Pelvic organ prolapse

Borders Ref Help Toolkit
NHS Borders

Pelvic organ prolapse is defined as the symptomatic descent of one or more of:

the anterior vaginal wall, the posterior vaginal wall, the cervix or uterus, or the apex of the vagina (vault or cuff scar after hysterectomy).

The vagina can be considered as having anterior, posterior and apical compartments.

Common symptoms:

  • Vaginal heaviness and bulge
  • Bladder and bowel difficulties (may include incomplete emptying, urgency, frequency)
  • Discomfort that may be felt vaginally, abdominally and may include low back pain.

Some 20–40% of all women will experience prolapse symptoms that may be bothersome and affect their quality of life. 

Treatment for pelvic organ prolapse should start with non-surgical (conservative) management options that may include: pelvic floor muscle training, lifestyle advice, a vaginal pessary to support the prolapse; and if indicated, vaginal (topical) estrogen for post-menopausal women. Nonsurgical management options may be used in combination to maximise a reduction in symptoms.

Surgical treatment may also be offered with the aim of restoring the vaginal anatomy. If the prolapse symptoms are not very bothersome, a woman may choose neither management option, and instead, wait to see if her symptoms worsen or improve.

Vaginal pessaries are used intravaginally to try to restore the prolapsed organs to their normal position and relieve symptoms.

Please see Primary Care Management for advice on the management of vaginal prolapse and the fitting of a ring pessary.

Who to refer, who not to refer, how to refer

For women with symptoms of prolapse, a prolapse that is not beyond the introitus and have not had previous prolapse surgery – initial referral is to the pelvic floor physiotherapy team.  They will refer on to the Bladder and Pelvic Floor clinic if indicated. 

If conservative measures are not satisfactory (see Primary Care Management) and

  • there is a the prolapse is beyond the introitus
  • or the woman has had previous prolapse surgery

 refer to Gynaecology routinely via Sci Gateway to be seen in the Bladder and Pelvic Floor Clinic

Primary care management

Advice for both symptomatic and asymptomatic cases:

  • Constipation – avoidance and effective management should be offered.
  • Healthy weight – Weight loss if indicated

Further measures are only indicated if the prolapse is symptomatic:         

  • Typical prolapse symptoms: Feeling a bulge or a dragging sensation with discomfort
  • Pain or dyspareunia – not usually caused by prolapse – consider topical estrogen if postmenopausal
  • Urinary symptoms – may often co-exist but rarely directly caused by a prolapse

→ Please refer to advice regarding management of urinary symptoms – Urogynaecology refhelp

For management of prolapse symptoms, vaginal pessaries can be helpful (independent of age, sexual activity, degree of prolapse)

The correct pessary is the smallest device that does not fall out and is comfortable. Patients should be unaware of their pessary and be able to void normally after a pessary has been fitted.

Vaginal pessaries require to be removed and replaced at regular intervals (every 6 months unless self-managed) – pessary neglect increases risks of complications

We are happy for GPs and nurses to change ring pessaries in primary care but also have a nurse pessary change clinic at the BGH for gelhorn and more complex pessaries.

Resources and links

UK Clinical Guideline for best practice in the use of vaginal pessaries for pelvic organ prolapse:

https://www.thepogp.co.uk/_userfiles/pages/files/resources/uk_pessary_guideline_final_april21.pdf

Editorial Information

Last reviewed: 24/07/2025

Next review date: 24/07/2027

Author(s): Faye Rodger.

Author email(s): obsandgynae.mailbox@borders.scot.nhs.uk.