Anterior and posterior vaginal relaxation, as well as incompetence of the perineum, often accompanies prolapse of the uterus. Large anterior vaginal prolapse is more common than posterior vaginal prolapse because the bladder is more easily carried downward than is the rectum. Before menopause, the prolapsed uterus hypertrophies and is engorged and flaccid. After the menopause, the uterus atrophies. In procidentia, the vaginal mucosa thickens and cornifies, coming to resemble skin.
The symptoms of POP are in general not unique to any particular vaginal defect. Often the symptoms are a reflection of only the most prominent point of prolapse. Most women become symptomatic only when the prolapse nears the vaginal opening. A critical concept is that the functional complaints may not always relate to the anatomic findings.
- Sensation of vaginal fullness, pressure, heaviness, “something falling out”
- Sensation of “sitting on a ball”
- Discomfort in the vaginal area
- Presence of a soft, reducible mass bulging into the vagina and distending through vaginal introitus
- With straining or coughing, there is increased bulging and descent of the vaginal wall.
- Back pain and pelvic pain are often also associated with POP. It is important in women with these complaints to investigate other causes, as a direct link in mild to moderate prolapse is unproven.
- Urinary symptoms are also common:
- Feeling of incomplete emptying of the bladder
- Stress incontinence
- Urinary frequency
- Urinary hesitancy
- Perhaps a need to push the bladder up in order to void (splinting)
- Patients with advanced prolapse may have “potential” stress urinary incontinence. A condition in which underlying urinary incontinence is masked by kinking of the urethra and causing functional continence.
Defecatory symptoms may also occur, more commonly in posterior vaginal prolapse. The sense is one of incomplete emptying, need to strain, or manually splint in the vagina or on the perineal body (space between vagina and anus) in order to defecate. The history may include prolonged, excessive use of laxatives or frequent enemas. Other nonspecific symptoms such as low back pain, dyspareunia, or even fecal and gas incontinence may be reported.
Symptoms of sexual function may also be elicited. Coital laxity or a sense of feeling “loose” may be reported. Avoiding intercourse as a consequence of embarrassment may occur. Attention to this aspect of a woman's symptoms is especially critical if any surgical intervention is considered.
For pelvic organ prolapse, proven risk factors include age, increasing parity, obesity, and history of pelvic surgery, specifically hysterectomy. Additionally, certain lifestyle or disease conditions can promote the development of POP. Chronic coughing from lung disease and straining from chronic constipation, for example, may increase the pressures on the pelvic floor. Acting as a constant piston, driving forces exerted onto the pelvic support tissues can cause herniation of the vaginal walls. In a similar manner, occupational activity requiring repetitive heavy lifting (eg, environmental service workers or care providers of the elderly) may promote the development of POP with this daily insult of frequent pelvic pressure.
Furthermore, menopausal status, physical debilitation, and even neurologic decline can contribute to the development of POP. Yet even with a multitude of risk factors, certain women are predisposed to developing POP. As prolapse has been demonstrated in women with no identifiable risk factors, the inherent quality of a woman's connective tissue plays a large role in the susceptibility to the development of prolapse and related conditions. Investigating the genotype, consistency, and composition of the endopelvic “fascial” tissues and the interplay of enzymatic remodeling is an area of intense interest and current research.
Parity has long been recognized as a prime risk factor for the development of POP. Not surprisingly, it is also strongly associated with anal and urinary incontinence as well. Parity is clearly associated with POP, as case-controlled studies show vaginal parity as an independent risk factor with a 3-fold increased risk for POP among parous women compared with nullipara controls. This risk increases up to 4.5-fold with more than 2 vaginal deliveries. The question of whether it is the pregnancy, the size of the baby, or the mode of delivery that plays the largest role in the development of POP is still not clear. During labor, as the vertex descends through the vagina, the physical forces on the pelvic tissues can be severe. The muscles, viscera, connective tissue, and nerves are all potentially susceptible to injury. Forces of compression and stretching combine to injure pelvic-floor nerves, leading to ischemia and neurapraxia. Myofascial fibers can be disrupted or torn because of distention of the fetal head and body. When tissues are injured, the body will repair them. Factors impairing adequate tissue repair and wound healing may also play an as yet undetermined role in the development of POP.
