Pelvic Organ Prolapse Surgery

Introduction

Pelvic organ prolapse is a condition in which one or more of the pelvic organs — the bladder, uterus, vaginal walls, or rectum — drop from their normal position because the muscles and connective tissues that support them have weakened or stretched. Many women live with prolapse for years before seeking treatment, often because the symptoms develop slowly and can feel embarrassing to discuss.

If you are reading this, you likely already know you have prolapse, or your doctor has suggested that surgery may be the next step. This article is written for that moment. It explains what pelvic organ prolapse surgery is, the different types of repair, what alternatives exist, how to prepare, what happens during and after surgery, and what life looks like in the months and years that follow. The goal is to help you go into your conversations with your surgeon with a clearer picture of the choices ahead.

What Is Pelvic Organ Prolapse Surgery?

Pelvic organ prolapse surgery — sometimes called pelvic floor repair surgery or prolapse repair — is a group of operations designed to restore the normal position and support of pelvic organs that have descended into or out of the vagina. The pelvic floor is a hammock-like layer of muscles, ligaments, and connective tissue that holds these organs in place. When this support weakens, organs can shift downward, causing a sensation of pressure, a visible or palpable bulge, and problems with bladder, bowel, or sexual function.

The aim of surgery is to:

• Return the prolapsed organ to its normal anatomical position
• Reinforce the weakened support structures
• Improve bladder, bowel, and sexual function where these are affected
• Reduce the physical discomfort caused by the prolapse

Prolapse is described by which compartment of the pelvis is affected. Anterior prolapse (cystocele) involves the bladder pushing into the front wall of the vagina. Posterior prolapse (rectocele) involves the rectum pushing into the back wall. Apical prolapse involves descent of the uterus, the cervix, or — in women who have already had a hysterectomy — the top of the vagina (vaginal vault prolapse). Many women have prolapse in more than one compartment, and surgery is planned accordingly.

Why Pelvic Organ Prolapse Surgery Is Performed

Prolapse is common, particularly after childbirth and around menopause, but not everyone with prolapse needs surgery. Doctors typically consider surgery when prolapse causes bothersome symptoms that have not improved with conservative treatments, or when the prolapse is moderate to severe and affects daily life.

Symptoms That May Have Led to Surgical Evaluation

• A noticeable bulge or pressure inside or outside the vagina
• A feeling that something is “coming down” or “falling out,” especially toward the end of the day
• Difficulty emptying the bladder or bowel completely
• Urinary leakage, urgency, or recurrent urinary tract infections
• Constipation or the need to press on the vaginal wall to pass stool (splinting)
• Pelvic heaviness, low back ache, or discomfort with prolonged standing
• Pain, dryness, or difficulty during intercourse
• Visible tissue protruding from the vaginal opening

Prolapse is generally not a medical emergency. However, when the prolapse is severe and tissue is exposed outside the body for long periods, problems such as ulceration, bleeding, or interference with urination can develop. In those cases, doctors may recommend more prompt treatment.

Why Prolapse Develops

Pelvic organ prolapse usually results from a combination of factors that weaken pelvic support over time. These include:

• Vaginal childbirth, especially multiple deliveries, large babies, or long second-stage labour
• Ageing and the gradual loss of tissue strength
• Reduced oestrogen levels after menopause, which affects the strength and elasticity of vaginal tissues
• Chronic increases in abdominal pressure from long-standing constipation, chronic cough, or repeated heavy lifting
• Obesity
• Previous pelvic surgery, including hysterectomy
• Inherited differences in connective tissue strength
• Nerve injury during childbirth that affects pelvic floor muscle function

Who Is a Candidate for Surgery?

Surgery is one option among several, and the decision to proceed depends on the severity of the prolapse, the impact on quality of life, the woman’s general health, her reproductive plans, and her preferences. Major societies such as the American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS) describe surgery as appropriate when symptoms are bothersome and conservative measures have not provided adequate relief, or when the woman prefers surgical correction after a full discussion of options.

