Guideline sources The following summarized guidelines for the evaluation and management of pelvic organ prolapse (POP) are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021; 2019; 2017), the American College of Radiology (ACR 2021), the American College of Obstetricians and Gynecologists (ACOG 2019), the American Urogynecologic Society (AUGS 2017), the British Society of Urogynaecology (BSUG/RCOG 2015), and the American Urological Association (AUA/SUFU 2014). 1 2 3 4 5 6 7 8 9 Guidelines 1. Classification and risk stratification Classification: use standardized classification systems for the assessment and documentation of POP, including vault prolapse. B https://web.pathway.md/diseases/rec5tA6xCoS3DEbeF 1/6 6/29/23, 11:01 PM Pelvic organ prolapse Pathway 2. Diagnostic investigations History and physical examination: As per ACOG 2019 guidelines: Recognize that many patients with POP on physical examination do not report symptoms of POP. Offer treatment only if the prolapse is causing bothersome bulge and pressure symptoms, sexual dysfunction, lower urinary tract dysfunction, or defecatory dysfunction. B Perform a POP-Q examination before treatment for the objective evaluation and documentation of the extent of prolapse. B As per SOGC 2019 guidelines, perform pelvic examination to identify benign or malignant disease in all patients with POP symptoms. B As per AUGS 2017 guidelines, elicit medical history determining the duration and severity of pelvic symptoms and associated bother, asking specifically about urinary, bowel, and sexual symptoms, previous treatments, and previous pelvic surgery. E Show 3 more As per RCOG 2015 guidelines, address quality of life issues using standardized tools during patient assessment. B Urodynamic testing: As per RCOG 2015 guidelines, do not obtain routine urodynamic assessment in patients with post-hysterectomy vaginal vault prolapse. D As per AUA 2014 guidelines, obtain stress testing with reduction of the prolapse in patients with high-grade POP but without the symptom of stress urinary incontinence. Consider obtaining multi-channel urodynamics with prolapse reduction to assess for occult stress incontinence and detrusor dysfunction in these patients with associated LUTS. B Diagnostic imaging: consider obtaining fluoroscopic cystocolpoproctography or magnetic resonance defecography as the initial imaging in patients with vaginal protrusion or bulge or clinically suspected POP, if imaging is deemed necessary after clinical evaluation. C 3. Medical management Expectant management: consider offering expectant management in asymptomatic patients without evidence of urinary retention. E 4. Nonpharmacologic interventions Pelvic floor muscle training: offer pelvic floor muscle training as an effective treatment option in patients with stage I-II vaginal prolapse, including post-hysterectomy vaginal vault prolapse. B Vaginal pessary: As per ACOG 2021 guidelines, consider offering vagina pessary in all patients presenting with bothersome POP and/or stress urinary incontinence. B https://web.pathway.md/diseases/rec5tA6xCoS3DEbeF 2/6 6/29/23, 11:01 PM Pelvic organ prolapse Pathway As per ACOG 2019 guidelines: Offer a vaginal pessary as an alternative to surgery in patients considering treatment of POP. B Consider offering a vaginal pessary in patients with symptomatic POP wishing to become pregnant in the future. C As per AUGS 2017 guidelines, offer vaginal pessary based on medical history and treatment goals in asymptomatic patients. E As per RCOG 2015 guidelines, offer vaginal pessaries as an alternative treatment option in patients with stage II-IV post-hysterectomy vaginal vault prolapse. B 5. Perioperative care Preoperative evaluation for urinary incontinence: Obtain a preoperative evaluation for occult stress urinary incontinence, with cough stress testing or urodynamic testing with the prolapse reduced, in all patients with significant apical prolapse, anterior prolapse, or both. B Counsel patients with POP but without stress urinary incontinence undergoing either abdominal or vaginal prolapse repair that postoperative stress urinary incontinence is more likely without a concomitant continence procedure but that the risk of adverse effects is increased with an additional procedure. B 6. Surgical interventions Indications for surgery: As per AUGS 2017 guidelines, offer surgery based on medical history and treatment goals in asymptomatic patients. E As per RCOG 2015 guidelines: Offer surgical treatment in patients with symptomatic post-hysterectomy vaginal vault prolapse after appropriate counseling. B Perform post-hysterectomy vaginal vault prolapse surgery by an accredited subspecialist urogynecologist or gynecologist with an equivalent level of training or expertise. B Pelvic reconstructive surgery: As per SOGC 2021 guidelines, prefer minimally invasive laparoscopic or robotic approaches (if surgical equipment and appropriate training are available) over open sacrocolpopexy due to improved overall objective outcomes and similar subjective outcomes in the short and medium term. B Show 2 more As per ACOG 2019 guidelines: Consider offering hysteropexy as an alternative to hysterectomy in patients with uterine prolapse. C Offer either uterosacral or sacrospinous ligament suspension with native tissue for apical POP. A https://web.pathway.md/diseases/rec5tA6xCoS3DEbeF 3/6 6/29/23, 11:01 PM Pelvic organ prolapse Pathway As per RCOG 2015 guidelines, inform patients that both abdominal sacrocolpopexy and sacrospinous fixation are effective treatments for primary post-hysterectomy vaginal vault prolapse. A Show 6 more Considerations for mesh use: As per ACOG 2019 guidelines, recognize that the use of synthetic mesh or biologic grafts in transvaginal repair of posterior vaginal wall prolapse does not improve outcomes. A Show 5 more As per SOGC 2017 