Examination for pelvic organ prolapse should begin in the dorsal lithotomy position. Inspection of the vulva and perineum should focus on evaluation of vulvar architecture and the presence of pressure ulceration or erosions or other skin lesions. Epithelial skin lesions, particularly in the elderly, should be biopsied.
At first, with the patient at rest, the labia should be separated and any prolapse noted (Figs. 42–8 and 42–13). Examination of the patient with vaginal prolapse reveals a relaxed and open genital hiatus with a thin-walled, rather smooth, bulging mass. Vaginal rugae are normally present. A loss of rugation denotes disruption of the connective tissue attachment below the epithelium.
During evaluation for urinary incontinence, a stress test is performed at this initial portion of the examination. The patient should be asked to cough forcefully, and any loss of urine is noted.
For prolapse assessment, when using the POP-Q system, the genital hiatus, perineal body, and vaginal length can be recorded. (Use of a wooden PAP spatula and tape measure can be helpful.) Vaginal support can then be assessed with strain (cough or Valsalva's maneuver), and the point of maximal protrusion should be noted in centimeters relative to the hymen and recorded. A speculum can also be used to “usher” the prolapse out during straining. This is also the most effective way to evaluate uterocervical support. In posthysterectomy patients, the cuff can often be visualized by the presence of “dimples” in the vaginal epithelium at the apex. Discriminate examination of the vaginal walls using the posterior blade of a Graves' speculum or Sims' retractor should then be used to evaluate the anterior and posterior walls separately, again noting the point of maximal prolapse during strain. For evaluation of the anterior wall, compress the posterior wall and have the patient strain. For evaluation of the posterior wall, elevate the anterior wall and have the patient strain. Complete examination should also include a rectovaginal palpation. In this way, one can evaluate for the presence of concurrent enterocele in addition to a rectocele. The septal defect may involve only the lower third of the posterior vaginal wall, but it often happens that the entire length of the rectovaginal septum is thinned out. The finger in the rectum confirms sacculation into the vagina. A deep pocket into the perineal body may be noted, so that on apposition of the finger in the rectum and the thumb on the outside, the perineal body seems to consist of nothing but skin and rectal wall.
Assessment of anal sphincter tone should also be performed both at rest and with squeeze contraction. The presence of perianal lesions or hemorrhoids should be noted.
If during examination the prolapse is not able to be reproduced based on symptoms, examination with the woman in the standing position should be performed. With the patient facing the seated examiner, knees slightly bent, and with strain, prolapse not demonstrable in the supine position because of poor Valsalva's maneuver can often be confirmed in the upright position.
Assessment of the pelvic floor strength is accomplished by vaginal or rectovaginal palpation of the levator ani musculature. Within 2 to 3 cm from the hymen, the bulk of the pubococcygeus component of the levator ani muscle can be palpated. The patient should be asked to contract the muscle, and the tone, symmetry, and duration of contraction should be recorded. This portion of the examination is often a valuable time to provide feedback to the patient about the volitional ability to contract the pelvic floor muscles. If the patient's ability to identify and contract the muscles is inadequate, the examiner may facilitate isolation of the proper muscles using verbal cues and manual feedback.
Evaluation of urinary function is also important in patients with POP. This is most germane in patients with large anterior vaginal defects. With prolapse of the anterior vagina, the bladder and urethra may herniate into the vagina. The urethra can bend and kink as it is fixed distally at the level of the pubourethral ligament. This “kinking” can alter normal voiding function in 2 fundamental ways. First, it will increase outflow resistance and impair normal emptying. After voiding, simple catheterization or ultrasonographic measure should be performed and the residual volume measured. Although not standardized, postvoid residual volumes greater than 100 mL are considered elevated and may indicate abnormal voiding and require referral for more sophisticated testing.
The second way urethral kinking can impact voiding is by masking underlying stress urinary incontinence. With increased outflow resistance, functional continence is created. Reduction of the prolapse during examination can be performed (elevation of anterior segment with a pessary, ring forceps, or speculum). The patient strains/coughs and the presence of urinary loss confirms the condition of SUI. This is termed stress incontinence on prolapse reduction and may be addressed with an anti-incontinence procedure at the same time if surgery is offered for POP.
