RAG rating
Document type
Clinical policy
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions

Uterine/Vaginal Prolapse (part of Pelvic Organ Prolapse)

July 2022 v.10

The Royal College of Obstetricians and Gynaecologists define Pelvic Organ Prolapse (POP) as a weakening of the structures [ligaments and muscles] that hold the organs within a woman’s pelvis (uterus, bladder, and rectum) in place. This leads to the protrusion of one or more pelvic organ(s) bulging from their natural position into the vagina. These prolapses can be large enough to protrude outside the vagina1. More specifically Uterine Prolapse is when the uterus hangs down into the vagina. Vaginal vault prolapse is when the top of the vagina – vault – bulges down after a hysterectomy has been performed. POP is common and 50% of women over 50 will have some symptoms of POP1. 

Patients with POP should usually initially be assessed in primary care and conservative management tried.

Conservative Measures
  • Watchful Waiting – in cases of asymptomatic/mild prolapse it is appropriate to observe for the development of new symptoms or complications1. 
  • Lifestyle Modification – including losing weight and reducing causes of increased intra-abdominal pressure: management of chronic cough, avoiding constipation, avoiding heavy lifting, and avoiding physical activity such as trampolining or high-impact exercise1. However, it is important to note that even though prolapse is associated with these lifestyle factors, the role of lifestyle modification as a prevention or treatment of prolapse has not been investigated2. 
  • Pelvic Floor Exercises – to strengthen the pelvic floor muscles. A large multicentre RCT (the Pelvic Organ Prolapse Physiotherapy [POPPY] trial)3 showed that one-to-one PFMT for prolapse is effective for the improvement of prolapse symptoms. A Cochrane review in 2011 found that "the largest most rigorous trial to date suggests that six months of supervised Pelvic Floor Muscle Training has benefits in terms of anatomical and symptom improvement (if symptomatic) immediately post-intervention.” Four trials compared pelvic floor muscle training (PFMT) with no intervention and found that doing PFMT improved prolapse symptoms. 
  • Vaginal Oestrogen Creams – these are often offered in cases of mild prolapse.  
Vaginal Pessaries

Vaginal pessaries are a good way of supporting prolapse and are more likely to support a uterine prolapse than other types of prolapse1. A study on the use of pessaries found that up to 60% of women found pessaries to be effective4. Pessaries are a good option for women who wish to have children/more children in the future, in cases where a woman does not want surgery or surgery is not recommended and for relief prior to having surgery1,5. A pessary is a plastic or silicone device that fits into the vagina to help support the pelvic organs and hold up the uterus. The most common type of pessary used is a ring pessary1.
  • Fitting the correct size of pessary is important and may take more than one attempt1
  • Pessaries may cause inflammation. Patients should be informed to see their doctor if they experience any unexpected bleeding 1.
  • Pessaries should be changed or removed, cleaned and reinserted regularly1 
  • It is possible to have sexual intercourse with some types of pessary although the woman and her partner may occasionally be aware of it1
  • Complications tend to occur in women who are not regularly followed-up5

If conservative management has not been successful there are some surgical procedures that can be used to treat prolapse. Indications for surgery are failure of pessary and other conservative management, prolapse combined with urinary or faecal incontinence and women with moderate to severe prolapse. However, it is important for a woman to be fully informed before she consents to surgery, and that she knows that for surgical treatments to be effective a combination of procedures may be required, and re-operation may also be required5. 

Clinical scenarios where referral for specialist assessment will be funded by the ICB:
  • Women with symptomatic prolapse (who have moderate or severe prolapse)
  • Prolapse combined with urethral sphincter incompetence/ urinary incontinence or faecal incontinence
  • Failure of pessary and conservative treatments 
  • Women with moderate to severe prolapse who want definitive treatment
Clinical scenarios where surgery will not be routinely funded by the ICB:
  • Asymptomatic pelvic organ prolapse.
  • Mild pelvic organ prolapse (unless combined with urinary/faecal incontinence)

In July 2018, the Government announced a period of ‘high vigilance restriction’ on the use of a group of procedures to treat stress urinary incontinence and pelvic organ prolapse, in England. This followed a recommendation by Baroness Cumberlege, who is chairing an independent review of surgical mesh procedures and has heard from women and families affected by them. For details, see the letter from NHS England and NHS Improvement to trust medical directors. The high vigilance restriction period was extended in March 2019.