Pelvic Organ Prolapse (POP) Treatment Options

Pelvic Organ Prolapse (POP) is a frequently encountered gynecological condition characterized by the descent of one or more pelvic organs—such as the bladder, uterus, rectum, or vaginal apex—into or through the vaginal canal due to the loss of normal support provided by the pelvic floor musculature and connective tissue. The condition reflects a complex interplay between musculoskeletal integrity, hormonal status, and intra-abdominal forces. While not life-threatening, POP can profoundly impact physical function and emotional well-being, often leading to a cascade of secondary effects including impaired urinary and fecal continence, altered body image, and reduced sexual satisfaction. The condition may present progressively, with anatomical changes that worsen over time if left unaddressed. Though POP is especially prevalent among postmenopausal and multiparous women, it can affect individuals across a wide age range and may coexist with other pelvic floor disorders. Due to its multifactorial nature and varying degrees of severity, pelvic organ prolapse requires a nuanced, multidisciplinary approach to management, encompassing considerations for both structural correction and preservation of function. 

Why Cuba 

Management of Pelvic Organ Prolapse (POP) in Cuba is centered on restoring anatomical support, preserving pelvic function, and preventing long-term complications such as chronic discomfort, urinary and bowel dysfunction, and recurrent prolapse. Care is delivered through a structured, evidence-based clinical pathway in which each patient undergoes a thorough gynecological evaluation to determine the degree and nature of organ descent, the impact on bladder and rectal function, coexisting pelvic floor disorders, prior surgical history, and individual treatment goals.  

Cuban gynecology teams employ advanced diagnostic imaging and pelvic assessments—often complemented by minimally invasive endoscopic techniques—to ensure precise anatomical mapping and personalized care planning. When surgery is indicated, preference is given to minimally invasive procedures that offer reduced recovery times and excellent functional outcomes, reflecting Cuba’s broader commitment to preserving quality of life through cost-effective, patient-centered care. 

Causes of Pelvic Organ Prolapse 

 The weakening of pelvic support structures may result from: 

• Childbirth (especially vaginal deliveries and large babies) 
• Advancing age and menopause 
• Chronic coughing or constipation 
• Heavy lifting or repetitive straining 
• Pelvic surgery (e.g., hysterectomy) 
• Obesity 
• Genetic predisposition affecting collagen and tissue integrity 

Types and Classification of Pelvic Organ Prolapse 

 Pelvic Organ Prolapse (POP) is classified based on the specific pelvic organ involved in the descent and the degree to which it displaces from its normal anatomical position. Accurate classification is essential for guiding treatment decisions, as it helps clinicians assess the extent of functional disruption, anticipate associated complications (such as urinary or defecatory dysfunction), and determine the most appropriate intervention—whether conservative or surgical. 

Types: 

• Cystocele (Anterior Prolapse): The bladder bulges into the front wall of the vagina. 
• Rectocele (Posterior Prolapse): The rectum bulges into the back wall of the vagina. 
• Uterine Prolapse: The uterus descends into or outside of the vaginal canal. 
• Enterocele: The small intestine pushes into the upper posterior vaginal wall (typically after hysterectomy). 
• Vaginal Vault Prolapse: Post-hysterectomy prolapse of the vaginal apex. 

Classification by Degree: 

• Grade I (Mild): Organ drops into the upper vagina 
• Grade II (Moderate): Organ descends near the vaginal opening 
• Grade III (Severe): Organ protrudes through the vaginal opening 
• Grade IV (Complete Prolapse): Entire organ is outside the vaginal canal 

 Symptoms of Pelvic Organ Prolapse 

Symptoms vary depending on the type and severity, but may include: 

• A sensation of vaginal bulging or pressure 
• Urinary incontinence or retention 
• Difficulty with bowel movements 
• Low backache or pelvic pain 
• Pain or discomfort during intercourse 
• Tissue protruding from the vaginal opening 

Diagnosis of Pelvic Organ Prolapse 

 The diagnosis of Pelvic Organ Prolapse (POP) involves a comprehensive clinical evaluation aimed at confirming the presence, extent, and functional impact of pelvic organ descent. It typically includes a detailed medical history, symptom assessment, and a focused pelvic examination to identify anatomical changes and guide further management. 

