Pelvic organ prolapse (POP) is the descent of any wall of the vagina (anterior, posterior, apex or cervix) which leads to a wide range of symptoms in patients (1). The prevalence of POP increases in older ages and has a significant association with pregnancy and damage to muscle and connective tissue of the pelvis related to vaginal delivery. Furthermore, hysterectomy, pelvic surgeries, and high abdominal pressure due to obesity can be the etiology of prolapse. Although POP can be asymptomatic in some patients, it can cause several signs and symptoms. There are various symptoms associated with pelvic organ prolapse:  urinary symptoms (stress, urge or mixed urinary incontinence), bulge symptoms (heaviness, obstructive urination or defecation ) and colo-rectal symptoms (constipation and dyschezia) which can decrease the quality of life in women (2). There are several treatments for POP such as conservative treatment, pessary, and reconstructive surgeries that are used considering patients' condition and prolapse-related symptoms(1). In this study, we aimed to investigate the impact of reconstructive surgery based on sacrospinous ligament suspension on colo –rectal symptoms, urinary symptoms, voiding function and free flowmetry in patients with organ prolapse.

We designed a multicenter prospective study on patients with POP in two Hospitals. Inclusion criteria were defined as follows: all patients with uterovaginal prolapse ≥ stage 2 based on urogynecologist examination using pelvic organ prolapse quantification system (POP-Q). Exclusion criteria were: patients with neurogenic bladder 
The voiding function of patients was evaluated based on the Pelvic Floor Disability Index-20 (PFDI-20) and free flowmetry test. the quality-of-life questionnaires that used in our study was the PDFI-20, a 20-item questionnaire, validated in persian and separated into three subscales: The Urinary Distress Inventory 6 (UDI-6) explores the urinary symptoms of prolapse, the Colorectal-Anal Distress Inventory 8 (CRADI-8) colorectal symptoms and finally the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6) bulge and heaviness symptoms. In our study, patients were assessed before surgery and 8 weeks after intervention as follow-up. All included participants underwent surgery by one surgeon with the unilateral sacrospinous ligament suspension (SSLS) using automatic suturing instrument (anchorsure) with anterior and or posterior colporrhaphy. In this surgery, we suspended uterosacral ligament to ipsilateral sarospinous ligament.  Patients with objective stress urinary incontinency (SUI) underwent TOT surgery.
All statistical analyses were conducted using IBM SPSS statistic 26. Continuous variables were compared using paired sample T-test, Wilcoxon, Independent sample T-test, and Mann-Whitney test. Categorical variables were analyzed by McNemar and Chi-Square test. The level of significance was set to 0.05 for all variables.

118 patients were included in this study from June 2023 to September 2024. The mean age of participants was 52.74 ± 11.95 years and the mean BMI was 27.34 ± 4.18 Kg/m2. 50.8% of patients were menopaused and, thirteen cases had diabetes mellitus. 21.2% of participants underwent trans-obturator tape (TOT) surgery. Also, 8.5% of patients had a previous hysterectomy and 3.4% of patients had a SUI surgery in the past.
Three subgroups of PFDI-20 (prolapse, colorectal, and urinary symptoms) had obvious improvement after surgery (p<0.001) (Figure 1). Lower urinary tract symptoms including stress urinary incontinency, frequency, urgency, post-void dribbling, and incomplete emptying had significant improvement after SSLS surgery (p<0.001). Furthermore, There was lower rate of hesitancy in included patients post-surgery according to free flowmetry (p= 0.031).
Post-void residual volume (PVR) were reported 60.53 ± 80.59 vs. 31.72 ± 66.45 before and after surgery which had a statistically significant improvement (p=0.043). However, Voiding volume (264.71 ± 164.82 vs. 209.41 ± 177.95) and peak flow rate (Qmax) (17.16 ± 8.66 vs. 16.25 ± 7.47) had no obvious changes in the included participants (p=0.213 and p=0.681).
Post-surgery variables didn’t have significant difference between groups with and without TOT surgery. There was not any report of significant adverse event of SSLS surgery in follow-up visits.

The results of our study showed that uterovaginal suspension surgery(ssls) with anterior and or posterior colporrhaphy (based on pelvic examination) for POP had an obvious corrective effect on pelvic organs function. there was not any significant difference between group of with and without TOT surgery (as a specific surgery for urinary incontinency), which need to be investigated in further studies. Also we didn’t meet significant complication during surgery or 8 weeks of follow up.
On the other hand, comparison of flowmetry results before and 2 months after surgery, showed significant reduction in post-void residual urine and hesitancy.

In present study, we faced dramatic resolution in patient’s symptoms especially urinary and POP symptoms after reconstructive surgery.
so for patients complaining bothersome urinary and or colo-rectal symptoms and have significant pelvic prolapse, we recommend correction of uterovaginal prolapse as a first line therapy, because returning the pelvic anatomy to its original position will help to repair bladder, vagina and ano-rectal coordinated function.

Collins S, Lewicky-Gaupp C. Pelvic Organ Prolapse. Gastroenterol Clin North Am. 2022;51(1):177-93.
Iglesia CB, Smithling KR. Pelvic Organ Prolapse. Am Fam Physician. 2017;96(3):179-85.