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Pelvic organ prolapse, except in rare situations, is a condition that impacts only the quality of life. Consequently, the
extent and type of treatment should reflect and be commensurate with the degree of negative impact on the quality of life
the patient experiences. Patient perception is also a critical component, and self-image and conceptual discomfort are
relevant to any discussion of therapy. Common reasons to intervene are when function is impaired because of the
prolapse. Anterior prolapse can contribute to urinary incontinence or, when severe, urinary obstruction. Bulging vaginal
epithelium can come into contact with undergarments and clothing and over time develop pressure sores and erosion,
leading to cellulitis. A posterior vaginal defect can become so large that fecal evacuation is difficult, or the patient finds it
necessary to manually reduce the posterior vaginal wall into the vagina to expedite expulsion of feces. Mobility can be
impaired by a large prolapse. All of the above complaints are reasons to discuss surgical repair.

Chronic decubitus ulceration of the vaginal epithelium may develop in procidentia. Urinary tract infection may occur with
prolapse because of anterior vaginal prolapse; and partial ureteral obstruction with hydronephrosis may occur in
procidentia. Hemorrhoids result from straining to overcome constipation. Small-bowel obstruction from a deep enterocele
is rare.

Conservative Measures

The patient with a small or moderate-sized POP requires reassurance that the pressure symptoms are not the result of a
serious condition and that, in the absence of urinary retention or severe skin pressure ulceration, no serious illness will
result. The natural history of POP is such that it either will stay the same or progress. There is some evidence that a small
subset of patients may experience regression of the prolapse after the menopause or postpartum if the prolapse is noted
shortly after delivery. Reassurance and observation of prolapse should be encouraged in the absence of symptoms.

If prolapse presents in the reproductive years, surgical correction of POP is rarely indicated in women who may still wish
to have children. If the young woman does present with significant symptoms related to POP or with a disturbing degree of
urinary incontinence—temporary medical measures may provide adequate relief until she has completed childbearing,
whereupon a definitive operative procedure can be accomplished.

Pessary

Pessary use in selected patients may provide adequate relief of symptoms. There are a variety of available pessary types
and sizes that allow for individualization of therapy (Fig 44–8). For the most common type of POP of the anterior or apical
segment, a ring pessary is usually a sensible starting point for treatment. For the patient with complicating medical factors
who is a poor operative risk, the temporary use of a vaginal pessary may provide relief of symptoms until her general
condition has improved.

Pelvic Floor Muscle Exercises

In some patients, improvement of pressure symptoms and of urinary control may be obtained by using pelvic floor muscle
exercises, also referred to as Kegel exercises. These exercises are aimed to tighten and strengthen the pubococcygeus
muscles. Evidence strongly supports use of Kegel exercises as first-line management in the treatment of urinary and fecal
incontinence; however, they may also have some benefit in the relief of POP symptoms. Kegel exercises work best after
specific instruction on how to perform them as most women do not perform them either correctly or in optimal fashion
without supervised instruction and feedback.

Estrogens

In postmenopausal women, local estrogen therapy for a number of months may improve the tone, quality, and vascularity
of the musculofascial supports. It is available in cream, parvule, and ring insert forms. With counseling, local estrogen can
be offered to all postmenopausal women to reduce urogenital atrophy. For postmenopausal patients with exposed
prolapse, who are awaiting surgery, or using a pessary, local therapy should be recommended to promote healthy
epithelium.

Surgical Measures

Anterior Vaginal Prolapse

Anterior Vaginal Colporrhaphy

Anterior vaginal colporrhaphy is the most common surgical treatment for anterior vaginal prolapse (Fig 44–10). Traditional
anterior colporrhaphy (anterior repair) is a vaginal approach that involves dissecting the vaginal epithelium from the
underlying fibromuscular connective tissue and bladder, then plicating the vaginal muscularis across the midline. Excess
vaginal epithelium is excised and the wound closed. Recurrence of anterior prolapse as high as 52% has been reported
and has always been a limitation of all reparative procedures. Modifications involving permanent suture material and most
recently graft materials have been introduced in the hope of increasing durability.