Pelvic Organ Prolapse

While minor degrees of POP affect up to 75% of women who have had a vaginal delivery, symptomatic POP with descent beyond the hymen affects 3% to 6% of the population ~10% of them will require surgery to correct the prolapse, of whom ~30% will require at least another one (1-5) operation. In the US, every year, 210,000 – 300,000 women undergo surgical interventions for POP.

The most commonly reported figure is that ~3.5 million USA women (range 1.36-5.33) currently suffer from symptomatic POP. This figure equates to ~2.9% of the US female population over the age of 30, and is expected to rise 46% to 4.9 million by 2050.

Management options 

Within the ~3.5 million USA women with POP who are considered to have symptomatic POP, there are 4 available management options:

  1. Expectant – women may consult regarding their problem, but will prefer to defer any management, due to various reasons.
  2. Reconstructive surgical management – various operations, by various routes. The purpose of surgery is to correct the anatomy as well as provide better bowel, bladder and vaginal function.
  3. Pelvic Floor Physiotherapy/Kegel exercises – considered acceptable for low stages of prolapse, perhaps a way for relieving some POP symptoms, but it is no longer considered a viable management option.
  4. Vaginal pessaries

Vaginal pessaries are the only proven and well-studied noninvasive means of managing POP. A pessary is a device inserted into the vagina to support the walls and related pelvic organs. Modern pessaries are made of hypoallergenic silicone, rubber, or pliable plastic and are indicated for all pelvic prolapse stages. 77% of gynecologists in the US prescribe pessaries as first-line therapy for women with POP. Similarly in the UK, 86.7% of obstetricians and gynecologists surveyed prescribed pessaries in the management of POP. Pessaries are experiencing resurgence in popularity following the problems experienced with surgical solutions (high symptomatic recurrence rate while using native tissue and morbidity with the trans-vaginal mesh implants), and are now again viewed as a very viable option for the management of prolapse for women in any age group. Reports suggest that 76% of women can be successfully fitted at the follow-up visits. Success or failure will depend on appropriate pessary selection, patient characteristics, provider training and experience, thorough counselling, as well as the achievement of an adequate fit and patient satisfaction.

Vaginal ring pessaries are known to the medical literature for many centuries. Most of the prolapse cases which can be managed by pessaries, may be managed by ring pessaries, with or without internal support, and this is the most commonly used configuration.