Open access peer-reviewed chapter

Management of Vaginal Vault Prolapse after Hysterectomy

Written By

Johnstone Shabaya Miheso

Submitted: 05 October 2021 Reviewed: 25 October 2021 Published: 07 September 2022

DOI: 10.5772/intechopen.101385

From the Edited Volume

Hysterectomy - Past, Present and Future

Edited by Zouhair Odeh Amarin

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Pelvic organ prolapse is described as the symptomatic downwards displacement of pelvic organs through the vagina. The incidence of pelvic organ prolapse is difficult to ascertain, but it is said to affect up to 50% of women worldwide over their lifetime. Majority are asymptomatic, but some will complain of a feeling of something coming down their vagina, discomfort, ‘sitting on a ball’, pelvic pressure or back pain. It has a huge impact on the quality of life of individuals and also has an economic impact on the patients and healthcare systems. Risk factors include vaginal births, age. Race menopause, increased intra-abdominal pressure and pelvic surgery including hysterectomy. Assessment of prolapse entails evaluation of bowel, bladder and sexual function. Treatment may take a conservative approach with pelvic floor muscle training before surgery is undertaken. The choice of treatment and route of surgery are individualized to each patient. Post hysterectomy prolapse presents even greater challenges and thorough patient assessment and counselling is essential. The surgeon must have the right skills and choose the right operation to ensure optimal outcome. The surgery itself can be undertaken vaginally or abdominally (open, laparoscopic or robotic), by use of native tissue or mesh and ideally in a multidisciplinary set up.


  • hysterectomy
  • vault or vault prolapse
  • recurrent prolapse
  • surgery for prolapse
  • mesh for prolapse
  • quality of life

1. Introduction

Pelvic organ prolapse is defined as the symptomatic downward displacement of pelvic organs usually through the vagina. The incidence is 3–6% based on symptoms but as high as 50% based on examination as a majority of the women are asymptomatic [1].

Risk factors for prolapse include previous vaginal deliveries, assisted/difficult vaginal deliveries, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and family history of pelvic organ prolapse.

There is no agreed definition of pelvic organ prolapse after hysterectomy. The International Continence Society (ICS) joint report defines it as “descent of the apex of the vagina after hysterectomy” [2]. The route of hysterectomy does not seem to be of consequence in developing prolapse later and subtotal hysterectomy does not prevent development of prolapse. Efforts should be made to support the top of the vagina at the time of hysterectomy. Techniques that have been employed include McCall’s culdoplasty, attaching the posterior vaginal wall to the uterosacral ligaments and sacrospinous ligament fixation.

The incidence of post hysterectomy vaginal prolapse ranges from 0.2 to 43% [3, 4] according to older case series but more recently the incidence has been quoted at 11.6% if hysterectomy was done for prolapse and 0.2% for non-prolapse benign cases [5]. A large Austrian study revealed the incidence of post hysterectomy prolapse to be between 6 and 8% [6].


2. Relevant clinical anatomy

The pelvic floor comprises skeletal muscle (levator ani and coccygeus), urogenital diaphragm, endopelvic fascia and perineal body. The levator ani comprises of pubococcygeus, ileococcygeus and puborectalis muscles. The striated muscles are under tonic contraction. The pelvic diaphragm provides a hammock which anteriorly has a defect or hiatus that allows passage of urethra, vagina and rectum.

The striated muscles of the pelvis contain both slow and fast twitch fibres. Fast twitch contract suddenly with increased abdominal pressures while slow twitch fibres maintain the muscle tone over a long time.

The perineal membrane or urogenital diaphragm is a dense fibrous tissue which spans the anterior part of the outlet and provides attachment for vagina, urethra and rectum. The perineal body lies between the vagina and anus and provides attachment for pelvic floor muscles.