Factors a surgeon will typically weigh include:

• The compartments involved and the stage of prolapse
• Symptoms and how much they affect daily life
• Whether the woman has completed childbearing (future pregnancy can stress repairs)
• Sexual activity and preferences about preserving vaginal function
• Age, general health, and ability to tolerate anaesthesia
• Previous pelvic surgeries
• Co-existing conditions such as stress urinary incontinence, which may be addressed at the same time

Women who have not completed childbearing are usually advised to delay surgical repair where possible, because pregnancy and vaginal delivery can place significant stress on repaired tissues and increase the chance of recurrence.

Alternatives to Surgery

Before recommending surgery, doctors typically explore non-surgical options. For many women with mild or moderate prolapse, these are effective and may be continued indefinitely.

Pelvic Floor Muscle Training

Supervised pelvic floor muscle exercises, often guided by a women’s health physiotherapist, can strengthen the muscles that support pelvic organs. Studies have shown that pelvic floor training reduces symptoms and can slow progression, particularly in milder prolapse. The exercises are most effective when taught and supervised, rather than learned from a leaflet, because many women contract the wrong muscles without feedback.

Vaginal Pessary

A pessary is a small, flexible device — usually silicone — placed inside the vagina to support prolapsed organs. Pessaries come in several shapes and sizes and are fitted by a clinician. They can be used as a long-term alternative to surgery, as a trial to see whether symptom relief from repositioning the organs is meaningful, or as a way to manage symptoms while waiting for surgery. Some women remove and clean their own pessary; others return to the clinic for regular care.

Lifestyle Measures

Several lifestyle changes can reduce symptoms and slow progression:

• Weight loss if overweight
• Treatment of chronic cough, including smoking cessation
• Management of constipation with fibre, fluids, and stool softeners
• Avoiding heavy lifting where possible and using correct technique

Local Oestrogen

For postmenopausal women, low-dose vaginal oestrogen can improve the health of vaginal tissues, which may help with comfort, pessary tolerance, and sometimes with mild symptoms. It does not correct prolapse but is often used alongside other measures.

If these approaches do not provide adequate relief, or if the prolapse is severe, surgery becomes one of the options that doctors and patients discuss together.

Types of Pelvic Organ Prolapse Surgery

Pelvic organ prolapse surgery is not a single operation. The procedure is selected based on which compartments are prolapsed, how severe the prolapse is, whether the uterus is still present, sexual activity, and prior surgical history. Common repair types are grouped below.

Anterior Repair (for Cystocele)

Anterior colporrhaphy repairs a prolapse of the bladder into the front wall of the vagina. The surgeon makes an incision in the front vaginal wall, identifies the weakened tissue layer, and stitches the supporting tissues together to restore the bladder’s position.

Posterior Repair (for Rectocele)

Posterior colporrhaphy repairs prolapse of the rectum into the back wall of the vagina. The approach is similar to an anterior repair but on the rear vaginal wall, and may include repair of the perineum (perineorrhaphy) if that area is also weakened.

Apical Suspension Procedures

These procedures address descent of the uterus, cervix, or vaginal vault. Common options include:

• Sacrocolpopexy: The top of the vagina (or the cervix) is attached to the sacrum at the base of the spine using a synthetic mesh. It is usually performed abdominally — through open surgery, laparoscopy, or robotic assistance — and is considered durable, particularly for women with severe apical prolapse.
• Sacrospinous ligament fixation: The vaginal apex is stitched to the sacrospinous ligament inside the pelvis through a vaginal incision. It avoids an abdominal incision and is often used for vaginal vault prolapse.
• Uterosacral ligament suspension: The vaginal apex is supported using the woman’s own uterosacral ligaments. This can be done vaginally or abdominally.

Hysterectomy with Prolapse Repair

When the uterus is prolapsed and the woman has completed childbearing, removal of the uterus (hysterectomy) is sometimes combined with prolapse repair. Hysterectomy alone does not correct the underlying support problem, so it is usually combined with an apical suspension to support the top of the vagina.

Uterus-Sparing Procedures

For women who wish to keep their uterus — for personal, cultural, or fertility reasons — uterus-preserving operations such as sacrohysteropexy or sacrospinous hysteropexy can lift and resuspend the uterus rather than remove it. The choice depends on the woman’s preferences, the type of prolapse, and surgical expertise.

