British Journal of Obstetrics and Gynaecology
January 1998,Vol. 105,pp. 13-17
REVIEW
Management of vaginal vault prolapse
Introduction
Vaginal vault prolapse occurs in 0.2% to 43% of women
who have had a hysterectomy and still represents a
difficult area of clinical management. Vault prolapse
presents as a medium or long term failure of the sup-
porting mechanisms' and results from a combination of
intrinsic defects such as weakness of tissue
and damage to the pelvic floor and its nerve supply
during childbirth5.Additionally, failure of vaginal vault
support may occur as a consequence of hysterectomy.
It is interesting to note that equal numbers of vault
prolapse occur after vaginal and abdominal hysterec-
tomies6.'; however, abdominal hysterectomy is a far
more common procedure, with only 20% of hys-
terectomies being performed vaginally in the United
States8. Currently 21% of hysterectomies for dysfunc-
tional bleeding are performed vaginally in the United
Kingdom and 5% are laparoscopically assisted' where
the normal supports are not usually considered to be
defective. A common indication for vaginal hys-
terectomy is uterine prolapse where the supporting
structures are already compromised. The effects of
hypo-oestrogenism on the pelvic floor have yet to be
fully established, but recent work has shown that this
may be
During the last two decades the number of hysterec-
tomies performed has increased, and consequently the
number of women with vault prolapse has risen. This has
led to increased interest in repair of vault prolapse. The
symptoms commonly associated with vaginal vault pro-
lapse are protrusion of the vagina through the introitus;
pelvic discomfort on standing; hesitancy of micturition;
backache; constipation; difficulty with intercourse and,
when severe, ulceration of the vagina. The problems
associated with anterior and posterior colporrhaphy
such as dyspareunia, difficulty with evacuating the
bowels and recurrent refractory prolapse in association
with scarring and a narrow shortened vagina, have been
recognised for a long
This review article is based on a MEDLINE search
followed by hand searches of the major references iden-
tified by the electronic search. The searches performed
were based on the key words including pelvic froor
repair, surgey , vaginal vault and genital prolapse. The
searches identified 84 articles.
0 RCOG 1998 British Journal of'Obstetrics and Gynaecology
Anatomical considerations and assessment
The vagina is normally maintained in position by a com-
bination of ligaments arising from the pelvis and insert-
ing into the cervix (cardinal and uterosacral ligaments),
and by the pubocervical fascia. Additional support
arises from the fibres in the paracolpium which insert
vertically into the upper third of the vaginai4and by the
anatomical position of the vagina with its longitudinal
axis lying over the levator plate15with an angle towards
the third and fourth sacral vertebraet6.During episodes
of raised intra-abdominal pressure the vagina is com-
pressed against the pelvic floor rather than pushed
through the levator hiatus. Pelvic surgery can disrupt a
number of these natural supporting structures leading to
changes in the vaginal position". The changes that
occur vary depending on the nature of the procedure,
the skill and operative technique of the surgeon as well
as the woman's predisposition to prolapse. Symonds et
al. IRshowed that 39% of women present within the first
two years after a hysterectomy, 24% within ten years
and 37% more than ten years after their hysterectomy.
The effects of prolapse on the quality of life and the
success of repair in curing symptoms are being studied
in~reasingly'~. Treatment of vaginal vault prolapse must
address a wide range of issues such as sexual function,
bowel and bladder function in addition to symptoms of
prolapse, in order to obtain the best results. During ini-
tial assessment attention must be paid to uncovering
other concurrent pelvic dysfunction which may alter the
choice of operation used to repair the vault prolapse.
Investigation with urodynamics using a ring pessary to
reduce displacement of the bladder neck and stop ure-
thral kinking can often reveal occult genuine stress
incontinence''.
Recently, the International Continence Society have
introduced a prolapse scoring system which allows
more objective assessment of the prolapse and has
important implications for standardising the results of
treatments20. This involves an objectively structured
approach to the assessment of prolapse. The scoring
system relies on the identification and measurement of
nine points within the vagina at rest and on perfomring
the valsalva manoeuvre. This enables a grade to be
given to a prolapse. The system has been demonstrated
to be reproducible, accurate and easy to perform within
13
14 REVIEW

anterior anterior cervix or

wall wall cuff

Aa Ba C
genital perineal total
hiatus body vaginal
length
gh Pb tvl
posterior posterior posterior
wall wall fornix
I AP BP D

Fig. 1. (a) Six sites (points Aa, Ba, C, D, Bp and Ap), genital hiatus (gh), perineal body (pb), and total vaginal length (tvl) used for pelvic organ
supprt quantitation. (b) Three-by-three grid for recording quantitaive description of pelvic organ support. (Previously published in Bump et al.?O.
Am JOhstet Gynecol 1996; 175: 10-17. Reproduced with kind permission of Mosby-Year Book Inc.)

the confines of a normal clinic setting21,22.

