Pelvic organ prolapse: pessaries, surgery, and the AU pathway

Pelvic organ prolapse (POP) is not a disease in the traditional sense — it is an anatomical change that is extremely common after childbirth and through menopause, often found on examination in women who have no symptoms at all. What determines whether and how it is treated is symptoms, not stage. Understanding that simple distinction changes the whole conversation.

RANZCOG estimates that examination evidence of Stage II or higher prolapse is present in around half of parous women, but only 12–19% experience symptoms that prompt them to seek care. The lifetime risk of needing prolapse or incontinence surgery is around 20%, and about 30% of women who have POP surgery require a second operation at some point.

A. Core clinical — the AU general practice framework

What prolapses

IUGA and ICS define prolapse by compartment. Anterior wall descent brings the bladder forward into the front vaginal wall — a cystocele. Posterior wall descent brings the rectum or small bowel into the back vaginal wall — a rectocele or enterocele. Apical descent means either the uterus descending (uterine prolapse) or, after hysterectomy, the vaginal vault descending.

Most women present with involvement of more than one compartment. The apical compartment is the most important and the most commonly under-treated — an anterior or posterior repair that does not address apical support often recurs because the root cause has been left untreated.

Risk factors

Vaginal birth is the dominant risk factor, particularly instrumental delivery, a prolonged second stage, perineal trauma, and large babies. Obesity and chronic cough (from smoking, asthma, or COPD) maintain intra-abdominal pressure. Oestrogen deficiency after menopause weakens connective tissue. Prior hysterectomy increases vault-prolapse risk fivefold. Connective-tissue disorders such as Ehlers-Danlos hypermobility syndrome substantially increase risk.

Symptoms to ask about

The most specific symptom is a vaginal bulge that the woman can see or feel. Other important symptoms include:

• Pelvic pressure, heaviness, or a dragging sensation worse with prolonged standing
• Needing to reduce the bulge manually to empty the bladder or bowel (splinting)
• Incomplete bladder or bowel emptying, recurrent urinary tract infections
• Stress incontinence — though severe anterior prolapse can paradoxically mask stress incontinence by kinking the urethra; it may emerge after repair
• Sexual discomfort, embarrassment, or change in sensation

Examination and staging

Ask the woman to lie in the dorsal lithotomy position first, then repeat the examination standing if supine findings are mild but symptoms are significant — many prolapses are underestaged in the supine position.

Use a Sims speculum (single blade) to isolate each compartment while the woman performs a maximal Valsalva and cough. Document which compartments prolapse and how far they descend relative to the hymenal ring.

Formal staging uses the POP-Q system (Bump, 1996), which measures defined anatomical points in centimetres relative to the hymen during maximal Valsalva. Stage 0 is no prolapse; Stage I is the most distal point more than 1 cm above the hymen; Stage II is within 1 cm of the hymen either way; Stage III is more than 1 cm below; Stage IV is complete eversion (procidentia). For general practice referral purposes, a simplified compartment description with an estimate of descent is acceptable — the formal POP-Q is performed at the urogynaecology clinic.

A bladder scan for post-void residual volume is useful when voiding symptoms are prominent — a residual above 100–150 mL suggests obstructive pattern from the prolapse.

The three-step treatment ladder

NICE NG123 and RANZCOG 2024 agree on a three-tier approach:

Step 1 — Conservative. Supervised pelvic-floor muscle training (PFMT) with a women’s health physiotherapist is first-line for Stage I–II symptomatic prolapse. The PEPPI trial (Hagen, Lancet 2014) demonstrated that 16 weeks of supervised training with five physiotherapy visits significantly improved prolapse symptom scores at 12 months compared with advice alone. Weight reduction of 5–10% meaningfully reduces symptoms. Constipation management (fibre, fluids, footstool for defecation posture), cough optimisation, and vaginal oestrogen for menopausal atrophy complete the conservative package.

