Key messages
- In women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI), continence surgery at the same time as POP surgery likely improves rates of SUI after surgery. In continent women with POP, an additional continence procedure may not be required.
- In continent women with POP, anterior vaginal native tissue repair may be better than transvaginal mesh repair for SUI after surgery. However, there may be more recurrent POP on examination at 1 year and up to 7 years after surgery.
What is pelvic organ prolapse (POP)?
POP is a common condition, especially among women who have given birth and who are postmenopausal. It involves the descent (prolapse) of pelvic organs such as the womb (uterus), bladder, bowel, and vagina within and outside the vaginal opening. It is often associated with urinary leakage on coughing or physical exertion as in sports. This is called 'stress urinary incontinence' (SUI). However, in some women, the prolapse blocks the urethra, and stress urinary incontinence might not be noticed until the prolapse has been repaired. This is called 'occult' (or hidden) SUI. SUI may also develop only after surgery to repair the prolapse, called 'new-onset SUI'. POP can have a severe impact on women's quality of life. Bothersomeness usually increases with the degree of prolapse and also with associated urinary and bowel symptoms.
How can POP be treated?
Surgical treatment options for POP include vaginal and abdominal procedures, which are usually performed laparoscopically ('key-hole' surgery) or robotically assisted. The woman's own connective tissue can be used ('native tissue repair'), and mesh can be employed to replace or strengthen the connective tissue. SUI can be treated surgically at the same time as the POP surgery. Treatments include mesh slings to support the urethra (a 'midurethral sling'), or lifting the tissue on both sides of the urethra from the pelvis (a Burch colposuspension).
What did we want to find out?
We wanted to find the best treatment for women with and without urinary incontinence conditions, who were undergoing POP surgery. We were interested in whether POP surgery, with or without surgery for SUI, reduced incontinence after surgery. We also wanted to find out if women experienced another prolapse, overactive bladder symptoms (a sudden urge to urinate), voiding dysfunction (when bladder emptying is impaired), or need for further surgery after POP surgery.
What did we do?
We searched for studies and collected, summarised, and analysed appropriate data to help identify the optimal treatment.
What did we find?
We found 22 studies with 3095 women, that investigated surgery for POP, with or without incontinence procedures, in continent or incontinent women.
Surgery to treat women with POP and SUI
A mid-urethral sling placed during POP surgery may decrease SUI (2 studies, 319 women) and rates of further continence surgery (1 study, 134 women). The continence procedure might also be postponed for three months after prolapse surgery with similar success rates. In this situation, some women might avoid an additional continence operation because they are continent.
It remains unclear whether abdominal prolapse repair (sacrocolpopexy or sacrohysteropexy) with an additional abdominal continence procedure (Burch colposuspension) improves SUI (1 study, 47 women). Another study (113 women) compared the Burch colposuspension with a mid-urethral sling at the time of sacrocolpopexy and at two years, the mid-urethral sling may decrease SUI more than the Burch colposuspension.
The comparison of vaginal armed mesh placement (mesh with attachment arms) for prolapse and vaginal native tissue repair with an additional midurethral sling for SUI did not result in relevant differences regarding postoperative SUI and other outcomes.
Surgery to treat women with POP and occult SUI
Vaginal POP surgery with compared to without a midurethral sling probably decreases SUI and rates of further continence surgery (5 studies, 369 women). But there may be little to no difference in recurrence of POP, overactive bladder, new-onset overactive bladder or voiding dysfunction.
Surgery to treat women with POP without SUI
Vaginal POP surgery with compared to without a midurethral sling may make no difference to new-onset SUI (1 study, 220 women).
It is unclear whether abdominal sacrocolpopexy with compared to without Burch colposuspension improves SUI (2 studies, 364 women).
At 3–7 years' follow-up, vaginal native tissue POP repair may reduce SUI slightly compared to vaginal mesh repair (3 studies, 417 women). However, vaginal mesh placement may reduce rates of recurrent POP (3 studies, 458 women).
What are the limitations of the evidence?
We have moderate or low confidence in the evidence. The main limitations were that, in some studies, those assessing the outcome of the surgery were not blinded to the type of surgery, the evidence does not cover all the outcomes we were interested in, and small numbers of women participated in most studies.
How up to date is this evidence?
The evidence is current to July 2025.
Read the full abstract
Pelvic organ prolapse (POP) is common in women and frequently associated with stress urinary incontinence (SUI). SUI may be present following prolapse reduction (occult SUI) and may develop after surgery for POP (new-onset SUI).
Objectives
To determine the impact of surgery for symptomatic POP, with or without concomitant or delayed two-stage continence procedures, to treat or prevent SUI, on postoperative bladder function.
Search strategy
We searched the Cochrane Incontinence Specialised Register, two trials registries, journals and conference proceedings (searched 29 April 2024, updated 23 July 2025), and reference lists of articles.
Selection criteria
Randomised controlled trials (RCTs) including surgical interventions for POP with or without continence procedures in continent or incontinent women. Our primary outcome was subjective postoperative SUI. Secondary outcomes included POP on examination, overactive bladder, further continence surgery, and voiding dysfunction.
Data collection and analysis
We used standard Cochrane methodological procedures. We assessed evidence certainty using GRADE.
Main results
We included 22 RCTs with 3095 women. Evidence certainty ranged from low to moderate. Limitations were risk of bias (especially blinding of outcome assessors), indirectness, and imprecision associated with low event rates and small samples.
