Conservative Management for Pelvic Organ Prolapse
Conservative Management for Pelvic Organ Prolapse
This article discusses whether women with Pelvic organ prolapse and/or continence issues should be trialled conservative management first before surgery.
What is Pelvic Organ prolapse?
Pelvic Organ Prolapse (POP) is a common condition in which the pelvic organs herniate into the vagina due to ligament or muscular weakness and where one or more pelvic organs drop from their position making a bulge in the vagina which is a prolapse. In Australia, between 2005 to 2021, there have been a total of 408,881 POP procedures. A sudden growth in private operative procedures was noted. Between 2019 to 2020 and 2020 to 2021, from 218.2 to 268.6 procedures per 100,000 population, creating a 23.1% increase.
Case Example
A 44-year-old woman was referred to a Gynaecologist (the Defendant) for review and management of longstanding abdominal pain and vaginal prolapse.
The Defendant recorded the following symptoms:
- Cyclical pain
- Prolapse
- Radiating pain throughout the plaintiff’s hips, pelvis and upper legs
- Urinary frequency
- Difficulty with sexual intercourse during periods the plaintiff experienced urinary frequency
- Stress incontinence
- Coital incontinence
- Incomplete bladder emptying
- Constipation and issues with defecation
- Bladder neck rotation
It was recommended that the patient undergo insertion of a midurethral sling and cystoscopy. Prior to the surgery, the Defendant discussed the potential complications such as bleeding, voiding dysfunction, mesh erosion, vaginal pain, necessity for loosening or removal of mesh, recurring incontinence and painful intercourse.
The patient detailed post-surgery pain and an indentation on the right side of the vagina. While it was accepted that the Defendant acted in a manner that is widely accepted in Australia as competent professional practice in performing and documenting the surgery, it was also said that most practitioners would have arranged a referral to continence/pelvic physiotherapy for bladder retraining.
Conservative Treatment vs Surgical Treatment
There are various treatment options which are individualised and can involve physiotherapy, pessary insertion and surgical treatments. Conservative management would be non-surgical treatments including physiotherapy and pessary insertion. Surgical options available include anterior and posterior colporrhaphy, sacrospinous fixation and abdominal sacro-colpopexy. Most of the procedures can be performed without the addition of synthetic mesh.
Treatment options are typically tailored to the individual patient’s needs with the common practice is that the treatment should be given to those who are symptomatic. Most gynaecologists would have conducted a urodynamic study with similar circumstances as the patient in the case study had overactive bladder and urodynamic stress incontinence. In the study case detailed, expert evidence detailed that most gynaecologists would have conducted a urodynamic study with similar circumstances as the patient who had an overactive bladder and urodynamic stress incontinence.
Furthermore, the choice of surgery could also depend on other factors including but not limited to the preservation of reproductive and/or menstrual function and the desire to preserve the uterus as well as factors like the presence of vaginal vault prolapse in hysterectomized and concomitant intrapelvic disease. An assessment of POP complications including urinary incontinence, bladder outlet obstruction and fecal incontinence needs to be made.
If a patient would like to preserve reproductive feminism, there are various surgical options available including:
a. Shirodkar’s Sling Operation b. Shirodkar’s Vaginal Prolapse Operation c. Purandare’s Cervicopexy d. Modification of Purandare’s Cervicopexy e. Khanna’s Sling operation f. The Composite Sling operation g. Soonawala’s sling operation h. Nakarni Operation
The above are types of sling operations which are performed abdominally either by open or laparoscopic techniques and may be associated with paravaginal repair of vaginal prolapse where necessary.
There are limitations in conservative (non-surgical) treatment of pelvic organ prolapse dependant on the stage of the symptomatic prolapse. The greater the stage of the symptomatic prolapse, the less likely it is for conservative treatment to be successful. The lifetime risk for women undergoing pelvic organ prolapse surgery is between 10 to 20%.
In the case study, the patient had more overactive bladder symptoms and less urodynamic stress incontinence. Therefore, the patient’s pelvic organ prolapse was not a life-threatening condition and rather affects quality of life.
However, there are also risks of the surgery including by not limited to infection, bleeding at the time of surgery or haematoma formation following surgery, postoperative pain and injury to abdominal organs. As detailed above the defendant listed out the risk of the surgery to the patient prior to the surgery.
Conclusion
Pelvic Organ Prolapse (POP) is a common yet complex condition that significantly impacts the quality of life for affected women. While surgical interventions are often effective, particularly in advanced cases, conservative management—including pelvic floor physiotherapy and pessary use—should be considered as a first-line treatment, particularly in patients with less severe prolapse or predominant bladder symptoms.
The case study highlights the importance of individualised treatment planning, informed consent, and the consideration of non-surgical options prior to proceeding with surgery. Although the surgical approach adopted in the case was deemed professionally acceptable, expert evidence indicated that a referral for conservative management, such as pelvic floor physiotherapy and bladder retraining, would have aligned more closely with standard clinical practice.
Key learning points include:
• Conservative management should be trialled first, where clinically appropriate, especially in cases where prolapse is not advanced or life-threatening.
• A comprehensive preoperative assessment, including urodynamic studies, is critical for accurate diagnosis and optimal treatment planning.
• Informed consent must include a discussion of all reasonable treatment options—both surgical and non-surgical—and their associated risks.
• Quality of life considerations, rather than urgency or severity alone, should guide clinical decision-making in POP cases.
Ultimately, a patient-centred, evidence-based approach that prioritises conservative management where possible may reduce unnecessary surgical interventions and improve long-term outcomes.
How TMLEP’s Services Can Help?
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Through these services, TMLEP not only assists in resolving individual incidents but also contributes to the broader objective of elevating healthcare standards across the board. This commitment to improving clinical practice enables healthcare providers to not only meet but exceed patient safety expectations.
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