guidelines, do not place a transvaginal mesh in the rectovaginal space after rectal injury. D Show 2 more As per RCOG 2015 guidelines, do not use transvaginal mesh kits as first-line treatment in patients with post-hysterectomy vaginal vault prolapse. D Show 3 more Intraoperative cystoscopy: perform routine intraoperative cystoscopy during POP surgery when the surgical procedure performed (such as suspension of the vaginal apex to the uterosacral ligaments, sacrocolpopexy, anterior colporrhaphy, and mesh placement in the anterior and apical compartments) is associated with a significant risk of injury to the bladder or ureter. B Obliterative surgery: As per SOGC 2021 guidelines, consider offering colpocleisis as a treatment option in patients not wishing to be sexually active in the future. B As per ACOG 2019 guidelines, consider offering obliterative procedures (narrowing, shortening, or completely closing the vagina) as first-line surgical treatment in patients with significant medical comorbidities not desiring future vaginal intercourse or vaginal preservation. C As per RCOG 2015 guidelines, consider offering colpocleisis in frail patients and/or patients not wishing to retain sexual function. C Management of stress urinary incontinence: perform colposuspension at the time of sacrocolpopexy to reduce postoperative symptomatic stress urinary incontinence in previously continent patients. B Show 2 more 7. Patient education General counseling: As per SOGC 2021 guidelines: Counsel patients seeking surgical correction of apical POP about the higher risk of objective failure but similar rates of subjective failure, reoperation for POP recurrence, and complications after vaginal suture suspensions compared with abdominal sacrocolpopexy (any approach), balanced against the ongoing risk of mesh exposure after sacrocolpopexy, possibly requiring reintervention. B https://web.pathway.md/diseases/rec5tA6xCoS3DEbeF 4/6 6/29/23, 11:01 PM Pelvic organ prolapse Pathway Provide counseling about the lack of comparative data on postoperative pelvic pain and sexual function for various procedures in patients undergoing surgery for symptomatic apical POP. Counsel that the risk of postoperative pelvic pain appears to be low, and sexual function seems to improve among sexually active patients with POP undergoing reconstructive surgery. B As per ACOG 2017 guidelines, provide thorough preoperative counseling including the following to assist patients in making informed decisions regarding transvaginal mesh procedures: improved anatomical outcomes marginal expected improvement in bulge symptoms insufficient evidence for improvement in quality of life risk of mesh exposure and non-sexual pain possible need for reoperations compared with native tissue repair. B Show 2 more 8. Preventative measures Prevention of post-hysterectomy POP: As per ACOG 2019 guidelines, perform vaginal apex suspension at the time of hysterectomy for uterine prolapse to reduce the risk of recurrent POP. B As per RCOG 2015 guidelines, perform McCall culdoplasty at the time of vaginal hysterectomy for preventing subsequent post-hysterectomy vaginal vault prolapse. B Show 4 more 9. Follow-up and surveillance Assessment of treatment response: Use patient-reported outcomes, including patient-reported success rates and relief of presenting symptoms, as the primary assessment outcomes. B Recognize that objective cure is important as it correlates to symptoms of vaginal bulge, and a POP-Q stage of I or O in the apical compartment seems to be acceptable and widely used as the optimum postoperative result. B Management of recurrent POP: manage recurrent vault prolapse through a specialist multidisciplinary team with experience and training in this field. B Clinical findings Symptoms Past obstetric history Defecation urgency Postmenopause Difficult defecation Gynecologic exam Dyspareunia Fecal incontinence Vaginal bulge https://web.pathway.md/diseases/rec5tA6xCoS3DEbeF 5/6 6/29/23, 11:01 PM Pelvic organ prolapse Pathway Feeling a bulge from the vagina Feeling of incomplete bladder emptying Feeling of incomplete evacuation after defecation Pelvic pressure Urinary frequency Urinary incontinence Urinary urgency Weak urine stream Past surgical history Hysterectomy References 1. No authors listed. Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019 Nov;134 5):e126-e142. Open 2. Roxana Geoffrion, Maryse Larouche. Guideline No. 413 Surgical Management of Apical Pelvic Organ Prolapse in Women. J Obstet Gynaecol Can. 2021 Apr;43 4 511 523.e1. Open 3. American Urogynecologic Society AUGS Guidelines and Statements Committee, Cassandra L. Carberry, MD et al. American Urogynecologic Society Best Practice Statement: Evaluation and Counseling of Patients With Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg. Sep/Oct 2017;23 5 281 287. Open 4. Expert Panel on GYN and OB Imaging: Gaurav Khatri, MD, Priyadarshani R. Bhosale et al. American College of Radiology ACR Appropriateness Criteria Pelvic Floor Dysfunction in Females. ACR. 2021. Open 5. No authors listed. Post-Hysterectomy Vaginal Vault Prolapse: Green-top Guideline No.46. RCOG. 2015 Jul 1. Open 6. Marie-Andr e Harvey, Marie-Claude Lemieux, Magali Robert et al. Guideline No. 411 Vaginal Pessary Use. J Obstet Gynaecol Can. 2021 Feb;43 2 255 266.e1. Open 7. Maryse Larouche, Roxana Geoffrion, Jens-Erik Walter. No. 351 Transvaginal Mesh Procedures for Pelvic Organ Prolapse. J Obstet Gynaecol Can. 2017 Nov;39 11 1085 1097. Open 8. Collins CW, Winters JC, American Urological Association et al. AUA/SUFU adult urodynamics guideline: a clinical review. Urol Clin North Am. 2014 Aug;41 3 353 62, vii. Open 9. Devon Evans, Susan Goldstein, Amanda Loewy et al. No. 385 Indications for Pelvic Examination. J Obstet Gynaecol Can. 2019 Aug;41 8 1221 1234. Open https://web.pathway.md/diseases/rec5tA6xCoS3DEbeF 6/6