In general, a complete discriminative gynecologic examination is all that is necessary to accurately assess pelvic organ prolapse. In certain cases, further diagnostic studies can be used.
Recent advances in radiologic medicine have allowed assessment of the pelvic floor with sonography and MRI. Despite newer techniques, intravenous pyelogram or computed tomography urogram still hold great value, as they are simple and safe methods to visualize the urinary tract. They can be used to evaluate the bladder and ureters. The course of the ureters can be identified preoperatively if obstruction caused by pelvic mass or scarring is suspected. These imaging tests can be used to evaluate for fistulae, congenital anomalies, or suspected damage as a result of operative injury. However, they lack sensitivity in imaging the pelvic floor and its associated defects, do not yield much information regarding vaginal support and pelvic floor musculature, and lack dynamic capabilities.
Ultrasound techniques can be an important tool to the urogynecologist. Compared with other radiologic techniques, ultrasound is noninvasive and inexpensive and does not require contrast media. Its main disadvantage is that the quality of the study depends heavily on the skill of the operator. When performed transabdominally, transvaginally, or transperineally and combined with Doppler or endoluminal transducers, the bladder, urethra, and surrounding structures can be visualized with detail.
VCUG combines a fluoroscopic voiding cystourethrogram with simultaneous recording of intravesical, intraurethral, and intra-abdominal pressure and urine flow rate. The contrast in the bladder allows dynamic evaluation of the bladder and bladder support.
Magnetic Resonance Imaging
MRI has evolved into an important tool for the evaluation of the pelvic floor. It is an ideal modality because its resolution of soft tissues is superior to that of other radiologic techniques. The capability to image in multiple planes is also an advantage, particularly when visualizing the complex 3-dimensional relationships of the pelvic floor. Dynamic straining can be used to demonstrate prolapse under pressure and is often useful in surgical planning. As this modality becomes less costly and techniques evolve to allow evaluation of patients in the upright position, the information provided by MRI will be invaluable in increasing our knowledge and understanding of functional pelvic support.
Prolapse of the vagina is generally a straightforward diagnosis. However, less common disease entities may present as bulges in the vagina. Tumors of the urethra and bladder are often more indurated and fixed than is anterior vaginal prolapse.
A large urethral diverticulum may look and feel like an anterior vaginal prolapse but usually is more focal and may be painful. With urethral diverticulum, compression may express some purulent material from the urethral meatus. Anterolateral defects can represent embryologic remnants such as a Gartner's duct cyst.
Skene's and Bartholin's glands can become obstructed and enlarge to form cysts or abscesses. Rarely, hemangiomas will present as vaginal bulging, although they will often have characteristic purple discoloration on the overlying epithelium.
Soft tumors (lipoma, leiomyoma, sarcoma, myofibroblastoma) of the vagina are more fixed and are nonreducible.
Cervical tumors—as well as endometrial tumors (pedunculated myoma or endometrial polyps)—if prolapsed through a dilated cervix and presenting in the lower third of the vagina, may be confused with mild or moderate uterine prolapse. Myomas or polyps may coexist with prolapse of the uterus and cause unusual symptoms.
Despite the variety of possibilities, the history and physical findings in vaginal or uterine prolapse are so characteristic that diagnosis is usually not a challenge.
Pelvic organ prolapse, except in rare situations, is a condition that impacts only the quality of life. Consequently, the extent and type of treatment should reflect and be commensurate with the degree of impact on the quality of life the patient experiences. Patient perception is also a critical component, and self-image and conceptual discomfort are relevant to any discussion of therapy. Common reasons to intervene are when function is impaired because of the prolapse. Anterior prolapse can contribute to urinary incontinence or, when severe, urinary obstruction. Bulging vaginal epithelium can come into contact with undergarments and clothing and over time develop pressure sores and erosions. A posterior vaginal defect can become so large that fecal evacuation is difficult, or the patient finds it necessary to manually reduce the posterior vaginal wall into the vagina to expedite expulsion of feces. Mobility can be impaired by a large prolapse. All of the preceding complaints are reasons to discuss surgical repair.
Chronic decubitus ulceration of the vaginal epithelium may develop in procidentia. Urinary tract infection may occur with prolapse because of anterior vaginal prolapse, and partial ureteral obstruction with hydronephrosis may occur in procidentia. Hemorrhoids result from straining to overcome constipation. Small-bowel obstruction from a deep enterocele is rare.
