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Treatment

Considerations

• Questions for surgical planning: is vault suspended (apical prolapse), prior hysterectomy, willing to undergo hysterectomy, and okay with mesh?

Mesh

• Okay: abdominal placement for prolapse, vaginal placement for stress incontinence
• Not okay: vaginal placement for prolapse (higher erosion risk)

Apical (+/- anterior/posterior) repair algorithm

Obliterative?	Uterus present?	Desires hysterectomy?	Approach?	Surgery
Yes	No			Colpocleisis
	Yes			Lefort colpocleisis
No	No		Abdominal	Sacrocolpopexy (w/ mesh)
			Vaginal	Sacrospinous ligament fixation Iliococcygeus suspension
	Yes	No	Abdominal	Sacrohysteropexy (w/ mesh)
			Vaginal	Uterosacral hysteropexy Sacrospinous hysteropexy
		Yes	Abdominal	Supracervical hysterectomy + sacrocolpopexy (w/ mesh)
			Vaginal	Hysterectomy + uterosacral suspension

Specific Surgical Details

Anterior repair

• Anterior colporrhaphy: native tissue repair, imbricate fibromuscular layer in midline, failure rate 40%, needs to be combined with lateral repair for lateral defects
• Vaginal paravaginal repair: reattach pubocervical fascia to the ATFP, better for lateral anterior prolapse

Apical repair

• Uterosacral ligament suspension (USLS): intraperitoneal transvaginal or transabdominal hitching vaginal cuff to midline uterosacral ligament, best choice when performing hysterectomy but not using mesh (due to intraperitoneal access) side effects include ureteral obstruction (11%), nerve injury
• Sacrospinous ligament fixation (SSLF): extraperitoneal transvaginal suspension of apex to sacrospinous ligament, best choice when patient already had hysterectomy (no need to enter peritoneum), sutures usually placed on right side to avoid rectum, success 63-97%, side effects include gluteal pain (usually resolves after 6wks), dyspareunia, anterior wall prolapse, good option for older/sicker patients (faster surgery), good option if history of prior abdominal surgeries
• Iliococcygeus suspension: alternative to SSLF
• Abdominal sacrocolpopexy: transabdominal placed mesh attached to anterior/posterior vagina and sacral promontory or anterior longitudinal ligament, correctly placed mesh should also fix anterior/posterior prolapse, less risk for recurrence, SUI, or dyspareunia compared to vaginal repairs

Posterior repair

• Posterior colporrhaphy: repair of rectocele, may need to be performed with apical repair
• Perineorrhaphy: reconstructs perineal body to decrease apical prolapse recurrence, ensure vaginal opening not overly narrowed

Obliterative procedures (colpocleisis)

• Candidates: non-sexually active older patients, multiple medical comorbidities, or partner without functional erections
• Technique: close vaginal vault 2-3cm from urethral meatus
• Lefort: perform partial closure to provide uterine drainage if unable to perform hysterectomy
• Success: 80-90% satisfaction rate

Conservative management

• Observation: if asymptomatic, can follow as needed or with serial exams
• Physical therapy if subjective symptoms are worse than objective prolapse, strengthens core and improves sensation

Pessary

• Benefits: treats SUI + POP, consider for short term (anticipating surgery) or for poor surgical candidates
• Management: remove 2-3x weekly or in office q1-3mo, use estrogen cream to decrease erosion risk
• Genital hiatus: wider GH more likely to fail pessary use
• Choice: ring for Stage II, Gelhorn for Stage III-IV, cube for complete prolapse