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Pelvic organ prolapse

Key sources
The following summarized guidelines for the evaluation and management of pelvic organ prolapse are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2023), the American College of Radiology (ACR 2021), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021; 2019; 2017), 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).
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Guidelines

1.Classification and risk stratification

Classification: use standardized classification systems for the assessment and documentation of POP, including vault prolapse.
B
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2.Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, perform POP reduction test to identify patients with occult stress urinary incontinence.
A

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  • Urodynamic testing

  • Diagnostic imaging

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
As per EAU 2023 guidelines:
Inform patients with POP not needing a vaginal pessary or surgical intervention about the potential relief from LUTS from pelvic floor muscle training.
A
Do not offer preoperative pelvic floor muscle training to improve lower urinary tract symptom outcomes if pessary therapy or surgical intervention is indicated for POP.
D

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  • Vaginal pessary

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

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  • Pelvic reconstructive surgery

  • Considerations for mesh use

  • Intraoperative cystoscopy

  • Obliterative surgery

  • Management of stress urinary incontinence

7.Patient education

General counseling
As per EAU 2023 guidelines:
Counsel patients with POP and stress urinary incontinence about the pros and cons of additional anti-incontinence surgery at the time of POP surgery. Inform patients of the increased risk of adverse events with combined prolapse and anti-incontinence surgery compared to prolapse surgery alone.
A
Inform patients that there is a risk of developing de novo stress urinary incontinence after prolapse surgery.
A

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

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

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  • Management of recurrent POP