Pelvic organ prolapse: a patient's guide
Understand pelvic organ prolapse: types, causes, severity grading, conservative treatment options (PFMT and pessary), and when to consider surgery.
Pelvic organ prolapse (POP) is the descent of one or more pelvic organs — bladder, uterus, rectum or small bowel — towards or through the vagina. It occurs when the muscular and ligamentous supports of the pelvic floor can no longer keep the organs in their correct position.
It affects between 30 and 50% of women who have had children, though most initial cases are asymptomatic or mild.
See the complete pelvic floor guide →
Types of prolapse
Cystocele (bladder prolapse): the bladder presses the anterior vaginal wall downward. The most common type.
Rectocele (rectal prolapse): the rectum presses the posterior vaginal wall. Can cause difficulty defaecating.
Uterine prolapse: the uterus descends into the vaginal canal.
Enterocele: the small bowel herniates through the vaginal vault.
Vaginal vault prolapse: occurs in women who have had a hysterectomy.
Severity grading (POP-Q system)
| Grade | Description |
|---|---|
| 0 | No prolapse |
| I | Most distal point more than 1 cm above the hymen |
| II | Between 1 cm above and 1 cm below the hymen |
| III | More than 1 cm below the hymen |
| IV | Complete eversion |
Causes and risk factors
| Factor | Mechanism |
|---|---|
| Vaginal delivery | Stretching and potential direct injury |
| Multiple deliveries | Cumulative effect |
| Overweight | Chronically elevated intra-abdominal pressure |
| Chronic constipation | Repeated straining |
| Menopause | Reduced hormonal support for connective tissue |
| Genetic predisposition | Collagen and connective tissue abnormalities |
Conservative treatment: PFMT
PFMT is the first-line option for symptomatic grade I–III prolapse. Evidence shows it improves subjective symptoms (heaviness, pressure), can reduce prolapse grade on objective measurement, improves quality of life and reduces progression in mild-to-moderate cases.
Key principles specific to prolapse management:
- Train strength in loaded positions (standing), not just lying down
- Learn to contract the pelvic floor before any increase in pressure (coughing, lifting)
- Manage bowel habits to avoid straining
- Coordinate breathing and avoid Valsalva manoeuvres
Explore the evidence sources →
Conservative treatment: pessary
A pessary is a silicone device inserted into the vagina to provide mechanical support. Many types exist (ring, cube, Gellhorn…) and the choice depends on prolapse type and grade.
Advantages: reversible, no surgery, compatible with PFMT or as a long-term option.
Surgery
Prolapse surgery is generally reserved for symptomatic grade III–IV prolapse that has not responded to conservative treatment. Surgery does not eliminate the risk factors that caused the prolapse, so postoperative PFMT is fundamental for long-term maintenance of results.
FAQ
Does prolapse always get worse over time?
Not necessarily. With conservative treatment (PFMT and management of risk factors), many prolapses remain stable or even improve. Mild prolapse in active women with consistent PFMT rarely progresses to severe grades.
Can I exercise if I have prolapse?
It depends on the grade and the type of activity. Low-impact exercise is generally safe with appropriate modifications. High-impact activities in moderate-to-severe grades should be assessed individually with a specialist.
Is a pessary permanent?
No. A pessary is a reversible option. Many women use it temporarily (for example, during sport) or while doing PFMT. Others prefer to continue using one long-term as an alternative to surgery.
Does prolapse surgery have good outcomes?
Success rates for well-indicated prolapse surgery are high, but there is a risk of recurrence and complications. Most guidelines recommend exhausting conservative options first, except in symptomatic severe prolapse.
Related articles
Learn what the pelvic floor is, why it matters, what symptoms signal dysfunction, and how to train it effectively with evidence-based exercises.
Understand how menopause affects the pelvic floor, incontinence and prolapse risk, and how to adapt PFMT at this stage.
Understand stress, urgency and mixed urinary incontinence, main causes, and why PFMT is first-line conservative treatment.
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