POP surgery in women with SUI
Vaginal POP surgery with versus without midurethral sling: a concomitant midurethral sling may decrease SUI, (risk ratio (RR) 0.30, 95% confidence interval (CI) 0.19 to 0.48; 2 studies, 319 women), and rates of further continence surgery (RR 0.04, 95% CI 0.00 to 0.74; 1 study, 134 women), both low-certainty evidence. This suggests that if the risk of SUI with POP surgery alone is 39%, the risk with midurethral sling is between 8% and 19%.
Vaginal POP surgery with concomitant versus delayed midurethral sling: low-certainty evidence suggested little or no difference in SUI (RR 0.41, 95% CI 0.12 to 1.37; 1 study, 140 women).
Vaginal transobturator mesh versus vaginal POP surgery with midurethral sling: evidence from one study with 84 women suggested little or no difference in SUI (RR 1.47, 95% CI 0.51 to 4.26); POP (RR 6.29, 95% CI 0.79 to 50.03); new-onset overactive bladder (RR not estimable); and voiding dysfunction (RR 3.14, 95% CI 0.13 to 75.02), low-certainty evidence.
Abdominal sacrocolpopexy with versus without Burch colposuspension: an additional Burch colposuspension may have little or no effect on SUI after five years (RR 1.17, 95% CI 0.60 to 2.26; 45 women), or on overactive bladder (RR 0.85, 95%CI 0.61 to 1.18), new-onset overactive bladder (RR 1.92, 95% CI 0.19 to 19.73) or voiding dysfunction (RR 0.96, 95%CI 0.06 to 14.43) all after one year (1 study, 47 women, all low-certainty evidence).
Abdominal sacrocolpopexy with concomitant midurethral sling or Burch colposuspension: midurethral sling may decrease SUI at two years (RR 0.54, 95% CI 0.34 to 0.86; 113 women) but not POP (RR 1.85, 95%CI 0.18 to 19.62; 79 women), overactive bladder (RR 1.18, 95% CI 0.71 to 1.94; 44 women), new-onset overactive bladder (RR 0.59, 95% CI 0.06 to 6.09; 48 women), or voiding dysfunction (RR 1.23, 95% CI 0.52 to 2.90; 92 women), low-certainty evidence from one study. This suggests that if the risk of SUI with Burch is 55%, the risk with midurethral sling is between 19% and 48%.
POP surgery in women with occult SUI
Vaginal POP surgery with versus without midurethral sling: probably decreases SUI (RR 0.38, 95% CI 0.26 to 0.55; 5 studies, 369 women) and further continence surgery rates (RR 0.15, 95% CI 0.04 to 0.53; 4 studies, 279 women) both moderate-certainty evidence. This suggests that if the risk with POP surgery alone is 34%, the risk with concomitant midurethral sling is between 10% and 22%. Low-certainty evidence suggests little or no difference in POP (RR 0.86, 95% CI 0.34 to 2.19; 1 study, 50 women), overactive bladder (RR 0.75, 95% CI 0.52 to 1.07; 1 study, 43 women), new-onset overactive bladder (RR 2.11, 95% CI 0.73 to 6.11; 2 studies, 75 women) or voiding dysfunction (RR 1.00, 95% CI 0.15 to 6.55; 1 study, 50 women).
POP surgery in stress urinary continent women
Vaginal POP surgery with versus without concomitant midurethral sling: there is probably no difference in SUI between groups (RR 0.69, 95% CI 0.47 to 1.00; 1 study, 220 women; moderate-certainty evidence). This suggests that if the risk with POP surgery alone is 40%, the risk with concomitant midurethral sling is between 19% and 40%.
Abdominal sacrocolpopexy with versus without Burch colposuspension: there may be little or no effect on SUI after two years (RR 0.72, 95% CI 0.53 to 0.99; I² = 75%; 2 studies, 364 women; low-certainty evidence). This suggests that if the risk with sacrocolpopexy alone is 36%, the risk with concomitant Burch colposuspension is between 19% and 36%. Low-certainty evidence from one study suggests there may be little or no difference in POP (RR 0.98, 95% CI 0.74 to 1.30, 250 women), new-onset overactive bladder (RR 1.41, 95%CI 0.25 to 7.91, 66 women) and voiding dysfunction (RR 8.49, 95% CI 0.48 to 151.59, 66 women).
Vaginal transobturator mesh repair versus native tissue repair: low-certainty evidence suggests that transobturator mesh repair may increase SUI at 3–7 years (RR 1.77, 95% CI 1.08 to 2.91; 3 studies, 417 women) but may decrease POP (RR 0.40, 95% CI 0.31 to 0.52 ; 3 studies, 458 women). There may be little or no difference in voiding dysfunction at 12 months (RR 1.65, 95% CI 0.22 to 12.10; 2 studies, 125 women).
Authors' conclusions
In women with POP and symptomatic or occult SUI, a concomitant midurethral sling probably reduces SUI, but adverse effects remain unclear. It is also feasible to postpone the midurethral sling and perform a continence procedure only if required.
In continent women, a Burch colposuspension during abdominal POP surgery reduced new-onset SUI rates in one underpowered study, but another RCT reported conflicting results. Adding a midurethral sling during vaginal POP repair might prevent new-onset SUI. An anterior native tissue repair might be better than vaginal transobturator mesh for preventing new SUI; however, POP recurrence may be more common with native tissue repair.
