Pelvic Organ Prolapse (POP) occurs when the muscles, ligaments, and fascia supporting the pelvic organs weaken, causing the bladder, uterus, or rectum to descend into the vaginal canal. This common condition often causes symptoms like pressure, a feeling of a bulge, or urinary and bowel dysfunction. Synthetic surgical mesh was widely used to reinforce these weakened tissues, but its use in transvaginal POP repair was linked to serious complications, including chronic pain and mesh erosion. Citing that its benefits did not outweigh the risks, the U.S. Food and Drug Administration (FDA) reclassified transvaginal mesh as a high-risk device in 2016 and ordered manufacturers to halt its sale and distribution in 2019. This regulatory action refocused attention on established, non-mesh alternatives, which remain the preferred methods for safe and effective prolapse treatment.
Non-Surgical Treatment Options
The first line of defense against Pelvic Organ Prolapse, particularly for mild to moderate cases, involves non-surgical management focused on mechanical support and muscle strengthening. These conservative methods are also preferred for patients who may not be medically suitable for surgery or who wish to delay an operation.
Pelvic Floor Physical Therapy (PFPT) is a cornerstone of this approach, using targeted exercises to improve the strength, coordination, and endurance of the levator ani muscles. A specialized therapist employs techniques like neuromuscular re-education and biofeedback to help patients correctly identify and contract the specific muscles of the pelvic floor. PFPT incorporates behavioral adjustments, such as instruction on proper lifting mechanics and techniques to avoid straining during bowel movements, which can prevent further downward pressure on the pelvic organs.
The use of a vaginal pessary offers mechanical support by physically holding the prolapsed organs in a more anatomical position. These removable medical devices, typically made of soft silicone, come in various shapes (ring, Gellhorn, cube) to accommodate different prolapse stages. Pessaries are suitable for women who want to avoid or delay surgery, are planning future pregnancies, or have medical conditions that make surgery risky.
Fitting involves finding the smallest size that resolves symptoms and stays comfortably in place. Ring-shaped pessaries are often used by patients who manage the device themselves, while space-occupying types like the Gellhorn may require follow-up with a clinician for maintenance and tissue monitoring.
Repair Using Native Tissue
When conservative options fail, surgical intervention using the patient’s own supportive structures is the primary alternative to synthetic mesh. This native tissue repair is performed by re-approximating and reinforcing existing ligaments and fascia with permanent or absorbable sutures. While generally associated with higher rates of anatomical recurrence compared to mesh, this approach carries a significantly lower risk of the severe foreign body complications seen with transvaginal mesh.
Colporrhaphy
Specific defects in the front and back walls of the vagina are commonly addressed through a procedure known as colporrhaphy. An anterior colporrhaphy is performed to correct a cystocele, where the bladder bulges into the front vaginal wall, while a posterior colporrhaphy addresses a rectocele, where the rectum bulges into the back wall.
In both procedures, the surgeon makes an incision along the vaginal wall, separates the prolapsed organ from the vaginal skin, and then plicates the underlying fibromuscular tissue, such as the pubocervical or rectovaginal fascia, before closing the incision.
Apical Suspension Techniques
For apical prolapse, which involves the descent of the uterus or the top of the vagina (vaginal vault) after a hysterectomy, two primary native tissue suspension techniques are used. Uterosacral ligament suspension (USLS) involves shortening and reattaching the uterosacral ligaments to suspend the vaginal apex back toward the tailbone. This procedure can be performed vaginally or laparoscopically, providing a more central suspension point.
Sacrospinous ligament fixation (SSLF) involves attaching the vaginal apex to the sacrospinous ligament, a strong, fibrous structure near the ischial spine. SSLF is typically performed through a vaginal incision. While highly effective, it carries a small risk of postoperative buttock pain due to the proximity of nerves. Both USLS and SSLF provide apical support with comparable long-term success rates and without the foreign body reaction risk of synthetic material.
The Role of Biological Grafts
Biological grafts represent a distinct category of material-augmented repair, serving as a bridge between pure native tissue repair and synthetic mesh. These materials are derived from natural sources, either human donor tissue (allograft) or animal tissue (xenograft), which is processed to remove cellular components that could trigger an immune rejection. The purpose of these grafts is to provide a temporary scaffold for the patient’s own cells to grow into and eventually replace with new, host-generated connective tissue.
Biological grafts are designed to be absorbed by the body over time, unlike permanent synthetic mesh. However, clinical evidence has not consistently demonstrated that adding a biological graft significantly improves long-term outcomes, such as recurrence or reoperation rates, compared to meticulous native tissue repair. This lack of proven superiority, combined with the material’s cost, limits its routine application.
Biological grafts are now primarily reserved for highly specific and complex cases, such as patients with recurrent prolapse, severely damaged or deficient native tissue, or significant scarring from prior surgeries. The FDA’s 2019 ban on transvaginal synthetic mesh also included restrictions on xenografts for this application, further limiting commercially available options and decreasing the overall use of biological materials in transvaginal POP surgery. Surgeons who utilize these grafts do so after carefully weighing the potential benefit of a temporary scaffold against the risk of adding foreign material.