Step 2 — Pessary. A pessary is a clinician-fitted silicone device that mechanically supports the prolapse from within. It is an equally valid alternative to surgery for any stage of prolapse, not merely a bridge. Cochrane review (Bugge 2020) confirms that pessaries improve symptoms in around 70% of women. The ring with knob is first choice for anterior and apical Stage I–III prolapse in sexually active women; the Gellhorn suits severe apical descent. Australian GPs can be trained in pessary fitting through Continence Foundation workshops; GP-fitted pessary services are growing. Review every 3–6 months for clinician-managed pessaries; teach self-management (remove, wash with soap and water, reinsert) where possible.

Step 3 — Surgery. Surgery is offered when conservative measures have failed, are not preferred, or when the patient chooses it. Native-tissue vaginal repair — anterior colporrhaphy (MBS 35691), posterior colporrhaphy (MBS 35730), and apical fixation by sacrospinous ligament fixation (MBS 35727) or uterosacral ligament suspension — is the standard for most cases. The OPTIMAL trial (Barber, JAMA 2014) found sacrospinous and uterosacral fixation equivalent at two years for composite success. Abdominal/laparoscopic sacrocolpopexy (MBS 35719) using mesh placed from above remains the gold standard for vault prolapse and recurrent apical prolapse — Cochrane (Maher 2016) shows 50% lower recurrence than native-tissue vaginal repair, at the cost of longer operating time and mesh-specific risks (extrusion 2–10%). Le Fort colpocleisis (MBS 35650) — partial vaginal closure — offers very low recurrence (~5%) with short operating time for women who are medically frail and not sexually active; it is underused and should be explicitly discussed. Uterine-sparing sacrohysteropexy is equivalent to vaginal hysterectomy at three years per the SUPeR trial (Nager, JAMA 2019) and preferred by women who wish to retain the uterus.

B. The transvaginal mesh story — what patients need to know

The TGA cancelled transvaginal mesh kits for POP in 2017 and tightened mid-urethral mesh rules in 2018, following the 2018 Senate Community Affairs References Committee inquiry. Post-market surveillance had documented mesh erosion in 8–15% of women, chronic pelvic pain in around 8%, and persistent dyspareunia.

Transvaginal mesh for POP is now restricted to selected centres under multidisciplinary review. It is not available in routine surgical practice.

Abdominal sacrocolpopexy mesh is different and remains accepted practice. It is placed from above (laparoscopically or robotically), anchors to the sacral promontory, and has a much lower erosion rate than the cancelled transvaginal kits. Patients anxious about “mesh” often do not realise these are categorically different — this distinction needs to be clearly communicated.

Women with mesh-related complications can access state-funded removal services at Royal Hospital for Women NSW, Royal Women’s Hospital Victoria, and Mercy Hospital Melbourne. The Continence Foundation of Australia Mesh Information Service provides guidance.

C. Post-operative considerations and MBS billing

After surgical repair, recovery takes 6–12 weeks before return to lifting and exercise. Vaginal oestrogen (Vagifem, Ovestin cream, Estring — all PBS General Schedule) helps mucosal healing in postmenopausal women and improves pessary tolerance at any age.

Key MBS items in GP management:

• Item 23/36/44 — consultations for assessment, pessary review, surgical counselling
• Item 10960 — women’s health physiotherapy under GP Management Plan
• Item 55054 — pelvic ultrasound including post-void residual
• Item 35712 — vaginal pessary fitting (specialist or accredited GP)
• Items 91790/92029/92060 — telehealth consultations for pessary follow-up

D. Australian operations

The Continence Foundation of Australia (National Continence Helpline 1800 33 00 66) provides patient and clinician resources, specialist directories, and pessary fitting workshop listings for GPs. The Continence Aids Payment Scheme (CAPS) assists women with the cost of continence products.

Women’s-health physiotherapists accredited by the Australian Physiotherapy Association (APA) in continence and pelvic floor provide PFMT under the GP Management Plan and Team Care Arrangement framework (GPCCMP preparation item 965 and review item 967 from July 2025). Most capital cities and many regional centres have APA-accredited continence physiotherapists; the APA website maintains a searchable directory.