Furthermore
use of this scoring and grading system now facilitates
longitudinal and cross-sectional analysis of surgical
reconstruction(Fig. 1).
Nonsurgical treatment
Nonsurgical treatment can benefit many women and
should always be offered. Much of the discomfort of
vaginal vault prolapse may be due to atrophic vaginitis,
and the woman may obtain considerable relief from top-
ical oestrogen. Weak oestrogens such as oestriol, may
reverse these changes with minimal adverse effects23,
but they need to be administered long term. Other
women may experience substantial improvement with a
ring pessary. This maintains vaginal position by holding
the vault in its normal axis relative to the pubic symph-
ysis and consequently supporting the vault. The major
drawback with this kind of pessary is that it relies on an
adequate perineum to support and retain the pessary;
thus if the perineal body is deficient, then the pessary
will not be retained within the vagina”. Further limita-
tions with this kind of device are loss of sexual function
and the need to change it every six months to avoid
infection and to check for ulceration (these effects may
be limited by the use of local oestrogens). Other pes-
saries, such as a Hodge or a shelf pessary, are occasion-
ally used but have the same limitations as a ring pessary.
To date, there has been no formal randomised compari-
son of ring pessary and operative treatment of vaginal
vault prolapse, but because of the long term disadvan-
tages of a ring pessary most women opt for surgery
eventually. Current practice tends to limit long term use
of pessaries to infirm women who are unfit for surgery
or occasionally women who prefer not to have surgery.
Surgical treatment
1 . Vaginal procedures
The traditional approach to treating vaginal vault pro-
lapse has been to perform a pelvic floor repair. This is
not a logical procedure since the operation itself does
not support the vault. Posterior colporrhaphy performed
as part of a pelvic floor repair may be inappropriate,
particularly when the woman wishes to remain sexually
active, as this procedure inevitably results in shortening
and narrowing of the vagina which can lead to dyspare-
~ n i aCure
~ ~ of
. vaginal vault prolapse is more likely by
high dissection of the enterocele to allow plication of
the uterosacral ligaments and their attachment to the
vaginal vault for support26.In a case series with a follow
up of 2-22 years, Given2’ showed that the operation
was well tolerated with a low associated morbidity:
only 4 of the 68 women reviewed said that they were
unable to be sexually active because of their repair. The

