Pelvic Organ Prolapse


What is Prolapse?

Also called pelvic organ prolapse, uterine prolapse, vaginal prolapse, bladder prolapse, cystocele, rectocele, or enterocele.

Pelvic organ prolapse with or without urinary incontinence is very common. In fact, even though it may not be talked about much, minor degrees of prolapse affect up to 50% of all women who have had a vaginal delivery, while 20% have symptoms that require them to seek care. One in 9 women will have surgery for prolapse or incontinence in her lifetime.

Normally, a woman's pelvic organs are supported by the muscles of the pelvis. Her uterus, vagina, bladder, and rectum are held over the muscles that provide support to keep the organs in place. If the muscles or supportive connective tissue are weak, damaged, or stretched, eventually any or all of the organs can begin to slip downward into the vagina. Occasionally, if left untreated, the organs can actually protrude outside of the vagina or body.

The early symptoms of this can be a feeling of pressure at the end of the day, feeling like one is sitting on something all the time, feeling something protruding when wiping after voiding, an altered urinary stream or difficulty initiating voiding. Sometimes a woman will experience vaginal laxity, altered sensation with intercourse, or feel like her partner is hitting something. Women with prolapse may also experience bladder or bowel symptoms such as difficulty controlling urges or incontinence with coughing, sneezing, exercising, and other activities.

What causes prolapse or pelvic floor disorders?

Although the exact cause of prolapse or vaginal laxity is not known, vaginal childbirth is the most important risk factor. Certainly the birth weight and number of children a woman has may increase her risk, but even a single small child can lead to prolapse, laxity or urinary incontinence. We don't completely understand it yet, but we believe it is related to muscle and nerve damage that can occur with vaginal delivery. Not every woman who delivers her child vaginally will get prolapse and not every woman with prolapse has delivered a child vaginally. Even a cesarean section does not eliminate the risk for prolapse or incontinence. So there must be other factors. We think the next most important factor is related to genetics. Pelvic floor disorders are more common among siblings with prolapse or incontinence. Other factors that can increase a woman's risk are anything that put chronic straining or stress on the pelvic organs (chronic cough, obesity, constipation or repetitive heavy lifting).

How is prolapse or vaginal laxity treated?

First, if a patient is not bothered by prolapse or laxity, she may not need any treatment at all. In general, treating prolapse is about quality of life. Patients should be reassured that this is common and except in rare situations, can usually be followed without treatment. However, patients should also be reassured that if they are bothered by prolapse, laxity, or incontinence, there are many treatments available that can help them get back to normal life. There is no reason to live with prolapse or incontinence if it bothers you or affects your quality of life. It is never too early and a woman is never too young to start treatment.

Nonsurgical treatments

Kegel exercises or physical therapy can help strengthen the pelvic muscles. These are a great place to start and I encourage all of my patients to do pelvic floor exercises. This can be helpful with urinary incontinence and may delay the development or progression of prolapse. However, it is unlikely that exercises alone will repair significant vaginal prolapse.

Pessaries are removable rubber or silicone devices that can be placed in the vagina to hold the organs in place. Once appropriately fitted, a pessary can be removed and cleaned on a regular basis by the patient for as long as she would like. Pessaries often work well, but the prolapse will likely return if pessary use is stopped. Therefore, we recommend pessaries for young woman who may want to have more children, women who have a medical condition that makes surgery inadvisable, or for women who aren't ready for surgery or would like to pone surgery for some period of time - perhaps to take care of an ill family member or when it may be more convenient for her schedule.

Vaginal laser therapies have also gained popularity for treatment of early prolapse, laxity, and incontinence. There are several types of lasers that can be used to treat the vaginal skin and deeper connective tissue in the office setting. CO2 and Erbium are the most common types of lasers used. Several manufactures produce different laser types (Sciton diVa, Fotona IntimaLase, Cynosure Mona Lisa, and others). There are advantages and disadvantages to each treatment type. Dr. Stepp has presented nationally on the different types of lasers and can discuss what type may be best for a particular patient.

Surgical Treatments

Patients may elect to proceed with surgery. There are also several techniques available. In general, the options that will be offered will depend on the training and experience of the surgeon. Dr. Stepp is able to perform all of these procedures minimally invasively. There is no one right answer for all patients. We suggest a consultation with a fellowship-trained urogynecologist to determine which option is best for each patient. Below is a brief explanation of the different types of surgical repairs that may be considered for pelvic organ prolapse.