The patient with a small or moderate-sized POP requires reassurance that the pressure symptoms are not the result of a serious condition and that, in the absence of urinary retention or severe skin pressure ulceration, no serious illness will result. The natural history of POP is such that it either will stay the same or progress. There is some evidence that a small subset of patients may experience regression of the prolapse after menopause or postpartum if the prolapse is noted shortly after delivery. Reassurance and observation of prolapse should be encouraged in the absence of symptoms.
If prolapse presents in the reproductive years, surgical correction of POP is rarely indicated in women who are not family complete. If the young woman does present with significant symptoms related to POP or with a disturbing degree of urinary incontinence, then temporary medical measures may provide adequate relief until she has completed childbearing, whereupon a definitive operative procedure can be accomplished.
Pessary use in selected patients may provide adequate relief of symptoms. There are a variety of available pessary types and sizes that allow for individualization of therapy (Fig. 42–15). For the most common type of POP of the anterior or apical segment, a ring pessary is usually a sensible starting point for treatment. For the patient with complicating medical factors who is a poor operative risk, the temporary use of a vaginal pessary may provide relief of symptoms until her general condition has improved.
Prolonged use of pessaries, if improperly managed, may lead to pressure necrosis and vaginal ulceration. The vaginal pessary is a prosthesis of ancient lineage, now made of rubber, plastics, and silicone-based material, often with a metal band or spring frame. Many types have been devised, but fewer than a dozen are basically unique and specifically helpful.
Pessaries are principally used to support the uterus and vaginal walls. They are effective because they reduce vaginal prolapse and increase the tautness of the pelvic floor structures. Little or no leverage is involved. Either by placement behind the pubic bone and perineal body or by filling the vaginal vault, pessaries remain in place to hold up the prolapsing vaginal walls or uterus. In most cases, adequate support anteriorly and a reasonably good perineal body are required; otherwise, the pessary may slip from behind the symphysis and extrude from the vagina.
Pessaries are contraindicated in acute genital tract infections and in adherent retroposition of the uterus.
Several pessary types are available:
- A ring pessary with or without support provides relief of uterine prolapse or anterior vaginal prolapse.
- Gellhorn pessaries are uniquely shaped like a collar button and provide a ringlike platform for the cervix or apex. The pessary is stabilized by a stem that rests on the perineum. These pessaries are used to correct marked prolapse when the perineal body is reasonably adequate.
- The doughnut is made of soft rubber or silicone, and this type of pessary provides support for severe uterine prolapse or vault prolapse.
- The Gehrung pessary resembles 2 firm letter Us attached by crossbars. It rests in the vagina with the cervix cradled between the long arms; this arches the anterior or posterior vaginal wall and helps reduce the vaginal prolapse.
- The Hodge pessary (Smith-Hodge, or Smith and other variations) is an elongated, curved ovoid. One end is placed behind the symphysis and the other in the posterior vaginal fornix. The anterior bow is curved to avoid the urethra; the cervix rests within the larger, posterior bow. This type of pessary is used to hold the uterus in place after it has been repositioned.
- The inflatable pessary functions much like a doughnut pessary. The ball valve is moved up and down; when the ball is in the down position, air inflates the pessary; when in the up position, the air is sealed in and inflation is maintained.
- The cube is a flexible rubber cube with suction cups on each of its 6 sides that adhere to the vaginal walls. This is useful in women with severe prolapse. However, vaginal erosions are common and can be severe. Frequent monitoring initially to identify pressure ulcers is critical.
Medicine is known as both an art and a science. Pessary fitting (Fig. 42–16) falls into the art category. Pessaries that are too large cause irritation and ulceration; those that are too small may not stay in place and may protrude.
Insertion of Hodge-type pessary.
In general, fitting a pessary is very much a trial-and-error endeavor. Once a type is selected based on the defects in the vaginal anatomy and on symptoms, sizing is best done with an office sizing set. This task is somewhat complicated as each pessary has its own measurement system, but familiarity with each pessary over time simplifies this task. The pessary should be lubricated and inserted with its widest dimension in the oblique diameter of the vagina to avoid painful distention at the introitus. With a finger of the opposite hand, depress the perineum to widen the introitus. Each pessary type has an optimal method for insertion.