Detailed History and Physical Examination 

• Review of obstetric history, prior pelvic surgeries, menopause status, and risk factors such as chronic constipation or heavy lifting. 
• Review of specific symptoms including pelvic pressure, sensation of bulging, urinary incontinence, or bowel dysfunction. 
• Functional impact on daily activities and sexual health is also assessed. 
• General physical examination helps rule out systemic contributors like obesity or connective tissue disorders. 

Pelvic Examination 

• It involves assessment of six specific vaginal points in relation to the hymen while the patient performs maneuvers such as Valsalva (bearing down). 

Urinalysis and Urodynamic Studies if Urinary Symptoms Are Present 

• Urinalysis helps rule out urinary tract infections or hematuria that may mimic or complicate prolapse symptoms. 
• Urodynamic testing is used when patients present with voiding dysfunction, urgency, stress incontinence, or retention. 
• These studies assess bladder compliance, detrusor overactivity, and outlet obstruction, which can influence the choice of surgical repair or need for adjunct procedures like sling placement. 

Transvaginal or Pelvic Ultrasound, or MRI 

• Transvaginal or pelvic ultrasound provides real-time imaging of pelvic organs and can detect uterine pathology, adnexal masses, or bladder abnormalities. 
• MRI of the pelvis is highly effective for visualizing multi-compartment prolapse, particularly in obese patients or those with prior surgeries. 
• These imaging tools are often reserved for complex or recurrent cases where anatomical detail is crucial for treatment planning. 

Conservative (Non-Surgical) Treatment Options 

Conservative management is typically recommended for mild to moderate prolapse or for patients who are not surgical candidates: 

Non-Surgical Approaches: 

• Pelvic Floor Physical Therapy – includes Kegel exercises to strengthen support muscles 
• Pessary Devices – silicone or rubber devices inserted into the vagina to support pelvic organs 
• Estrogen Therapy – topical estrogen may improve tissue tone, especially in postmenopausal women 
• Lifestyle Modifications – weight management, treating constipation, and avoiding heavy lifting 

Surgical Treatment Options 

Surgical intervention is considered when: 

• The prolapse is moderate to severe and symptomatic 
• Conservative management fails 
• There is significant interference with bladder or bowel function 
• There is recurrent vaginal ulceration or protruding tissue 
• The patient expresses a strong desire for a definitive solution 

Surgical options vary depending on the type of prolapse and whether the patient desires to preserve the uterus. 

Anterior Colporrhaphy (for Cystocele) 

• Type: Minimally invasive (vaginal approach) 
• Tightens the front vaginal wall to restore bladder support 
• Sometimes includes the use of grafts or mesh (though mesh is less commonly used now due to complications) 

Posterior Colporrhaphy (for Rectocele) 

• Type: Minimally invasive (vaginal approach) 
• Strengthens the posterior vaginal wall to correct rectal bulge 
• May be combined with perineorrhaphy to reinforce the vaginal entrance 

Uterine Suspension (for Uterine Prolapse) 

• Types: 
  • Sacrospinous ligament fixation (vaginal; minimally invasive) 
  • Uterosacral ligament suspension (can be vaginal or laparoscopic) 
  • Sacrohysteropexy (laparoscopic; uterus-sparing) 
• Repositions and supports the uterus without removal 

Hysterectomy with Vault Suspension 

• Type: Can be open, laparoscopic, or vaginal 
• Removes the uterus and suspends the top of the vagina to ligaments or sacral structures to prevent future prolapse 

Colpocleisis (for Advanced Prolapse in Non-Sexually Active Patients) 

• Type: Minimally invasive (vaginal approach) 
• Closes the vaginal canal to provide internal support 
• Best suited for elderly patients not desiring vaginal function 

Sacrocolpopexy (for Vaginal Vault Prolapse) 

• Type: Minimally invasive (laparoscopic or robotic) 
• A surgical mesh is used to attach the vaginal vault to the sacrum for durable support 
• Highly effective with low recurrence rates