The role of the pelvic floor is to support and assist in the function of the bladder, uterus, vagina, and rectum. The pelvic organs rest on the band of muscles and fascia that make up the pelvic floor. The muscular component of the pelvic floor consists of the coccygeus muscle; the levator ani complex, which is composed of the iliococcygeus and pubovisceral muscles; the external anal sphincter; the striated urethral sphincter; and the superficial perineal muscles. The iliococcygeus attaches the pelvic side wall to the arcus tendineus fascia pelvis (ATFP). The pubovisceral muscles are a U-shaped band running from the pubic bone to the lateral wall of the vagina and rectum, condensing on the ATFP. This muscular complex forms a sling-like band that supports the pelvic organs. The iliococcygeus and pubovisceral muscles work together to maintain tone in the levator hiatus, keeping it closed against intra-abdominal pressure.

There are three levels of connective tissue support as described by DeLancey. Level I consists of the uterosacral and cardinal ligaments. Level II support is made up of the paravaginal attachments of the vagina to the ATFP. Level III support describes the most distal support of the vagina and includes the endopelvic fascia and perineum. The muscular and fascial components of the pelvic floor work together to support the pelvic organs and prevent their descent into the levator hiatus.

There are data to suggest that genetic factors predispose some women to developing POP. European American and Latina women appear to have a higher incidence of prolapse compared to African American women. Increasing prevalence of POP is also seen with increasing age. Pregnancy, vaginal delivery, operative vaginal delivery and the delivery of larger infants are all associated with increased risk of POP. However, nulliparity and cesarean delivery do not preclude the development of prolapse. Data from the Women’s Health Initiative indicated that among women aged 50–79, 5% of nulliparous women have vaginal wall descent to the hymen or beyond. However, among younger women, vaginal delivery appears to be a significant factor in the development of POP.

There are modifiable risk factors for POP. According to data from the Women’s Health Initiative, a BMI of greater than 30 kg/m2 increases the risk of prolapse by 40–75%. Anything that causes chronically increased intra-abdominal pressure may increase the risk of POP; these include chronic cough from smoking, asthma, bronchitis or gastroesophageal reflux; chronic constipation; and chronic straining, such as with repetitive heavy lifting.

Symptoms of POP are subjective. What may be bothersome to one patient may be asymptomatic in another. While early stages of prolapse are often asymptomatic, it is common for women with prolapse beyond the hymenal ring to have some degree of bother.

The most common symptom is the sensation of a vaginal bulge or the complaint of vaginal pressure. This symptom has been found in epidemiologic studies to be most closely associated with the presence and degree of prolapse. Anterior compartment prolapse sometimes leads to urinary hesitancy, frequency and incomplete bladder emptying. Patients may report a need to reduce their prolapse in order to void. If the patient is unable to reduce her prolapse, elevated postvoid residual volumes are common with severe anterior prolapse. Stress incontinence is often decreased or absent with severe anterior prolapse due to the kinking of the urethra by the prolapse. Patients with posterior compartment prolapse often have difficulties with defecation, including constipation, straining, incomplete emptying and needing manually to reduce the prolapse in order to have a bowel movement. Other symptoms include difficulty with sexual intercourse and avoidance of sexual intercourse due to embarrassment.

Physical exam confirms the diagnosis and assesses the degree of prolapse. On speculum exam the practitioner should look for erosions and ulcers in the vaginal and cervical epithelium.