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Pelvic Organ Prolapse

Checked: 23-05-2023 by Rob Adams Next Review: 23-05-2024

Overview

Pelvic organ prolapse is when 1 or more of the organs in the pelvis slip down from their normal position and bulge into the vagina (1).

Pelvic organ prolapse is common, affecting 1 in 10 women over the age of 50 years. Mild prolapse often causes no symptoms and treatment is not always necessary (2).

The management of urinary incontinence and pelvic organ prolapse is now covered by the NICE guideline 2019, for women aged 18 and over (3). It also covers complications associated with mesh surgery for these conditions.

The treatment of prolapse depends on the patient's presenting symptoms. At the initial clinical assessment in primary care, categorise the woman's urinary incontinence as stress urinary incontinence, mixed urinary incontinence or urgency urinary incontinence/overactive bladder. Start initial treatment on this basis. In mixed urinary incontinence, direct treatment towards the predominant symptom.

See the Female Urinary Incontinence (Remedy BNSSG ICB) for further information.

Offer a trial of supervised pelvic floor muscle training of at least 3 months' duration as first-line treatment to women with stress or mixed urinary incontinence.

Who to Refer

Patients not responding to initial treatment in primary care can be referred to Pelvic Health physiotherapy.

In addition, patients with prolapse that comes down outside of the vagina when standing up and who would be suitable for surgical treatment, should be referred for a gynaecologist for a surgical opinion - see Referral section below. However, the risks of surgery for some, even for advanced prolapse, may not be warranted.

There is some further useful advice on management and when to refer below:

Genitourinary Prolapse (Causes, Symptoms, and Treatment) | Patient

Red Flags

Suspected Cancer

Consider referral via a Gynaecology 2WW pathway if:

unexplained palpable mass in or at the entrance to the vagina
physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids)
post-menopausal bleeding

Mesh complications

See the Mesh Complications (Remedy BNSSG ICB) page.

What to do before referral

Lifestyle Advice

Lifestyle advice from the RCOG patient information leaflet (March 2013) for women with pelvic floor prolapse includes:

Weight loss if overweight
Avoiding constipation
Avoiding heavy lifting or high impact exercise
Stopping a chronic cough if present (including smoking cessation)

Pelvic Floor Exercises

Give patient information about pelvic floor exercises such as those found on the following webpage produced by NBT: Pelvic floor exercises for women

Supervised pelvic floor exercises can be provided by the Pelvic Health Physiotherapists.

If there are also stress incontinence symptoms associated with prolapse or if physiotherapy is not appropriate then a community continence service referral may be helpful.

Pessaries

Vaginal pessaries can often be fitted in primary care. Refer to the guidance on fitting a vaginal pessary for pelvic organ prolapse (PDF).

Some pessaries may be removed and replaced by patients, so remain a potential option for sexually active women.

If a referral is needed for fitting of a pessary please see the Referral section below.

Referral

Referral for Pelvic Health Physiotherapy

See the Pelvic Health Physiotherapy page.

Referral to Pessary Clinic

If there is no-one within the practice who is able to fit pessaries, or if pessary fitting in primary care has proved difficult, or is anticipated to be challenging then consider referral to:

NBT Nurse-led Pessary Clinic - direct referral via email to: GynaeSecretaries@nbt.nhs.uk requesting the Nurse-led Pessary Clinic at Southmead Hospital
UHBW Pessary Clinic - accessed via eRS gynaecology referral (clinics run at South Bristol, St Michael’s and Weston General Hospitals).

Referral to Gynaecology

If a surgical opinion is required then refer to Gynaecology via eRS clearly stating what conservative measures have been attempted. Please also include information that will help with pre- operative assessment including BMI, BP, smoking status and recent bloods if available:

Pre-operative assessment (Remedy BNSSG ICB)

You can also request Gynaecology advice and guidance via eRS: Advice & Guidance Service (Remedy BNSSG ICB)

Resources

(1) Pelvic organ prolapse - NHS (www.nhs.uk)

(2) Pelvic organ prolapse patient information leaflet | RCOG

(3) Overview | Urinary incontinence and pelvic organ prolapse in women: management | Guidance | NICE

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.