Uterine support (De Lancey I) comprises of uterosacral and cardinal ligaments which are attached to the cervix and upper vagina. Uterosacral ligaments comprise of smooth muscles and form the medial border of the Pouch of Douglas while cardinal ligaments comprise of connective tissue and pelvic blood vessels. At hysterectomy providing support to these ligaments is key in avoiding vault prolapse regardless of the route of hysterectomy. The round ligament helps maintain anteflexion and version of the uterus whereas the broad ligament is just a fold of peritoneum and both have no role in supporting the uterus.

The middle third of the vagina is attached laterally to the arcus tendineus fascia pelvis, a condensation of obturator and levator fasciae (De Launcey II). Anteriorly this condensation is called pubocervical fascia and posteriolaterally it is attached to endopelvic fascia over pelvic diaphragm and sacrum by fascia of Denonvilliers (vaginal septum), and extends caudally into the into perineal body (De Launcey III) and cranially into peritoneum of the Pouch of Douglas.


3. Assessment

The general approach to patients presenting with prolapse symptoms entails a thorough and comprehensive obstetric and gynaecological history followed by a general, abdominal and pelvic examination. A review of risk factors which can be modified is essential as well as asking direct questions regarding bladder, bowel and sexual function. The impact on the quality of health should be assessed including time off work, relationships and coping mechanisms documented.

Table 1 shows the International Continence Society’s POPQ (pelvic organ quantification system) [7] which is used to assess pelvic organ prolapse. It has 6 points which are all measured at maximum Valsalva except total vaginal length. Table 2 shows the criteria for staging.

PointDescriptionRange of values
AaAnterior vaginal wall 3 cm proximal to the hymen−3 cm to +3 cm
BaMost distal position of the remaining upper anterior vaginal wall−3 cm to +tvl
CMost distal edge of cervix or vaginal cuff scar−10 cm to +10 cm
DPosterior fornix (N/A if post hysterectomy)
ApPosterior vaginal wall 3 cm proximal to the hymen−3 cm to +3 cm
BpMost distal position of the remaining upper posterior vaginal wall−3 cm to +tvl

Table 1.

POPQ system.

Stage 0Aa, Ap, Ba, Bp = −3 cm and C or D ≤ − (tvl – 2) cm
Stage IStage O criteria not met and leading edge < −1 cm
Stage IILeading edge ≥ −1 but ≤ +1 cm
Stage IIILeading edge > +1 cm but < + (tvl – 2) cm
Stage IVLeading edge ≥ + (tvl – 2) cm

Table 2.

POPQ staging criteria.


4. Management

4.1 Conservative management

Prevention of prolapse is important and measures should be taken to avoid conditions that increase intra-abdominal pressure. Constipation and chest conditions such as chronic obstructive pulmonary disease (COPD) should be treated adequately. Weight loss is key and hormone replacement therapy may help reduce the incidence. Antenatal exercises, proper intrapartum care and timely caesarean section are also important in reducing the incidence of prolapse.

Initial management should involve appropriate counselling and initiation of pelvic floor muscle training. The best outcomes have been seen when a trained physiotherapist is involved. A perineometer and biofeedback device can be used. Vaginal cones and electrical stimulation have been shown to be effective in incontinence management but no data is available regarding efficacy on urogenital prolapse.

There is a role for devices including vaginal pessaries. They are either silicone or polythene and come in different sizes. They are inserted into the upper vagina and support pelvic organs. They can be cleaned and replaced every 6 months which gives the practitioner a chance to check for any complications. Special attention and counselling should be done with regards to regular changing, sexual function and small possibility of side effects including vaginal discharge, infection and rarely fistula formation.

4.2 Surgical management

The definitive management of post hysterectomy vaginal prolapse is surgery. This should be done by an appropriately qualified surgeon following thorough assessment and counselling of a patient. Different routes of surgery should be considered and discussed with patient. The choice of surgery depends on type of prolapse, age of patient, previous surgery, comorbidities, surgeon’s skills and level of sexual and physical activity.

The aim of surgery is to restore normal vaginal anatomy and restore sexual, bowel and bladder functions. In studies, restoration of apical vagina (Point C on POPQ) to 0 or I is used as the measure of prolapse treatment [8].