Once a pessary is in place, the forefinger should pass easily between the sides of the frame and the vaginal wall at any point; if it cannot, the pessary is too large. After the pessary has been fitted, the patient should be asked to stand, walk, and squat to determine whether pain occurs or whether the pessary becomes displaced. The patient should be shown how to withdraw the pessary if it becomes displaced or is uncomfortable and cautioned that a contraceptive vaginal diaphragm cannot be used while a vaginal pessary is in place.
During the initial period of pessary wear, any discomfort, bleeding, or disturbance in defecation or urinary function should be reported immediately. The patient should be examined 1–2 weeks after insertion to inspect for the presence of pressure and inflammatory or allergic reactions. A repeat exam in 4 weeks can be done; then visits should be done at 3- to 6-month intervals to assess for continued proper fit and to evaluate for vaginal erosion and inflammation as a result of pessary use. For women who are unable to remove and clean the pessary themselves, the pessary should be changed approximately every 2–3 months.
The pessary should be maintained with an acidic pH gel such as Trimo-San (Milex Products, Chicago, IL). In postmenopausal patients, topical estrogen can vitalize the vaginal mucosa and reduce ulceration. An estrogen-containing ring can also be used in conjunction by “piggybacking” the ring with the pessary and then changing it every 3 months.
Vaginal pessaries are not curative of prolapse, but they may be used for months or years for palliation with proper supervision.
A neglected pessary may cause fistulas or promote genital infections, but there is no clear evidence that cancer occurs as a result of wearing a modern pessary.
Pelvic Floor Muscle Exercises
In some patients, improvement of pressure symptoms and of urinary control may be obtained by using pelvic floor muscle exercises, also referred to as Kegel exercises. These exercises are aimed to tighten and strengthen the pubococcygeus muscles. Evidence strongly supports use of Kegel exercises as first-line management in the treatment of urinary and fecal incontinence; however, they may also have some benefit in the relief of POP symptoms. Kegel exercises work best after specific instruction on how to perform them as most women do not perform them either correctly or in optimal fashion without supervised instruction and feedback.
In postmenopausal women, local estrogen therapy for a number of months may improve the tone, quality, and vascularity of the musculofascial supports. It is available in cream, parvule, and ring insert forms. With counseling, local estrogen can be offered to all postmenopausal women to reduce urogenital atrophy. For postmenopausal patients with exposed prolapse, who are awaiting surgery, or using a pessary, local therapy should be recommended to promote healthy epithelium particularly in preparation for surgery.
Anterior Vaginal Prolapse
a. Anterior Vaginal Colporrhaphy—
Anterior vaginal colporrhaphy is the most common surgical treatment for anterior vaginal prolapse (Fig. 42–17). Traditional anterior colporrhaphy (anterior repair) is a vaginal approach that involves dissecting the vaginal epithelium from the underlying fibromuscular connective tissue and bladder, and then plicating the vaginal muscularis across the midline. Excess vaginal epithelium may be excised and the wound closed. Recurrence of anterior prolapse as high as 52% has been reported and has always been a limitation of all reparative procedures. Modifications involving permanent suture material and graft materials have been introduced in the hope of increasing durability.
Repair of anterior vaginal prolapse.
The etiology of the anterior vaginal prolapse has been much debated, beginning with White in 1912. The repair of defects in the anterior vaginal segment has traditionally been done by midline plication. An alternative method based on the anatomic observations by Richardson and colleagues advocates identification of the specific defect in the pubocervical fascia underlying the anterior vaginal epithelium and repairing the discrete breaks (Fig. 42–9). This relationship and a lack of correction of apical defects may help explain why no single operative repair should be universally applied to patients with anterior vaginal wall defects and why traditional repair has resulted in high recurrence rates.
Paravaginal repair is performed for anterior vaginal prolapse that is confirmed to be a result of detachment of the pubocervical fascia from its lateral attachment at the arcus tendineus fascia pelvis (white line). This defect can be unilateral or bilateral. It can be confirmed preoperatively by noting loss of the lateral sulci and lack of rugation over the epithelium along the base of the bladder and elongation to the anterior vaginal wall. Clinically, vaginal examination using a speculum reveals a preponderance of the prolapse lateralized to 1 side as the speculum is withdrawn. In addition, a ring forceps can be used by gently exerting anterior traction along the vaginal sulci. If the defect is reduced, then the defect is consistent with a paravaginal defect and can be approached with a paravaginal repair technique.