0 RCOG 1998 Br J Obstet Gynaecof 105, 13-17

same author subsequently has reported an even better
outcome for sexual fimction using vault suspension28.It
is also interesting to note that in two large studies of
vaginal vault repair 65% and 70%, respectively, of the
women had previously had between one and four pelvic
floor repair~~~,~O.
An alternative procedure is sacrospinous ligament
fixation. Originally described in 1951, it has become
popular following the descriptions by Randell and
N i c h o l l ~ ~ The
' , ~ ~original
. operation involved bilateral
fixation of the vaginal vault to the ligaments but the
more common procedure now is to transfix just one
side of the vagina (usually the right side). This is easier
to perform and results in less tension and fewer compli-
cations. The technique involves identification of the
sacrospinous ligament by division of the rectal pillar;
accurate placement of sutures through the medial por-
tion of the ligament is mandatory to avoid damage to
the pudendal vessels33.Placement through the partial
thickness as opposed to the full thickness is also
described as a precaution against damage to the puden-
dal vessels and nerve. Placement can be made easier by
the use of a Miya needle hook.
Several studies have described, retrospectively, the
outcome of sacrospinousfixation with a follow up rang-
ing from 6 to 83 months; the subjective failure rate var-
ied from 3.6% to 14% 6-34-38. Suprisingly, Holley et a1.35
found that asymptomatic cystocele occurred in 92% of
cases. Farrell et al.39have described massive eviscera-
tion requiring emergency laparotomy in order to prevent
hernia strangulation, but such a complication has not
been reported by other authors. Other complications
included post-operative infections consistent with most
gynaecological surgery and in particular no different to
that expected for other vaginal surgery. The only
prospective study had an 8% failure rate with 2.5% of
women complaining of painful interco~rse~~. This
reduced incidence of dyspareunia is related to less vagi-
nal narrowing and possibly also the relative increase in
vaginal length2*.
Other vaginal procedures including le Fort's oper-
ation (colpocleisis) obliterate the vagina by stitching
the anterior and posterior walls together. There is a
risk of recurrent prolapse and these operations do not
strengthen the supports of the vagina. Stress inconti-
nence may develop if the bladder neck is displaced from
its normal position. There is now little to commend
these procedures in modem gynaecological practice and
it is not surprising that they have fallen into relative
obscurity4'.
2. Abdominal procedures
The major disadvantage of an abdominal operation is
the increased morbidity associated with a laparotomy.
0 RCOG 1998 Br J Obstet Gynaecol 105, 13-17
The most commonly performed procedure is sacro-
colpopexy as described by B i r n b a ~ mThis
~ ~ . appears to
be the most successful vaginal vault suspension opera-
tion with a failure rate of 1-3%,compared with 2.4% for
sacrospinous ligament fixation43in a series which had
130 sacrospinous procedures and 80 sacrocolpopexies.
The technique involves retroperitoneal tunnelling with
passage of a sling from the sacral promontory to the
vaginal vault. Theoretical advantages of tunnelling the
sling are that it will give a better resting position to the
vagina over the levator plate and that there is no risk of
an internal hernia from bowel becoming trapped under
the sling. Sacrocolpopexy does carry a small risk of
haemorrhage from the presacral vessels necessitating
transfusion in up to lo%*' of cases. Various strategies
have been used to treat this bleeding including the use
of orthopaedic bone thumbtacks4.
Various grafts (slings) have been described including
autografts with rectus fascia, skin and dura mater, or
synthetic material such as Marlex (Bard, Crawley, UK),
Prolene, Mersilene (both Ethicon Edinburgh, UK) or
Goretex (W L Gore UK Ltd, Kirkton, UK). The success
rate of sacrocolpopexy is consistently quoted at over
90%45-47irrespective of graft type. Infrequently a graft
has to be removed due to persistent infection or erosion
into the vagina or bowel.
Occasionally a combined abdomino-perinealapproach
using two teams of surgeons is used which is said to
allow a more anatomical repaiP. In the original
description the authors claimed a 93% success rate. The
only trial comparing sacrocolpopexy and a Zacharin
(combined abdomino-perineal) operation showed no
benefit from the larger combined procedure49.
Choice of treatment
Both sacrocolpopexy and sacrospinous ligament fixa-
tion appear to be effective operations for the correction
of vaginal vault prolapse, as they allow repositioning of
the vaginal axis over the levator plate, which results in
compression of the vagina against the pubcoccygeous
on straining. Both are superior to a pelvic floor repair
alone since they have lower failure rates, cause less
sexual dysfunction and are safe procedures with low
complication rates. Careful assessment of the patient's
symptoms and examination of the prolapse are impor-
tant in choosing the operation. Urodynamic assessment
before any surgery should be considered mandatory as
occult stress incontinence may need correction. If gen-
uine stress incontinence is present and requires treatment
an abdominal colposuspension or a vaginal bladder
neck suspension should be combined with the sacrocol-
popexy or sacrospinous ligament fixation. Sacrocolpo-
pexy is probably the best procedure for recurrent pro-
lapse, since previous surgery will lead to scarring and
16 REVIEW
shortening of the vagina, such that there may be difi-
culty in obtaining good approximation of the vault to
the sacrospinous ligament. Sacrocolpopexy relies on a
sling to maintain the position of the vaginal vault. The
sling is fashioned to the optimum size during the proce-
dure and is anchored over the posterior vaginal wall
allowing dissipation of the tension evenly over a wider
area. In comparison sacrospinous ligament fixation sus-
pends the vaginal vault through individual sutures
resulting in uneven tension in the vagina. Sacrospinous
ligament fixation, however, has the advantage that it is
easily performed at the time of repair of other prolapse
(concurrent cystocele) and is associated with a faster
recovery. It also has the advantage of allowing treat-
ment of a rectocele at the same time, which is virtually
impossible by the abdominal approach.
Both procedures allow adequate room for sexual
intercourse, but there is evidence that sacrocolpopexy is
associated (on average) with a slightly longer functional
length39.The woman should understand the risks of the
operations, that there is a small chance of recurrent pro-
lapse, the possibility that she will subsequently develop
problems, such as stress incontinence, and a small risk
of haemorrhage and infection.
The future
Increasing awareness of vault prolapse will hopefully
lead to renewed interest in its prevention, which is diffi-
cult due to its many causes. Pelvic floor exercises after
childbirth may help. Most gynaecologists attach the
uterosacral ligaments to the vaginal vault at vaginal
hysterectomy for prolapse, but may not do so at a vagi-
nal hysterectomy for menorrhagia, abdominal hysterec-
tomy or laparoscopic hysterectomy. Research is being
undertaken into oestrogen in the prevention of vault
prolapse. Sacrospinous ligament fixation and sacro-
colpopexy both appear to be superior to a pelvic floor
repair.
We need a randomised trial of sacrospinous ligament
fixation and sacrocolpopexy; in this context the pro-
lapse scoring system introduced by the International
Continence society will be useful in selecting women
for the trial and in the comparison of results. Recently
laparoscopic sacrocolpopexy has also been advocated,
but until long term results are seen this can not be rec-
ommended routinely.
Philip Toozs-Hobson, Specialist Registrar
Kelvin Boos, Research Fellow
Linda Cardozo, Professor
Urogynaecology Unit,
Department of Obstetrics and Gynaecology,
King k College School of Medicine and Dentistry, London
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