Obliterative Procedures (Colpocleisis)

Colpocleisis closes the vaginal canal partially or completely to support the prolapsed organs. It is typically considered only for older women who are not sexually active and who prefer a shorter, less invasive operation with a low chance of recurrence. The trade-off is that vaginal intercourse is no longer possible afterwards, so this decision is made carefully and with clear discussion.

Mesh and Native-Tissue Repairs

Some prolapse repairs use the woman’s own tissues (native-tissue repair), while others use a synthetic mesh for additional support. The use of transvaginal mesh — mesh placed through a vaginal incision specifically to treat prolapse — has been restricted or withdrawn in several countries following safety concerns raised by regulators such as the US Food and Drug Administration. Abdominal mesh used in sacrocolpopexy is generally considered to have a different safety profile and remains in use. Whether mesh is appropriate is a decision made between the patient and surgeon based on the type of prolapse, the surgical approach, and informed discussion of risks and benefits.

Surgical Approaches

In addition to choosing the type of repair, the surgeon also chooses how to access the pelvic organs. The same repair can sometimes be performed by more than one approach, and the choice depends on the type and severity of prolapse, prior surgeries, body habitus, surgeon experience, and available equipment.

Vaginal Approach

Many prolapse repairs are performed through the vagina, with no external incision. Vaginal surgery is associated with shorter operating times, no visible scar, and often a faster initial recovery. It is commonly used for anterior and posterior repairs, sacrospinous fixation, and vaginal hysterectomy.

Abdominal Approach (Open Surgery)

An open abdominal approach uses a horizontal or vertical incision in the lower abdomen. It is less commonly used today as the first choice but may be appropriate in complex cases, women with prior extensive pelvic surgery, or where laparoscopic access is not possible.

Laparoscopic Approach

Laparoscopic (keyhole) surgery uses several small incisions, a camera, and long instruments. It is widely used for sacrocolpopexy and some hysteropexy procedures. Compared with open abdominal surgery, laparoscopy is associated with smaller scars, less postoperative pain, shorter hospital stay, and quicker return to activity, though operating times can be longer.

Robotic-Assisted Approach

Robotic surgery is a form of laparoscopy in which the surgeon controls instruments through a console. It offers improved visualisation and finer instrument control, and is used in selected centres for sacrocolpopexy and other complex repairs. Clinical outcomes are broadly similar to laparoscopic surgery in experienced hands; availability depends on the hospital.

When more than one approach is reasonable, the surgeon will discuss the trade-offs — recovery, scarring, durability of repair, and individual anatomy — before a final plan is made.

Preparing for Pelvic Organ Prolapse Surgery

Preparation usually begins several weeks before the planned surgery date.

Pre-Operative Assessment

Your surgical team will typically arrange:

• A detailed history and pelvic examination, including staging of the prolapse
• Blood tests and other investigations to assess fitness for anaesthesia
• Urodynamic testing if urinary symptoms are present, to check bladder function
• Imaging such as ultrasound or MRI in selected cases
• An anaesthetic review
• A discussion of medications, including blood thinners that may need to be paused

Lifestyle Preparation

In the weeks before surgery, it can help to:

• Stop smoking, even temporarily, to support wound healing
• Optimise weight where feasible
• Treat constipation so that bowel movements after surgery are easier
• Continue pelvic floor exercises if recommended
• Use vaginal oestrogen if prescribed, to improve tissue quality

Practical Preparation

• Arrange help at home for the first one to two weeks after discharge
• Prepare easy meals and a comfortable resting space
• Plan for time off work, typically two to six weeks depending on the procedure and the nature of the job
• Note questions to discuss at the pre-operative appointment

You will usually be asked not to eat or drink for several hours before surgery. The exact instructions, including any bowel preparation, will be given by your surgical team.