The surgery can be performed either abdominally or vaginally. Both require identification of the white line and placement of serial sutures from the medial portion of the pubocervical fascia to the lateral side-wall at the level of the white line as it runs from the ischial spine over the obturator internus muscle to the posterior and inferior aspect of the pubic bone on the ipsilateral side. Reapproximation of the detached pubocervical fascia should reduce the anterior vaginal prolapse. This procedure can be done with other reconstructive procedures in the vagina as well as surgery to alleviate incontinence. Short-term surgical studies have shown good results, but no long-term or comparative data exist for this repair.
A transabdominal approach to the paravaginal repair may be elected to correct the anterior vaginal prolapse when an abdominal approach is necessary for other pelvic conditions such as abdominal hysterectomy, adnexal surgery, or, most commonly, with sacral colpopexy for apical prolapse repair.
Posterior Vaginal Prolapse
The traditional repair (Fig. 42–18) involves posterior midline incision, often high, to the level of the posterior fornix. The vaginal epithelium is separated off the underlying fibromuscular layer and endopelvic fascia. This fibromuscular layer is then serially plicated across the midline. Some describe adding levator muscle plication as well. No attempt at identifying specific fascial defects is made.
An alternate method of posterior vaginal defect (rectocele) repair relies on the identification of discrete defects in the rectovaginal fascia (Fig. 42–19). The surgeon inserts a finger of the nondominant hand into the rectum to inspect the rectovaginal fascia for defects. The rectal wall is brought forward to distinguish the uncovered muscularis (fascial defect) from the muscularis that was covered by the smooth semitransparent rectal vaginal septum. The defects are then repaired with interrupted sutures to plicate over the rectal wall. In this manner, the isolated defects are repaired, and the functional anatomy is optimally restored. Notably absent is any effort to plicate the levator ani musculature, as this often results in a bandlike stricture over the posterior wall—a likely cause of dyspareunia. Randomized trials do not support improved outcomes using this technique.
Site-specific repair of posterior vaginal prolapse. A: Dissection below vaginal epithelium exposes defect in rectovaginal (RV) fascia. B: Reflection of detached RV fascia. C: Restoration of the continuity of RV fascia by reapproximation with delayed absorbable suture.
Perineorrhaphy is generally combined with posterior vaginal repairs. This procedure is principally aimed at restoring the perineal body and reducing the vaginal outlet (genital hiatus) to more normal caliber. Reapproximation of the superficial transverse perinei muscle and the bulbocavernosus muscle rebuilds the perineum and lengthens the distance between vaginal opening and anal verge.
a. Postoperative Factors—
The prognosis after vaginal repair is excellent in the absence of a subsequent pregnancy or comparable factors (eg, constipation, obesity, large pelvic tumors, bronchitis, bronchiectasis, heavy manual labor) that increase intra-abdominal pressure. The recurrence of the POP is probable when a specific defect of pelvic supports has been overlooked or ignored; in such cases, subsequent progression of the overlooked site may itself lead to new symptoms or even to disruption of the previously repaired segment.
Postoperative avoidance of straining, coughing, and strenuous activity is advisable. Careful instruction about diet to avoid constipation, about intake of fluids, and about the use of stool-softening laxatives and lubricating suppositories is necessary to ensure durable integrity of the rectocele repair.
B. Mesh Augmentation in Vaginal Surgery—
Efforts to reduce prolapse recurrence rates have ushered in a dramatic increase in the use of mesh for vaginal repairs. Current evidence would only support the use of synthetic mesh to augment anterior vaginal repairs but at the expense of increased rates of complications. Clinically significant rates of vaginal erosions, painful intercourse, and pelvic pain have all been reported with the use of permanent mesh materials.
Prolapse of the vaginal apex includes:
- Uterine prolapse
- Posthysterectomy vaginal cuff prolapse
All of the preceding clinical conditions indicate a failure of apical support. The procedures used to address surgical repair require knowledge of the specific support structures available to reestablish normal anatomy.
