bowel, may protrude into the vagina due to weakness in the tissues that normally support them. The commonest symptom experienced by women with prolapse is the sensation or feeling, or seeing, a vaginal bulge. Commonly these women have abnormalities in bladder, bowel and sexual function that may or may not be related to the prolapse. The surgical repair performed depends on the type of prolapse seen on examination and on the associated symptoms. Women should be aware that the principle aim of surgery is to relieve the vaginal bulge. Women who have stress urinary incontinence in addition to their prolapse commonly have that corrected at the same surgery. Pelvic organ prolapse surgery is usually effective in controlling the principle symptoms of prolapse (awareness of vaginal bulge). The impact of pelvic organ prolapse surgery on specific bowel, bladder and sexual functions can be predicted however individual women should be aware that occasionally the intervention may make symptoms worse or result in new symptoms, such as leakage of urine or problems with sexual intercourse.

The review found 56 trials including 5954 women with a variety of types of prolapse. The trials showed that abdominal sacral colpopexy, 'abdominal route surgery', may be better than vaginal sacrospinous colpopexy or 'vaginal route surgery' for prolapse of the uterus or vaginal apex after hysterectomy. Limited evidence suggests that vaginal surgery may be better than surgery performed through the anus for posterior vaginal prolapse (rectocele). The use of grafts (biological or synthetic) reduces the risk of prolapse symptoms and recurrent anterior vaginal prolapse on examination when compared to native tissue repairs (colporrhaphy). However, the advantages of a permanent polypropylene mesh must be weighed against disadvantages including longer operating time, greater blood loss, prolapse in other areas of the vagina, new onset urinary stress incontinence, and the mesh becoming exposed in the vagina in 11% of women. In general, there is a lack of evidence to support transvaginal mesh operations used in apical or posterior compartment surgery.

Continence surgery performed at the time of prolapse surgery is effective in reducing the risk of urinary stress incontinence after the prolapse surgery. Overall, however, there was not enough evidence on most types of common prolapse surgery nor about the use of mesh or grafts in vaginal prolapse surgery.

This record should be cited as: 
Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub5
Assessed as up to date: 
20 August 2012