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Abstract Introduction and importance The most common complication of pelvic organ prolapse is stress urinary incontinence, whereas hydronephrosis or stasis ulcers are quite rare and typical of severe stages. The best treatment for this unusual presentation is still controversial. Here we present our approach. Case presentation Here we present the case of a 70-year-old White/Caucasian woman who presented to our hospital with genital procidentia lasting for 10 years that was associated with both hydronephrosis and stasis ulcers. Clinical findings and investigations The Pelvic Organ Prolapse Quantitation system was used to assess the severity of the prolapse, being evaluated as stage IV with the apical compartment leading. A thorough search of the literature was conducted to find any similar cases and evaluate the best evidence treatment. Interventions and outcomes A no-mesh procedure comprising vaginal hysterectomy, axial apex suspension, and anterior and posterior repair with ulcerated skin removal resulted in complete resolution of both mechanical and functional symptoms. At 3- and 6-month follow-up visits, a satisfying vaginal profile without hydronephrosis was seen. The Pelvic Organ Prolapse Quantitation at 6 months follow-up was as follows: Aa -3, Ba -3, C -7; gh 2, pb 3, tvt 9; Ap -3, Bp -3. Relevance and impact Pelvic organ prolapse involves many organs and causes further complications, leading seldom to renal insufficiency and stasis ulcers. A temporary solution to the obstruction can be achieved by utilizing a pessary, but this device cannot be applied when a stasis ulcer has been previously established. The use of mesh for pelvic floor repair is controversial, but a previous vaginal ulcer may represent a contraindication. A complete evaluation and a challenging surgery may allow the recovery of complicated and severe pelvic organ prolapse. Native tissue pelvic repair gives no erosion postsurgical risk, which is the typical complication of the prosthesis.