What Happens During Surgery

Pelvic organ prolapse surgery is performed under general or regional (spinal or epidural) anaesthesia. The exact steps depend on the type of repair, but the broad sequence is similar:

1. Anaesthesia: The anaesthetist puts you to sleep or numbs the lower body, depending on the planned approach.
2. Positioning: You are positioned for the chosen approach — usually on your back with legs supported in stirrups for vaginal procedures.
3. Access: The surgeon enters the pelvis through the vagina, the abdomen, or small keyhole incisions.
4. Repair: Weakened tissues are identified and reinforced. Prolapsed organs are repositioned and supported using sutures, native tissue, or mesh as planned.
5. Additional procedures: If a hysterectomy or an anti-incontinence procedure (such as a midurethral sling) is planned, this is performed at the same time.
6. Closure: Incisions are closed with dissolvable stitches. A vaginal pack and a urinary catheter are often placed temporarily.

In Hospital

Most women stay in hospital for one to three days. During this time:

• Pain is managed with oral medication, usually adequate after the first 24 hours
• A urinary catheter is in place for the first day or two, sometimes longer if the bladder is slow to start emptying
• The vaginal pack, if used, is removed within 24 hours
• Gentle walking is encouraged early to reduce the risk of blood clots
• You will be helped to eat, drink, and pass urine before discharge

The First Two Weeks at Home

Rest is the priority. You may feel tired, have some vaginal discharge or light bleeding, and notice mild swelling or bruising. During this period, doctors typically advise:

• Walking short distances several times a day
• Avoiding lifting anything heavier than 2–3 kg
• Not driving until you can perform an emergency stop without pain (often around two weeks)
• Showering rather than soaking in baths until cleared
• Avoiding tampons, vaginal intercourse, and swimming

Two to Six Weeks

You can usually return to light daily activities and desk-based work within two to four weeks. Physically demanding work, exercise classes, and longer travel are usually delayed to around six weeks. Vaginal intercourse is typically avoided for at least six weeks, or longer if your surgeon advises.

Six Weeks to Three Months

Tissues continue to heal for several months. Gradual return to exercise is encouraged, but heavy lifting and high-impact activity are usually avoided until your surgeon confirms the repair has settled. A follow-up appointment around six weeks allows the surgeon to assess healing and discuss return to specific activities.

Pelvic Floor Rehabilitation

Pelvic floor muscle exercises are usually restarted gently in the weeks after surgery and continued long term. A women’s health physiotherapist can guide this and help with any new or persistent symptoms.

Risks and Complications

Pelvic organ prolapse surgery is generally safe, particularly in experienced hands, but every operation carries some risk. Knowing the possibilities supports informed consent.

Short-Term Risks

• Bleeding or haematoma at the surgical site
• Infection of the wound, vagina, or urinary tract
• Difficulty emptying the bladder, sometimes requiring a temporary catheter
• Constipation or temporary changes in bowel function
• Reaction to anaesthesia
• Blood clots in the legs or lungs (uncommon, reduced by early walking and, sometimes, blood thinners)
• Injury to nearby structures such as the bladder, bowel, ureters, or blood vessels (uncommon)

Longer-Term Risks

• Recurrence of prolapse: Some women develop prolapse again, either in the same compartment or another, in the years after surgery. Risk factors include younger age, severe initial prolapse, ongoing constipation or chronic cough, and high physical demands.
• New urinary symptoms: Some women develop stress urinary incontinence that was not present before, because the prolapse was previously kinking the urethra and masking the problem.
• Painful intercourse: Scar tissue or narrowing of the vagina can sometimes cause discomfort during sex. This often improves with time, vaginal oestrogen, dilators, or physiotherapy.
• Mesh-related complications: Where mesh is used, complications can include exposure of mesh through the vaginal wall, pain, or infection. The risk profile depends on the type of mesh and the approach.
• Chronic pelvic pain: Uncommon but reported.

Discussing your individual risk factors with your surgeon before the operation helps set realistic expectations.

Life After Pelvic Organ Prolapse Surgery

For most women, surgery brings meaningful relief from the pressure, bulge, and functional problems that prompted the operation. Day-to-day activities such as walking, working, and exercising become more comfortable, and many women describe an improvement in confidence and quality of life. However, surgery is not a permanent guarantee, and long-term care plays an important role in preserving the result.