The type of surgery chosen should be individualised to the patient. This would depend on concomitant prolapse in other compartments, previous prolapse surgery, previous abdominal surgery, sexual activity, presence/absence of bowel or urinary symptoms, total vaginal length, presence of comorbidities and patient’s preference.

Abdominal sacrocolpopexy can be undertaken via open or laparoscopic route. Patient selection is vitally important. It is the route of choice for women with a short vaginal length, those who require concomitant abdominal surgery and those with history of dyspareunia. The vaginal vault is fixed to the longitudinal ligament on the anterior part of the sacrum using a permanent mesh. Abdominal sacrocolpopexy is associated with lower rates of recurrence, dyspareunia and post-operative stress urinary incontinence compared to sacrospinous ligament fixation [8]. Common complications include infection, bleeding from presacral veins and mesh erosion. Laparoscopy may not be available in all centres and the learning curve is long.

Robotic sacrocolpopexy is available in limited centres around the world owing to the huge cost associated with setting up.

Sacrospinous ligament fixation entails fixing the vaginal vault to the sacrospinous ligament on one side using absorbable or non-absorbable materials. For right handed surgeons this tends to be fixed to the right sacrospinous ligament. No benefit has been shown for bilateral compared to unilateral fixation. It is associated with low recurrence, high satisfaction and takes a short time to perform and a short recovery time. Common complications include buttock pain, pudendal nerve injury, high recurrence of 8–30% of anterior compartment and ureteral obstruction.

High uterosacral ligament suspension (HUSLS) is also an acceptable procedure for vault prolapse but should not be offered as a first choice and should be undertaken by a well-trained pelvic floor surgeon owing to the risk of complications. An RTC comparing high uterosacral ligament suspension and sacrospinous ligament fixation and found the two similar in terms of anatomical, functional and adverse effects [9]. Complications of high uterosacral ligament suspension include bladder injury, ureteric injury, urinary tract infection, blood transfusion and bowel injury.

Transvaginal mesh involves use of permanent mesh to support the vaginal vault to the uterosacral ligament bilaterally in order to restore level I supports. It has been withdrawn in most centres around the world owing to safety concerns and complications. An RTC compared transvaginal mesh and laparoscopic sacrocolpopexy and found that laparoscopic sacrocolpopexy had longer operating time but better success rate and patient satisfaction at 2 year follow up and women in the transvaginal mesh group had shorter vaginal length and risk of erosion [10].

Colpocleisis is the complete closure of the vagina when sexual activity is no longer desired. It can be used to treat vaginal vault prolapse after hysterectomy following careful assessment and counselling. It has the advantage of being minimally invasive, can be done under regional anaesthesia and the technique is easy to learn. Several techniques are known including purse string closure [11], vaginectomy [12], colpocleisis after performing standard anterior and posterior vaginal wall repair [13], purse-string closure of enterocele followed by approximation of perivesical and rectovaginal fascia and high levator plication [14] and le Forte’s colpocleisis [15].

It is recommended that one inserts a mid-urethral tape for cure of stress urinary incontinence at the time of surgery if the vaginal route is chosen. Colposuspension has not been shown to be effective in these patients. In case of recurrent vault prolapse post hysterectomy, the case should ideally be discussed at a multi-disciplinary team before an appropriate plan is made regarding the type of surgery and the person to undertake it.


5. Conclusion

Post hysterectomy vaginal prolapse is a challenging condition that requires adequate evaluation, counselling and appropriate management plan. It is becoming commoner because of increased longevity, withdrawal of vaginal meshes and changing techniques of fixing the vault at hysterectomy. Risk factors should be sought and appropriate measures taken to reduce these. Conservative care should always be attempted when appropriate before surgery. Surgery should be undertaken by a suitably trained surgeon ideally in a multidisciplinary set up.


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Written By

Johnstone Shabaya Miheso

Submitted: 05 October 2021 Reviewed: 25 October 2021 Published: 07 September 2022