Vaginal Repairs (Native Tissue or Non-Mesh Repairs)

Traditional vaginal repairs have been used for several decades. These repairs are used for bladder prolapse, cystocele, rectocele, enterocele, uterine prolapse, and vaginal prolapse. These repairs are very common and are performed by many gynecologists. They are called anterior or posterior repair, colporrhaphy, uterosacral or sacrospinous vault suspensions. They are the simplest to perform and have the advantage of being performed through an entirely vaginal approach. The surgeon treats the prolapse using the patient's own tissue to repair the connective tissue attachments. That means that they don't generally require a long hospital stay and are relatively well tolerated. Dr. Stepp’s technique generally allows patients to go home the same day as surgery.

Although this may be a good option for some patients, it is the approach that has the highest risk for recurrent prolapse. According to the literature, 20-40% of patients may develop return of their prolapse in the future. However, although this is a seemingly high recurrence rate, many of those patients will NOT have symptoms or need repeat surgery.

Laparoscopic and Robotic Assisted Repairs

Sacral colpopexy was first reported in 1962. It is a very good operation for uterine or vaginal prolapse. In fact, many would consider it to be the "gold standard." The success rate is well above 90% for at least 20-40 years. This success rate is, at least in part, because the repairs are performed using a permanent surgical mesh implant and don’t rely so much on the patient’s own tissue. This is complicated surgery that is difficult to learn to do well. So this is best performed by trained urogynecologists.

Dr. Stepp has been offering laparoscopic and robotic sacral colpopexy as an outpatient procedure since 2010. With this approach, patients can receive the "gold standard" procedure with the best success rates - but in a minimally invasive procedure. A small camera is inserted through the umbilicus (belly-button). Additional thin instruments are inserted through a few small incisions less than ½ inch long. The remainder of the surgery should be completed exactly like the well-studied abdominal approach.

Dr. Stepp’s fellowship thesis revealed the primary risk factor for complications was the duration of surgery. Over the past 20 years, he has spent his career working with surgical teams to optimize procedures for efficiency and minimizing risks. Many surgeons spend 4 or more hours to perform this repair, while Dr. Stepp’s cases are often half that or even less.

What about the Vaginal Mesh Repairs?

Sacral colpopexy offers more durability than traditional vaginal native tissue repairs. However, because it is such a difficult procedure to learn, surgeons explored placing mesh vaginally to repair prolapse. Surgeons in Europe were the first to develop some of these techniques and it was performed in the United States since 2001 under products marketed as vaginal mesh “kits.” During the procedure, a mesh implant was placed through vaginal incisions using specifically designed instruments. This is a very different process than the gold standard, trusted technique of sacral colpopexy as listed above.

Although the vaginal mesh “kits” were easier to learn than sacral colpopexy, many were concerned for patient safety. In the early years of development, Dr. Stepp traveled to France to train with one of the original developers to understand placement and managing potential mesh complications. After returning to the United States, he taught several courses helping others understand the pelvic anatomy involved with these complicated high-risk procedures. The FDA later issued a warning about the vaginal mesh “kits” in 2008.

Unfortunately, many patients have had vaginal mesh complications. Finding a surgeon qualified and experienced with vaginal mesh removal can be difficult. Since the early 2000’s, Dr. Stepp has built a practice treating hundreds of patients with vaginal mesh complications such as pain, mesh exposure, erosion or contraction.


The choice between native tissue repair and mesh for vaginal prolapse repair depends on various factors, including the specific anatomy and goals of the patient, the surgeon's experience, and the risks and benefits associated with each option. Both native tissue repair and mesh repair have their advantages and disadvantages, and the decision should be made on a case-by-case basis.

Native Tissue Repair

Mesh Repair

It's crucial for patients to have a thorough discussion with their healthcare provider to understand the risks and benefits of each option, considering their specific medical history and preferences. Surgeons should carefully evaluate the patient's condition and consider alternative treatments based on the individual circumstances. Additionally, it's important to stay informed about the latest research and regulatory developments regarding mesh use in prolapse repair.