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Understanding Your Treatment Options for Pelvic Organ Prolapse and Urinary Incontinence

Purpose of This Document

This document provides educational information about urogynecologic treatment options for pelvic organ prolapse and stress urinary incontinence. It is intended to help patients understand available treatments and how decisions are typically made.

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Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the bladder, uterus, vaginal apex, or bowel descends toward or through the vaginal opening due to weakening of the pelvic floor muscles and supporting connective tissue. Common symptoms include a vaginal bulge or pressure, pelvic discomfort, urinary or bowel difficulties, and interference with daily activities or sexual function.

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Prolapse is common and may develop after childbirth, menopause, prior pelvic surgery, or with aging and connective tissue changes. The degree of prolapse seen on examination does not always correlate with symptom severity.

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Stress Urinary Incontinence

Stress urinary incontinence is the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, laughing, lifting, or exercise. It affects a significant proportion of adult women and can have a substantial impact on quality of life.

Stress incontinence is caused by reduced support of the urethra or weakness of the urinary sphincter mechanism.

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Prolapse and stress incontinence are often both present and prolapse repair can unmask dormant stress urinary incontinence. 

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How Are Treatment Decisions Made?

Treatment decisions are guided by:

• The severity and type of symptoms

• The degree of anatomical findings

• The impact on quality of life

• Previous treatments

• Medical fitness for surgery

• Individual goals and preferences

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In most cases, treatment progresses from conservative options to procedural or surgical options  if symptoms remain bothersome. More severe degrees of prolapse and incontinence often do need surgery for resolution of symptoms..

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Conservative (Non-Surgical) Treatment Options

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For Pelvic Organ Prolapse

Conservative management may be appropriate for women with mild or moderate symptoms, or those who prefer to avoid surgery.

Options include:

• Observation: Appropriate if symptoms are minimal or absent

• Pelvic floor physiotherapy: Supervised muscle training to improve pelvic support

• Pessary use: A removable vaginal device that supports prolapsed organs

• Lifestyle modification: Weight management, avoidance of heavy lifting, and treatment of chronic cough or constipation

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For Stress Urinary Incontinence

First-line treatment typically includes:

• Pelvic floor muscle training, ideally supervised

• Weight reduction when applicable

• Bladder and fluid management

• Pessaries or vaginal continence devices in selected cases

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Conservative treatments may significantly reduce symptoms, though they may not completely eliminate leakage in all patients.

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When Is Surgery Considered?

Surgical treatment may be considered when:

• Conservative treatments have been tried and are insufficient

• Symptoms significantly affect daily activities or quality of life

• The patient desires a more definitive intervention

• The patient is medically suitable for surgery

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Surgery is elective and should be chosen only after informed discussion of risks, benefits, and alternatives.

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Treatment Options for Pelvic Organ Prolapse

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Pessary Therapy (Non-Surgical)

A pessary is a removable device placed in the vagina to support prolapsed organs.

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Advantages

• Non-surgical and reversible

• Effective for many women

• Can be used long-term or as a temporary measure

Considerations

• Requires fitting and follow-up

• May cause discharge or irritation

• Some women later choose surgery despite initial success

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Surgical Options for Prolapse

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Surgical management often involves a combination of procedures, tailored to the specific compartments involved, including anterior, apical, and/or posterior prolapse.

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Native Tissue Vaginal Repairs

These procedures use the patient’s own tissue to restore support and are performed through the vagina.

Common procedures include:

• Anterior colporrhaphy (bladder support)

• Posterior colporrhaphy (rectal support)

• Uterosacral ligament suspension

• Sacrospinous ligament fixation

Advantages

• No synthetic mesh

• Shorter operative time and recovery

• Lower risk of mesh-related complications

Limitations

• Higher long-term recurrence rates compared with abdominal mesh procedures

• Some patients may require additional surgery in the future

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Sacrocolpopexy (Laparoscopic)

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Sacrocolpopexy suspends the vaginal apex to the sacrum using synthetic mesh via minimally invasive abdominal surgery.

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Advantages

• Best long-term anatomical durability for apical prolapse

• Lower recurrence rates

• High patient satisfaction in appropriately selected cases

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Limitations

• Longer surgery

• Use of permanent mesh

• Small risk of mesh exposure or erosion

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Colpocleisis (Vaginal Closure)

Colpocleisis closes the vaginal canal to support prolapsed organs.

Appropriate for

• Women who no longer desire vaginal intercourse

• Patients with significant medical comorbidities

Advantages

• Shortest operative time

• Lowest recurrence rates

• Can often be done under regional or local anesthesia

Limitations

• Permanent loss of vaginal intercourse

• Not reversible

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Treatment Options for Stress Urinary Incontinence

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Midurethral Sling Surgery

A synthetic mesh sling is placed under the urethra to provide support during increases in abdominal pressure.

Benefits

• Most commonly performed procedure

• High success rates

• Short operative time and recovery

Approaches

• Retropubic (gold standard)

• Transobturator

Both approaches are effective, with small differences in risk profiles.

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Limitations

• Does not treat urgency incontinence

• Small risk of mesh exposure, voiding difficulty, or pain

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Non-Mesh Surgical Alternatives

Burch Colposuspension

• Laparoscopic procedure using sutures for urethral support

• Effective but more takes longer and less effective than mesh.

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Autologous Fascial Sling

• Uses the patient’s own tissue

• Highly effective

• Higher risk of postoperative voiding difficulty

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Urethral Bulking Injections

Material is injected around the urethra to improve closure.

Best suited for

• Mild stress incontinence

• Patients who are not surgical candidates

Limitations

• Lower success rates

• Often requires repeat treatments

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Decision-Making Pathways

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For Pelvic Organ Prolapse

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Step 1: Are symptoms present?

• No symptoms → Observation

• Mild symptoms → Conservative management

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Step 2: Conservative treatment

• Pelvic floor physiotherapy

• Pessary trial

• Lifestyle modification

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Step 3: Persistent bothersome symptoms

• Discuss surgical options

• Choose approach based on anatomy, goals, and risk tolerance

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For Stress Urinary Incontinence

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Step 1: Confirm diagnosis

• Exclude infection or predominant urgency incontinence

Step 2: Conservative management

• Pelvic floor therapy

• Behavioral measures

Step 3: Persistent symptoms

• Discuss surgical and non-surgical procedural options

• Select treatment based on severity, preferences, and risk profile

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Summary

Pelvic organ prolapse and stress urinary incontinence are common conditions with multiple effective treatment options. Most patients benefit from a stepwise approach that begins with conservative management and progresses to procedural or surgical intervention only when needed. Shared decision-making, based on evidence and individual goals, is central to successful treatment.

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More detailed resources: 

• Laparoscopy

• Anterior repair

• Posterior repair/perineorraphy

• Uterosacral ligament suspension

• Sacrocolpopexy

• Colpocleisis

• Sacrospinous fixation

• Vaginal/Laparoscopic hysterectomy

• Vaginal Mesh (only done in extremely rare cases)

• Mid-urethral sling procedure

• Sacral Neuromodulation

• Bladder Botox

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