Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- The only symptom specific to prolapse is the awareness of a vaginal bulge or protrusion. For all other pelvic symptoms, resolution with prolapse treatment cannot be assumed.
- Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse.
- Cadaveric fascia should not be used as graft material for abdominal sacral colpopexy because of a substantially higher risk of recurrent prolapse than with synthetic mesh.
- Stress-continent women with positive stress test results (prolapse reduced) are at higher risk for developing postoperative stress incontinence after prolapse repair alone compared with women with negative stress test results (prolapse reduced).
- For stress-continent women planning abdominal sacral colpopexy, regardless of the results of preoperative stress testing, the addition of the Burch procedure substantially reduces the likelihood of postoperative stress incontinence without increasing urgency symptoms or obstructed voiding.
- For women with positive prolapse reduction stress test results who are planning vaginal prolapse repair, tension-free vaginal tape (TVT) midurethral sling (rather than suburethral fascial plication) appears to offer better prevention from postoperative stress incontinence.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Clinicians should discuss the option of pessary use with all women who have prolapse that warrants treatment based on symptoms. In particular, pessary use should be considered before surgical intervention in women with symptomatic prolapse.
- Alternative operations for uterine preservation in women with prolapse include uterosacral or sacrospinous ligament fixation by the vaginal approach, or sacral hysteropexy by the abdominal approach.
- Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse, particularly enterocele.
- Round ligament suspension is not effective in treating uterine or vaginal prolapse.
- Compared with vaginal sacrospinous ligament fixation, abdominal sacral colpopexy has less apical failure and less postoperative dyspareunia and stress incontinence, but is also associated with more complications.
- Transvaginal posterior colporrhaphy is recommended over transanal repair for posterior vaginal prolapse.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Clinicians should discuss with women the potential risks and benefits in performing a prophylactic anti-incontinence procedure at the time of prolapse repair.
- Women with prolapse who are asymptomatic or mildly symptomatic can be observed at regular intervals, unless new bothersome symptoms develop.
- For women who are at high risk for complications with reconstructive procedures and who no longer desire vaginal intercourse, colpocleisis can be offered.
- Cystoscopy should be performed intraoperatively to assess for bladder or ureteral damage after all prolapse or incontinence procedures during which the bladder or ureters may be at risk of injury.
Definitions:
Grades of Evidence
I Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Levels of Recommendation
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.
