Two of the most common symptoms associated with prolapse are vaginal bulge and pelvic pressure. Patients with these symptoms often complain of feeling a ball in the vagina, sitting on a weight, or a bulge rubbing on their clothes. If bulge symptoms are the primary complaint, successful replacement of the prolapse with nonsurgical or surgical therapy will usually provide adequate treatment.

Patients with POP often have concurrent urinary symptoms, including stress urinary incontinence, urge urinary incontinence, frequency, urgency, urinary retention, recurrent urinary tract infection, or voiding dysfunction. Although some of these symptoms may be caused or exacerbated by the prolapse, it should not be assumed that surgical correction will be curative. For example, irritative bladder symptoms (frequency, urgency, urge urinary incontinence) may or may not improve with replacement of prolapse and sometimes worsen after surgical management. Therefore, urodynamic testing should be performed in women with urinary symptoms who are undergoing surgical correction of prolapse. This testing attempts to reflect the relationship of urinary symptoms to the prolapse. Additionally, consideration may also be given to temporarily placing a pessary prior to surgery to determine if urinary symptoms improve, thereby predicting whether surgical reduction of prolapse will be beneficial.

Constipation is often present in women with POP; however, replacement of the bulge either by surgical repair or with a pessary does not consistently cure this symptom and may actually worsen it. In one study of defect-directed posterior repair, constipation resolved postoperatively in 72% (1) of patients, while another study noted resolution in only 43% (2). Similarly, one study of posterior colporrhaphy reported a 28% reduction in constipation (3), while another reported a 50% increase (4). These seemingly contradictory data reflect that constipation frequently has different definitions,
and more importantly, has multiple causes besides POP. Therefore, if a patient’s primary symptom is constipation, surgical repair may not be indicated without a complete evaluation to address the other etiologies in its differential diagnosis.

Digital decompression of the posterior vaginal wall, the perineal body, or the distal rectum itself to defecate is often associated with prolapse. Surgical approaches to this problem are relatively ineffective, with symptom resolution as low as 36% (2).

Anal incontinence of flatus or liquid or solid stool may be seen in conjunction with POP. If this disorder is present, a full anorectal evaluation should be performed. On occasion, prolapse may lead to stool trapping in the distal rectum with subsequent leaking of liquid stool around trapped stool. However, most types of anal incontinence would not be expected to improve with surgical repair of prolapse. If evaluation reveals an anal sphincter defect as the cause of anal incontinence, anal sphincteroplasty may be performed in conjunction with prolapse repair.

Sexual dysfunction is often seen in women with POP. The etiology of this symptom is frequently multifactorial. However, an obstructing bulge can be part of the problem, and therapy that reduces the bulge may be beneficial. Some prolapse procedures, such as posterior repair with levator plication, are believed to contribute to postoperative dyspareunia, and care should be taken in planning appropriate surgical procedures for patients with concomitant sexual dysfunction.

Anecdotal experience suggests that POP is associated with pelvic and low back pain. This pain may not necessarily be caused by the bulge itself but may be due to altered body mechanics that result from prolapse. However, a cross-sectional study of 152 consecutive patients with POP did not find an association between pelvic or low back pain and prolapse after controlling for age and prior surgery (5). If the primary complaint is back pain, referral for back evaluation is indicated. Additionally in this situation, temporary pessary placement is often beneficial to determine whether prolapse reduction will improve pain symptoms.

Mild to advanced prolapse may also be present without bothersome symptoms. In this situation, the risk/benefit ratio must be evaluated prior to proceeding with surgical treatment. Because the natural history of prolapse is unknown, it is difficult to predict if the condition will worsen or if symptoms will develop. Therefore, in the absence of other factors, it is prudent to avoid invasive therapy in an asymptomatic patient.

Although POP has been associated with several different types of symptoms, the presence and severity of symptoms does not correlate well with advancing stages of prolapse. In addition, many common symptoms do not differentiate between compartments. Several studies have shown a poor predictive value between symptoms or the degree of their severity and the degree of prolapse in a particular vaginal compartment. Ellerkmann et al found that degree of prolapse in all vaginal compartments—anterior, posterior, and apical—correlated globally only with complaints of pelvic discomfort and visualization of a “bulge or protrusion” (6). The degree of posterior compartment prolapse only weakly correlated with complaints of incomplete evacuation and digital manipulation for bowel movements. Weber also found that with respect to stage of posterior compartment prolapse, there was no clinically significant correlation to symptoms of bowel dysfunction (7). The Pelvic Organ Support Study (POSST) found only weak associations between bowel symptoms and pelvic organ descent (8), and constipation has not been found to relate to the stage of prolapse (9).

Sexual dysfunction has been attributed to prolapse. One study has shown that increasing degree of prolapse did predict interference with sexual activity, but it did not affect the description of satisfaction with the sexual relationship or the frequency of intercourse (10). Ellerkmann et al found a moderate correlation between impairment of sexual activity and worsening prolapse in all three compartments (6). After surgery for incontinence or prolapse, Helstrom et al found no improvement in sexual function (11).

Urinary incontinence and hesitancy, as well as prolonged and intermittent micturition, correlate with worsening prolapse, but in all vaginal compartments. In contrast, there is a weak inverse relationship between worsening anterior compartment prolapse and stress incontinence. This improvement may result from mechanical kinking or obstruction of the urethra (6).

When planning surgical or nonsurgical therapy, realistic expectations should be set with regard to relief of symptoms. A patient must be made aware that some symptoms cannot reliably be expected to improve.