Uterine prolapse is almost always accompanied by some degree of enterocele, and, as the degree of uterine descent progresses, the size of the hernial sac increases. Similarly, posthysterectomy prolapse of the vaginal vault may be the result of poor repair and identification of cuff support structure at the time of hysterectomy or may develop as a result of an enterocele that was overlooked (not repaired). Consequently, it is critical to always address apical cuff support at the time of surgery if a hysterectomy is being performed. Less common, after hysterectomy, the enterocele is located anterior to the vaginal vault, where it may be easily confused with typical anterior vaginal prolapse.
Apical vaginal repair may be accomplished transabdominally or transvaginally. A review of vaginal operations includes, among others, sacrospinous ligament suspension, iliococcygeal fixation, and high uterosacral ligament suspension (high McCall culdoplasty).
Because the normal vaginal axis is directed some distance posteriorly (almost horizontally when the patient is in an erect position) over the levator plate, operative correction by any means, whether by the vaginal or the abdominal route, should restore a normal vaginal axis. This is accomplished by suspension of the vaginal apex far back on the uterosacral ligaments, the presacral fascia, or the sacrospinous ligaments.
a. Sacrospinous Ligament Fixation—
A popular method of vaginal vault suspension is that of unilateral or bilateral fixation to the sacrospinous ligament. In this technique, the vaginal epithelium is separated from the rectovaginal tissues. Perforation through the rectal pillar is accomplished by directing blunt dissection toward the ischial spine through the loose areolar tissue. After an appropriate location on the sacrospinous ligament is identified (usually 2–3 cm medial to the ischial spine), one of several techniques may be used to safely pass 2 or more permanent (or delayed absorbable) ligatures through the ligament to the submucosal apex of the vagina. Tying the sutures brings the vaginal apex to that sacrospinous ligament, and a posterior colporrhaphy is then performed (as noted previously). Closing the dead space by intermittently suturing the vaginal mucosa to the underlying reconstituted rectovaginal septum may be useful.
Vaginal vault suspension to 1 or both sacrospinous ligaments has the potential of injury to the pudendal nerve or pudendal vessels and is often technically difficult. Because gluteal and posterior leg pain is a potential complication of this procedure, particularly if the branches of the sacral plexus are disturbed by suturing deep to the ligament, the procedure requires a skilled vaginal surgeon and should be undertaken only by those familiar with the technique.
B. Iliococcygeal Vaginal Suspension—
First described in 1962, this procedure uses the fascia overlying the iliococcygeal muscle. Although not nearly as commonly used as other procedures, this point of attachment allows reliable apical fixation without the need to gain peritoneal access. It is generally a safe procedure requiring a posterior vaginal incision in the midline with wide dissection of the overlying epithelium. Bilateral placement of permanent or delayed absorbable suture can be used.
C. Bilateral Uterosacral Ligament Suspension—
The use of the uterosacral ligaments to attach the vaginal cuff has become a re-appreciated technique in apical repairs. Several modifications of the procedure have been described since its introduction in 1938. This technique, as with the other vaginal procedures, can be done at the time of vaginal hysterectomy or to correct posthysterectomy apical cuff prolapse. After entrance into the peritoneum is complete, traction on the ipsilateral posterior vaginal wall with rectal digital examination will facilitate transperitoneal identification of the uterosacral ligament. Placement of a pair of permanent sutures in a lateral-to-medial fashion, 1 at the level of the ischial spine and another placed more cephalad, can be performed bilaterally. These sutures are then brought to the ipsilateral vaginal apices. Fixation of the cuff at this level reproduces cuff placement to the normal position of the cervicovaginal junction. Anterior vaginal repair should be performed before tying down the vaginal cuff.
A risk of this procedure is medial displacement and kinking of the ureters, which has been reported to occur in up to 11% of patients undergoing this procedure. Cystoscopic assessment of ureteral function without and with tension on the fixation sutures, before tying down the vaginal apices, is critical to identify any potential compromise intraoperatively. If ureteral flow reduction is identified, then removal of the sutures on the affected side will often restore normal function.