Protecting the Repair

Several habits help reduce the chance of recurrence:

• Continue pelvic floor exercises long term
• Maintain a healthy weight
• Prevent and treat constipation
• Manage chronic cough; stop smoking
• Lift carefully and avoid repeated heavy lifting where possible
• Use vaginal oestrogen after menopause if recommended

Sexual Function

Many women find that sexual comfort improves after prolapse surgery, particularly when prior symptoms included bulging tissue or discomfort. Some experience temporary dryness, sensitivity, or pain as the tissues heal, and this usually improves over several months. If problems persist, vaginal oestrogen, lubricants, pelvic floor physiotherapy, or a return visit to the surgeon can help.

Bladder and Bowel Function

Bladder and bowel symptoms often improve, but some women notice new patterns — for example, urinary leakage with coughing or sneezing that was previously hidden by the prolapse. These can usually be treated, sometimes with further surgery (such as a midurethral sling), pelvic floor therapy, or medication.

Follow-Up

Follow-up visits, typically at around six weeks and then periodically, allow the surgeon to assess healing and pick up any early signs of recurrence. If new symptoms appear later — a returning bulge, urinary or bowel changes, or pain — it is worth seeking a review rather than waiting.

Pregnancy After Prolapse Surgery

Prolapse surgery does not directly affect the ovaries or fallopian tubes, so fertility is not changed by the procedure itself. However, pregnancy and especially vaginal delivery place significant strain on pelvic support tissues, including those that have been repaired. For this reason, prolapse surgery is generally considered after childbearing is complete. If a woman becomes pregnant after prolapse repair, her obstetrician and surgeon will discuss the safest delivery plan together, which may include a planned caesarean section.

Frequently Asked Questions

Will the prolapse come back after surgery?

Recurrence is possible. Some women develop prolapse again in the same compartment, while others develop it in a different compartment. Continuing pelvic floor exercises, maintaining a healthy weight, and managing factors that increase abdominal pressure (such as constipation and chronic cough) help reduce the risk.

How painful is the recovery?

Most women describe the discomfort as moderate in the first few days, then steadily improving. Pain is managed with oral medication, and many women are off strong painkillers within a week or two. Pelvic heaviness, mild ache, and vaginal discharge can continue for several weeks.

How long will I need to be off work?

This depends on the type of repair and the nature of your work. Desk-based work is often possible after two to four weeks. Jobs involving lifting, prolonged standing, or physical activity usually need around six weeks or more.

When can I have sex again?

Vaginal intercourse is usually avoided for at least six weeks, and sometimes longer depending on the type of repair. Your surgeon will give specific guidance at the follow-up visit.

Will I need a hysterectomy as part of the surgery?

Not necessarily. Many women have prolapse repaired without hysterectomy, including uterus-preserving suspension procedures. The decision depends on the type of prolapse, your symptoms, and your preferences, and is made together with your surgeon.

What is the difference between native-tissue repair and mesh repair?

Native-tissue repair uses your own ligaments and connective tissues, reinforced with stitches. Mesh repair uses a synthetic material to add support. Both have advantages and disadvantages. Transvaginal mesh specifically for prolapse has been restricted in several countries due to complications, while abdominal mesh for sacrocolpopexy is still widely used. The choice should be made after a full conversation with your surgeon.

Can I exercise after prolapse surgery?

Yes, with gradual return. Walking is encouraged from day one. High-impact exercise, heavy lifting, and core abdominal work are usually delayed until around three months. Pelvic floor exercises are typically continued long term.

What if I do not want surgery?

Pelvic floor muscle training, vaginal pessaries, lifestyle measures, and local oestrogen can all help manage prolapse without surgery. Many women use these long term. Surgery remains an option later if symptoms change.

Conclusion

Pelvic organ prolapse surgery is a well-established way to repair weakened pelvic support and relieve the bulge, pressure, and functional problems that prolapse can cause. Several types of repair and several surgical approaches exist, and the right choice depends on the kind of prolapse, the symptoms, and individual factors including whether childbearing is complete and whether the uterus is to be preserved.

For most women, surgery brings significant improvement. Long-term results are best supported by continuing pelvic floor exercises, managing the factors that contributed to prolapse in the first place, and attending follow-up. With clear information and a careful conversation with the surgical team, the decisions ahead become more manageable, and the path through preparation, surgery, and recovery becomes clearer.