Initial Assessment and Diagnosis in Primary Care: For women presenting with symptoms or an incidental finding of uterovaginal prolapse in primary care, take a thorough history including prolapse symptoms, urinary, bowel and sexual function, and perform a pelvic examination to rule out other pathology and document prolapse presence and severity NICE NG123,NHS Pelvic organ. Discuss the woman's treatment preferences, comorbidities, age, and desire for future childbearing NICE NG123.
Conservative and Non-Surgical Management Options: If the prolapse is asymptomatic or not bothersome, no treatment may be required NHS Pelvic organ. Lifestyle advice should be given, including weight loss if BMI is above 30, avoiding heavy lifting, preventing or treating constipation, and smoking cessation NICE NG123,NICE CKS,NHS Pelvic organ. For symptomatic women with mild to moderate prolapse (POP-Q stage 1 or 2), supervised pelvic floor muscle training for at least 4 months is recommended as a first-line treatment, preferably with specialist women's health physiotherapy or trained practitioners NICE NG123,NICE NG210,NICE CKS. Women should be advised to continue pelvic floor muscle exercises if beneficial NICE NG210. Vaginal oestrogen therapy may be considered for menopausal women with genitourinary symptoms associated with prolapse, including creams, tablets, or oestrogen-releasing rings especially if they have difficulty using pessaries NICE NG123.
Pessary Use in Primary Care: Vaginal pessaries can be offered for symptomatic prolapse alone or combined with pelvic floor muscle training NICE NG123,NICE NG210. Before starting pessary treatment, discuss with the woman that multiple fittings may be required, potential effects on sexual intercourse, complications such as discharge or bleeding, and the need for pessary removal at least every 6 months to avoid serious complications NICE NG123. Women using pessaries should have access to follow-up care; if local pessary management is unavailable or difficult, referral to a urogynaecology service is advised NICE NG123.
Referral Criteria: Refer women who decline or do not benefit from conservative management for specialist evaluation and consideration of surgical options NICE NG123. Also refer if symptoms are severe, unexplained by examination, or if there are bothersome urinary or bowel symptoms requiring further assessment NICE NG123. Surgery is reserved for women whose symptoms have not improved with, or who have declined, non-surgical treatment NICE NG123.