Merck Manual

Please confirm that you are a health care professional

honeypot link

Uterine and Apical Prolapse


Charlie Kilpatrick

, MD, MEd, Baylor College of Medicine

Reviewed/Revised Dec 2022
Topic Resources

Uterine prolapse is descent of the uterus toward or past the introitus. Apical prolapse is descent of the vaginal vault or vaginal cuff after hysterectomy. Symptoms include vaginal pressure and fullness. Diagnosis is clinical. Treatment includes reduction, pessaries, and surgery.

Severity of vaginal wall prolapse can be graded by the Pelvic Organ Prolapse-Quantification (POP-Q) system:

  • Stage 0: No prolapse

  • Stage I: Most distal prolapse is more than 1 cm above the hymen

  • Stage II: Most distal prolapse is between 1 cm above and 1 cm below the hymen

  • Stage III: Most distal prolapse is more than 1 cm below hymen but 2 cm shorter than total vaginal length

  • Stage IV: Complete eversion

The POP-Q system is recommended by professional organizations because it is a reliable and reproducible classification system that is based on predefined anatomic landmarks.

The Baden-Walker system, which is based on level of protrusion, is sometimes used. However, it is an older classification system that is not reproducible:

  • Grade 0: No prolapse

  • Grade 1: Halfway to the hymen

  • Grade 2 : To the hymen

  • Grade 3 : Halfway past the hymen

  • Grade 4: Maximal possible

Symptoms and Signs of Uterine and Apical Prolapse

Third-degree uterine prolapse manifests as a bulge or protrusion of the cervix or vaginal cuff, although spontaneous reduction may occur before patients present. Vaginal mucosa may become dried, thickened, chronically inflamed, secondarily infected, and ulcerated. Ulcers may be painful or bleed and occasionally resemble vaginal cancer. The cervix, if protruding, may also become ulcerated.

Symptoms of vaginal prolapse are similar. Cystocele or rectocele is usually present.

Urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem. The disorder is greatly underrecognized and underreported. Many... read more is common. The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence. Urinary frequency and urge incontinence may accompany uterine or vaginal prolapse.

Diagnosis of Uterine and Apical Prolapse

Treatment of Uterine and Apical Prolapse

  • For mild symptomatic prolapse, pessaries

  • Surgical repair of supporting structures if necessary, usually with hysterectomy

Uterine prolapse

Asymptomatic prolapse does not require treatment, but patients should be followed clinically for progression.

Symptomatic prolapse can be treated with a pessary if the perineum can structurally support a pessary; surgical repair is an option for women who do not wish to use a pessary or the perineum cannot support a pessary.

Surgery for uterovaginal prolapse can be done through the vagina or through an incision in the abdomen using various techniques. Factors determining choice of techniques include surgeon experience and patient desires. Techniques may include one or a combination of the following:

  • Hysterectomy

  • Surgical repair of the pelvic support structures (colporrhaphy)

  • Suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby)

  • Colpocleisis (closure of the vagina after removal of the uterus or with the uterus in place [Le Fort procedure])

Procedures are done using a transvaginal or abdominal route. Regardless of the surgical route, symptoms often recur, especially along the anterior vaginal wall.

Surgery is delayed until all ulcers, if present, have healed.

Vaginal apical prolapse

Vaginal prolapse is treated similarly to uterine prolapse.

The vagina may be stitched close (colpocleisis) if women are not good candidates for prolonged surgery (eg, if they have serious comorbidities). Advantages of vaginal closure include short duration of surgery, low risk of perioperative morbidity, and very low risk of prolapse recurrence. However, after vaginal closure, women are no longer able to have vaginal intercourse.

Urinary incontinence requires concurrent treatment.

Key Points

  • The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention and overflow incontinence and masking stress incontinence.

  • Third-degree uterine prolapse (cervix outside the introitus) may spontaneously reduce before patients present.

  • Confirm the diagnosis by examination.

  • Treat women with prolapse if they have troublesome symptoms.

  • Treat with a pessary if women have symptoms and the perineum can support a pessary.

  • Treat surgically if women prefer surgery to a pessary or if the perineum cannot support a pessary.

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
quiz link

Test your knowledge

Take a Quiz!