D. Abdominal Sacrocolpopexy—
Vaginal vault suspension can also be performed abdominally by attaching the vaginal cuff to the sacral promontory. Abdominal sacrocolpopexy is an excellent primary procedure for apical vaginal prolapse and enterocele and is the procedure of choice for those who are already having an abdominal approach for hysterectomy or for another indication. In this procedure, a laparotomy is performed, and the cul-de-sac and peritoneum overlying the sacrum are visualized. A window in the peritoneum over the sacral promontory is created, and 2 permanent sutures are placed through the anterior longitudinal ligament, approximately at the level of S1. The vaginal cuff is then exposed by dissecting off the overlying peritoneum. Fixation of a graft over the anterior and posterior vagina is then performed fashioning a Y-shape or 2 individual strips of graft. This Y graft is then brought posteriorly along the hollow of the sacrum and affixed to the anterior longitudinal ligament sutures overriding the sacral promontory. Avoidance of undue tension is critical to prevent postoperative dyspareunia.
Dissection and suture placement over the sacrum may introduce risk of operative hemorrhage. During placement of the sacral sutures, the nearby fragile sacral veins may be lacerated. Bleeding from these veins is difficult to control if the veins retract into the bone. Use of sterile thumbtacks to occlude these veins has been an operative technique used to stem potentially life-threatening hemorrhage.
Many different graft types have been described, as well as different methods of attaching these grafts to the vagina. Biologic grafts, however, have high failure rates when placed at the apex. Synthetic grafts are effective; however, they have erosion complication rates between 5% and 10%. As graft technologies continue to evolve, identification of the optimal graft material that maximizes durability and compatibility may materialize.
Numerous studies demonstrate this colpopexy to be highly curative of apical/uterine prolapse. Most surgeons consider the sacrocolpopexy to be the gold standard for apical repair. In the largest prospective evaluation of sacrocolpopexy outcome, the success rates are more than 95%. The procedure can also be performed laparoscopically. A prospective study evaluating outcomes of this approach in more than 100 women describe no apical recurrences and no mesh complication. Another retrospective study of 188 cases resulted in a 10% erosion rate; however, 13 of the 19 erosions occurred with concomitant hysterectomy.
The addition of robotic assistance has been introduced to facilitate the technical aspects of laparoscopic repair. To date no prospective trial exists on efficacy.
E. Obliterative Vaginal Operations (Colpocleisis and Le Fort's Operation)—
These are used primarily for severe uterovaginal prolapse in elderly patients and chronically ill patients who no longer desire coital function. It has the advantage of being done with either regional or local anesthesia. These procedures are highly effective and generally well tolerated. Traction produced by the obliterating scar tissue under the bladder neck and the urethra that may actually cause or aggravate stress incontinence is associated with these operations. Closing the genital hiatus may reduce the chance of recurrence and can be achieved by performing an “extended” perineorrhaphy concomitantly (Table 42–11).
Table 42–11. Follow-Up and Cure Rate after Abdominal Sacral Colpopexy. ||Download (.pdf)
Table 42–11. Follow-Up and Cure Rate after Abdominal Sacral Colpopexy.
Duration of Follow-Up (months)
No. of Patients
No. Cured (%)
Cowan and Morgan (1980)
Addision et al (1985)
Baker et al (1990)
Snyder and Krantz (1991)
Timmons et al (1992)
Grunberger et al (1994)
Valatis and Stanton (1994)
Burrows LJ, Meyn LA, Walters MD, Weber AM. Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol
2004;104(5 Pt 1):982–988.
Fitzgerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H; Ann Weber for the Pelvic Floor Disorders Network. Colpocleisis: A review. Int Urogynecol J Pelvic Floor Dysfunct
Handa VL, Garrett E, Hendrix S, Gold E, Robbins J. Progression and remission of pelvic organ prolapse: A longitudinal study of menopausal women. Am J Obstet Gynecol
Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. NeuroUrodyn
Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: Current observations and future projections. Am J Obstet Gynecol
Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol
Maher C, Feiner B, Baessler K, Adams EJ, Hagen S, Glazener CM. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev
Morgan DM, Larson K. Uterosacral and sacrospinous ligament suspension for restoration of apical vaginal support. Clin Obstet Gynecol
NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens Sci Statements
Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: A comprehensive review. Obstet Gynecol
Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorder in U.S. women. JAMA
Sung VW, Hampton BS. Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin North Am