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OG31.1 | Uterine Prolapse — SDL Guide (Part 2)

Classification and POP-Q Staging

Prolapse has historically been graded by the traditional clinical system, but internationally the Pelvic Organ Prolapse Quantification (POP-Q) system (Bump et al., 1996, adopted by the International Continence Society) is the standard. POP-Q uses the hymenal ring as a fixed reference point (0), with measurements in centimetres above (negative values, inside) or below (positive values, outside) the hymen at maximum Valsalva. Nine specific anatomical points are measured.

The POP-Q stages are: Stage 0 — no prolapse; Stage I — most distal portion is more than 1 cm above the hymen (< −1 cm); Stage II — most distal portion is between −1 cm and +1 cm of the hymen (within 1 cm either side); Stage III — most distal portion is more than 1 cm beyond the hymen but less than or equal to total vaginal length minus 2 cm; Stage IV — complete eversion (most distal portion ≥ total vaginal length minus 2 cm). Stage II is clinically the threshold for symptomatic, visually apparent prolapse.

The traditional system, still widely used clinically, grades uterine descent as: 1st degree — cervix descends into the vagina but does not reach the introitus; 2nd degree — cervix reaches the introitus; 3rd degree (procidentia) — cervix comes outside the introitus. The associated vaginal wall descent is described separately as cystocele (anterior wall), rectocele (posterior wall), and enterocele (small bowel entering the rectovaginal pouch, bulging the upper posterior wall).

Six-panel diagram showing the POP-Q staging system for uterine prolapse: Panel A presents labeled pelvic anatomy with hymenal ring as the reference plane; Panels B through F illustrate Stages 0 through IV with schematic sagittal views depicting progressive cervical descent relative to the hymenal ring. — **Panel A:** Sagittal pelvic anatomy: hymenal ring (0 reference plane, blue dashed line), cervix (C point), anterior wall points Aa and Ba, posterior wall points Ap and Bp, total vaginal length (TVL) scale bar. **Panel B:** Stage 0 — no prolapse; cervix and all measurement points ≥ −3 cm above hymenal plane. **Panel C:** Stage I — leading edge of prolapse > −1 cm above hymen; mild descent, cervix still above reference line. **Panel D:** Stage II — leading edge within ±1 cm of hymenal ring; cervix at or just below hymen. **Panel E:** Stage III — leading edge > +1 cm below hymen but ≤ TVL − 2 cm; significant cervical descent visible beyond introitus. **Panel F:** Stage IV — complete procidentia / total vaginal eversion; cervix and vaginal walls fully prolapsed well beyond hymenal ring.

Diagnosis and Investigations

Diagnosis is primarily clinical. The patient should be examined in the dorsal lithotomy position initially, and then in the left lateral (Sims') position using a Sims' speculum — this allows the anterior and posterior walls to be assessed separately while the patient strains. The clinician retracts the posterior wall and observes the anterior wall for cystocele, then retracts the anterior wall to look for rectocele, and finally removes the speculum blade to observe uterine descent on Valsalva. The patient should ideally be examined with a full bladder to demonstrate stress incontinence.

Investigations: A mid-stream urine culture is routine (urinary tract infection is common with prolapse). Urodynamic studies — cystometry (bladder capacity, filling pressures, detrusor overactivity) and uroflowmetry — are indicated before any surgical repair to detect occult stress incontinence and detrusor instability that may be unmasked after repair. Renal ultrasound and serum creatinine are indicated if there is evidence of ureteric obstruction (hydronephrosis from chronic urinary retention in advanced prolapse). Pap smear should be taken, particularly if there is cervical ulceration or discharge. MRI pelvis provides anatomical mapping of pelvic floor defects and is useful in recurrent or complex prolapse before reoperation. Haemoglobin and general anaesthetic fitness investigations are required before elective surgery.

Three-panel medical illustration showing Sims' speculum examination technique: patient in left lateral position (Panel A), the Sims' speculum instrument with labelled parts (Panel B), and the examiner's view of the posterior wall being retracted to reveal an anterior cystocele with step-by-step assessment annotations (Panel C). — **Panel A:** Left lateral (Sims) position; left hip slightly flexed; right knee flexed 90°; buttocks at table edge; inset cross-section of pelvic organs (uterus, bladder, rectum). **Panel B:** Sims' single-blade retractor speculum; curved blade tip; handle; insertion direction arrow. **Panel C:** Speculum blade retracting posterior vaginal wall; cystocele (anterior wall bulge); degree of descent grading (I–III); Valsalva instruction annotation; cervix at vaginal apex; four-step assessment sequence legend.

Management — Conservative and Pessary

Conservative management is appropriate for women who are not surgical candidates (elderly, medically unfit, or those who decline surgery), for mild-to-moderate prolapse (POP-Q Stage I–II), and as a temporising measure while awaiting surgery. General measures include weight reduction, treatment of chronic cough, management of constipation, and avoidance of heavy lifting. Topical oestrogen cream (in postmenopausal women) improves vaginal epithelial atrophy, reduces irritation, and strengthens connective tissues around a pessary or before surgery.

Pelvic floor muscle training (PFMT, Kegel exercises) is the first-line conservative treatment — systematic contractions of the levator ani (holding for 3–5 seconds, releasing, 10 repetitions, 3 sets daily, for at least 12 weeks) can reduce prolapse symptoms and stage in mild cases. Physiotherapy-supervised PFMT shows better outcomes than unsupervised.

Ring pessary is the most widely used mechanical device for uterine prolapse. It is a flexible silicone or PVC ring inserted into the vagina to sit at the level of the pelvic brim, mechanically supporting the prolapse. It is effective for Stage II–III prolapse and for women who decline or are unfit for surgery. Indications include: desire to avoid surgery, unfit for anaesthesia, desire for future pregnancy, prolapse in pregnancy. Contraindications include: active vaginal infection, non-compliant patient (cannot attend for follow-up), and severe pelvic floor atrophy where the pessary cannot be retained. The pessary should be changed every 3–6 months; complications include vaginal discharge, ulceration, and rare impaction. Other pessary types include shelf (Hodge), ring with support, and Gellhorn pessaries for more advanced prolapse.

Three-panel diagram showing a sagittal cross-section of the female pelvis with a ring pessary supporting a prolapsed uterus at the pelvic brim level, alongside an isolated view of the ring pessary device and a before-and-after comparison of uterine prolapse versus pessary-corrected position. — **Panel A:** Uterus (body and cervix, supported), ring pessary at pelvic brim / vaginal fornix level, vaginal walls (held open and supported), urinary bladder (anterior), pubic symphysis (anterior bony landmark), rectum (posterior), levator ani and pelvic floor muscles (inferior sling), sacrum and coccyx (posterior bony wall). **Panel B:** Silicone ring pessary device — toroidal/donut shape; central aperture (allows continued vaginal drainage); smooth rounded atraumatic edges; diameter indicator (65–75 mm typical adult size). **Panel C:** Left (Before): prolapsed uterus descended below pelvic floor toward vaginal introitus, labelled 'Prolapsed uterus'; Right (After): uterus elevated and restored to anatomical position above pelvic floor by ring pessary support, labelled 'Uterus elevated and supported'.