Pelvic organ prolapse results from a weakening of connective tissue or loss of muscular support. Risk factors include vaginal delivery, with a 10 percent increased risk of severe prolapse for each additional pound of infant birthweight. Although numerous risk factors are involved, high-impact occupational or recreational activities and increasing age are most often implicated. Cundiff discussed an 80-year-old woman with vaginal prolapse.

Patients with vaginal prolapse can present with a variety of symptoms including sexual, urinary, and bowel complaints. The physical examination focuses on the pelvic area but includes an evaluation of mental and nutritional status, mobility, abdominal wall integrity, and a neurologic examination. Ancillary tests often are used for patients who have urinary incontinence in addition to pelvic organ prolapse.

Patients with pelvic organ prolapse have three treatment options: nonsurgical approaches, surgical approaches, and observation. For mildly symptomatic pelvic organ prolapse, observation is a reasonable approach because of a one-year regression rate of 48 percent for uterine pelvic organ prolapse and a reoperation rate of up to 30 percent. Although studies of Kegel exercises address only their effectiveness in managing urinary incontinence, the exercises were proposed originally as a way to strengthen pelvic support.

Pessaries are available in space-occupying and supportive varieties. The poor retention of pessaries has been associated with a vaginal length of 6 cm or less and a wide vaginal introitus. These complications can be reduced with proper fitting and good pessary care.

Surgical options include reconstructive procedures through a vaginal, abdominal, or laparoscopic approach, or a combination of these. Obliterative procedures are an option only for women who do not plan to engage in further coital activity. Otherwise, data do not support one option over another.

The author concludes that future research is needed to assess the functional outcomes of the surgical management of pelvic organ prolapse. Observation and pessaries should be evaluated to determine which patients are more likely to benefit from their use, and physicians need to identify patients in whom restorative approaches are likely to fail.