Urogynaecology specialist services exist at major women’s hospitals in all states. Community-based pessary services are available through many regional health districts and via GP-led pessary clinics. Jean Hailes for Women’s Health offers evidence-based patient education on pelvic floor and prolapse in plain language.

E. Special populations

Postnatal prolapse is frequently noticed 3–6 months after a vaginal birth, often earlier than in older women. The standard recommendation is to defer surgical repair for at least 12 months from delivery and ideally until the family is complete. Pelvic tissue remodels throughout the first year, and many postnatal prolapses stage down or become asymptomatic. A pessary is safe and appropriate during this period. Supervised PFMT during the postnatal recovery has preventive as well as therapeutic benefit.

Pregnancy with prolapse. A pessary is safe throughout pregnancy. Surgery is deferred until after delivery and until the family is complete.

Recurrent POP after surgery. Multidisciplinary urogynaecology review is required. Imaging (pelvic MRI) helps characterise compartment-specific recurrence. Abdominal sacrocolpopexy should be considered if not previously performed, particularly for vault recurrence.

Procidentia with hydronephrosis. Complete or near-complete eversion of the vagina can kink the ureters, causing obstructive uropathy. A renal ultrasound is required for Stage IV prolapse. Urgent reduction — by pessary or surgical repair — is needed to prevent renal damage.

Concomitant stress urinary incontinence. Discuss the possibility of occult stress incontinence emerging after repair — masked by the kinked urethra when prolapse is severe. Urodynamic testing before surgery helps plan whether a concurrent anti-incontinence procedure (midurethral sling) is needed.

Body image and sexual distress are underdiagnosed dimensions of POP. A Mental Health Care Plan (item 2715) for psychology or psychosexual counselling is appropriate when prolapse significantly affects intimacy or self-image.

When to escalate

Refer to women’s-health physiotherapy for: symptomatic Stage I–II prolapse first presentation; all postnatal women with prolapse symptoms; women wanting supervised PFMT before considering surgery.

Refer to urogynaecology or gynaecology for: prolapse that has not responded to pessary plus supervised PFMT; patient preference for surgical assessment; Stage III–IV prolapse causing splinting, retention, or hydronephrosis; recurrent prolapse after prior surgery; diagnostic uncertainty; concomitant complex incontinence.

Refer urgently: acute urinary or faecal retention; suspected hydronephrosis from Stage IV prolapse; bleeding or ulceration from extruded cervix that requires biopsy to exclude malignancy.

What this article is and is not

This is general health information drawn from current Australian guidelines — RANZCOG, Therapeutic Guidelines, NICE NG123, RACGP, Continence Foundation of Australia — and major RCTs (PEPPI, OPTIMAL, SUPeR, Cochrane reviews). It is not personal medical advice and does not establish a doctor–patient relationship. Decisions about pessary fitting, physiotherapy referral, and surgical options are made together with your own GP and treating specialists.

For Australian consumer resources: Continence Foundation of Australia (1800 33 00 66), Jean Hailes for Women’s Health, HealthDirect — pelvic organ prolapse, Better Health Channel.

For urgent concerns: contact your GP, call 000 for urinary retention, or attend your nearest emergency department.

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Sources cited

1. RANZCOG — Management of Pelvic Organ Prolapse 2024
2. Therapeutic Guidelines (eTG) — Pelvic floor disorders
3. RACGP — Pelvic organ prolapse in general practice (AJGP)
4. NICE NG123 — Urinary incontinence and pelvic organ prolapse in women: management
5. Continence Foundation of Australia
6. TGA — Urogynaecological surgical mesh hub
7. Cochrane — Pessaries for pelvic organ prolapse (Bugge 2020)
8. Hagen et al. — PEPPI trial (Lancet 2014)
9. Barber et al. — OPTIMAL trial (JAMA 2014)
10. Nager et al. — SUPeR trial (JAMA 2019)
11. Cochrane — Surgery for women with apical vaginal prolapse (Maher 2016)
12. Haylen et al. — IUGA/ICS terminology for POP (2016)
13. HealthDirect — Pelvic organ prolapse
14. Better Health Channel — Pelvic floor
15. Jean Hailes for Women’s Health