Onset of pelvic organ prolapse (POP) in postpartum period is a well-noted disease among young women. Pregnancy itself, hormonal modification during gestation and baby passage through the birth canal determine a mechanical distortion that damages connective tissues, vessels, nerves, and muscular structures [1, 2]. Morbidity of pelvic organ prolapse has an impact on social, psychological, and sexual well-being.

Modification in pelvic organ support may be permanent or transitory. Generally, women are examined 6–8 weeks postpartum: during that time the reproductive tract, as well as the whole body, is believed to return to the original aspect. Chen et al. [3] demonstrated that the process of reconstruction is not completed until 1-year postpartum: Connective tissues and pelvic floor contractility takes up to 6 months to recovery after parturition.

Stage II prolapse is a common finding in postpartum women, with a prevalence of about 50 % 6 weeks after birth, and of 30 % 6 months postpartum, as well as in those presenting for general gynecological care [4]. Although the definition of anatomic prolapse has been defined by the National Institutes of Health [5] as descent of stage I or greater, perhaps the definition of “normal” should be reconsidered. The threshold at which pathology occurs, what is defined as symptomatic prolapse, and the optimal time of intervention, still remains unclear. There are no guidelines about the management of patients with vaginal prolapse immediately after pregnancy. Symptomatic women, which need surgical approach, are a little percentage of the total. Only symptomatic patients with POP-Q > stage 2 are candidate to the operating theater. There is no clear difference between surgery after childbirth or in older ages, but especially in younger women, when surgery is necessary, a careful counselling is mandatory. Great part of people think that a surgical reconstruction of genital prolapse will restore completely not only the pelvic floor anatomy, but also the pelvic function. As a result of a surgical procedure, patients must be informed about effect of scarring, fibrosis, weakened or reduced elasticity of the vaginal wall as well as impaired nerve function [6, 7].

The first question is about the best surgical approach. If the anatomical defect is in the anterior compartment (cystocele) or in the posterior one (rectocele), vaginal route is the better choice. More than 80 % of surgical repair involves anterior vaginal wall, with recurrence rate, following traditional native tissues repair, which varies from 30 to 60 %. Implementation in surgical techniques, with a proper dissection of the pubo-vesico-cervical fascia or a site-specific repair, and a close knowledge about the pathophysiology of POP, lead to a better anatomical result and to an improvement in quality of life. Those consideration reinforce the concept that native tissue repair is the first choice in young women. If rectocele is present, an accurate evaluation of rectal function must precede any surgical approach: bowel symptoms or difficult defecation leads patient to use manual pressure to defecate. Wexner’s Continence Grading Scale, transanal ultrasound and manometry are unavoidable in correct evaluation of this vaginal segment. Good anatomical and subjective cure rates are reached with posterior colporrhaphy and site-specific repair. There is no place for mesh augmentation because of high rate of dyspareunia, exposure, and worsening of bowel function.

After FDA pronunciation in 2011 [8], transvaginal mesh repair is not indicated in young women and in first surgery. Mesh insertion results in higher rates of adverse effect including mesh exposure, buttock and pelvic pain or discomfort, and de novo incontinence. Women must be informed about risk of recurrence both in the same compartment such as in the unrepaired site, because of a variation in the vaginal axis. In spite of an improvement in anatomic outcome, the reoperation rate is increased in comparison with a native tissues repair [9].

Symptomatic hysterocele needs a detailed evaluation to reveal cases of cervical elongation. In this group of patients, if patients desire a uterine-sparing procedure, a sacrospinous hysteropexy would not give a good anatomical result. Manchester procedure [10] is a practice specifically performed in patients with symptomatic genital prolapse in combination with cervical elongation. Women must be informed about elevated risk of cervical incompetence or cervical stenosis leading to mechanical dysmenorrhea, secondary infertility, or hematometra. In well-selected cases, Manchester procedure restores good apical support and vaginal length and maintains the physiological vaginal axis.

In premenopausal women, who have completed their family program, vaginal hysterectomy is the first choice: This procedure, added to a plication of uterosacral ligaments, represents an efficient treatment for symptomatic POP, and has been demonstrated to be less invasive in terms of hospital stay, blood loss, and return to daily activity [11–13].

For women who have not completed their family, or longing for uterine sparing surgery, sacrospinous cervicocolpopexy must be considered. Menstrual disorders, uterine or cervical pathology, and endometrial hyperplasia are absolute or relative contraindication to this procedure. In 1989, Richardson et al. [14] reported a case series of five women with utero-vaginal prolapse, age between 24 and 31 years, having a transvaginal sacrospinous hysteropexy. No recurrences were observed during a follow-up period of 6–24 month. SSH is a safe and effective alternative to hysterectomy in treating uterovaginal prolapse. SSH in associated with shorter operation time, less blood loss, shorter hospitalization, and earlier recovery and return to daily activities [15, 16].

Pelvic organ prolapse has a negative impact on sexual function: Vaginal bulging, pelvic pain, diminished sensibility are the most frequently reported issues [17]. Up to 64 % of sexually active women with POP suffer from sexual dysfunction [18]. Physicians are often inadequately trained to approach this problem, so it remains underestimated. Anne-Marie Roos et al. [19] demonstrated that both urinary incontinence (UI) and POP affect the sexual life of women. All stages of sexual excitement are affected by the fear for coital incontinence. Instead women with POP have a worse genital image than women who have never been diagnosed with prolapse. Zielinskj et al. [20] have shown that genital body image and sexual health are related, especially in the light of sexual satisfaction and desire. The most referred topics, affecting sexual satisfaction, are decreasing sexual desire, less lubrication, dyspareunia, fear of urinary or anal incontinence (especially gas incontinence).

In literature, there are few studies about sexual function after POP surgery and cases evaluated are not enough to have statistical significance. Women who had POP surgery with native tissues generally report improvement in sexual function for cessation of incontinence and sexual function. Pelvic pain and dyspareunia after prolapse repair are often multifactorial in nature, with vaginal shortening and narrowing, ipoestrogenism, and dryness playing a significant role [21]. It is also well accepted that the rate of dyspareunia, especially after a posterior compartment surgery, may approach 40 %. Lower vaginal wall sensibility is associated with vaginal POP surgery and/or suburetral sling procedure, but does not correlate with vaginal dryness and anorgasmia. Low rates of post-surgical sexual symptoms might be due to an improvement of the patients’ confidence and body image because of correction of the anatomical defect and cure of the associated symptoms such as urinary incontinence and bulging. Diminished sexual function after surgery can be the result of scarring, fibrosis, short or narrow vagina, contracted pelvic floor, weakened or reduced elasticity of the vagina as well as impaired nerve function [22–24].

Looking to the literature we can find a great number of uterine-sparing repairs, but very little is published about subsequent pregnancy, way of birth, and long-term follow-up [25, 26].

When a systematic review about pregnancy after prolapse surgery is performed, it is possible to find only few case reports and case series. There is no information available regarding the incidence of childbirth following pelvic procedures and no data about incidence of repeated POP surgery following delivery. Too little is known for a complete counselling about safety of pregnancy and mode of delivery after such surgery and the impact of further pregnancy on the outcome of the original procedure. Case reports generally suggest a scheduled cesarean section as the preferred mode of delivery after Prolapse surgery. In case of transvaginal sling instead little more data are available [27–29]. In case series vaginal delivery is referred as safe, and no higher recurrence is demonstrated. Anyway a second sling placement is considered safer than a scheduled cesarean section.

Given the relative rarity of pregnancy following any pelvic floor repair procedure, it is difficult to formulate any recommendation and studies are limited because of small numbers and their retrospective nature.