Vaginal Vault Prolapse

Definition

• Formally: POP is "descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy)," correlated with symptoms (Berek & Novak's Gynecology).
• In women after hysterectomy, the vaginal apex shifts downward toward the introitus - this is specifically termed vaginal vault (or apical) prolapse in the absence of the uterus.
• Complete vaginal vault prolapse represents full eversion of the entire vagina (analogous to procidentia in women with a uterus).
• The apex is the "cornerstone" of vaginal support; failure of apical support dramatically increases the risk of recurrence at other compartments (Campbell-Walsh Wein Urology).

Etiology / Risk Factors

1. Obstetric / Delivery-Related

• Vaginal delivery is the strongest single risk factor - women with at least one vaginal delivery are twice as likely to develop POP vs. nulliparous women.
• Birth trauma injures the pubococcygeal portion of the levator ani in ~55% of women with prolapse (vs. 16% in normal support).
• Direct nerve damage (pudendal neuropathy) leads to levator muscle atrophy and enlargement of the levator hiatus.

2. Iatrogenic - Post-Hysterectomy

• Hysterectomy without adequate apical suspension is the direct cause of vault prolapse.
• Disruption of the cardinal/uterosacral ligament complex at hysterectomy weakens Level I support.
• Rates of vault prolapse are higher after hysterectomy for prolapse than for other indications.

3. Loss of Connective Tissue Support (Level I)

• Attenuation or rupture of the uterosacral-cardinal ligament complex (Level I support) - the primary apical anchor.
• Failure of the paravaginal attachments (Level II - arcus tendineus, levator fascia) contributes to concurrent cystocele and rectocele.
• Histologic studies show uterosacral ligament integrity is often compromised, calling into question durability of repairs.

4. Non-Obstetric Risk Factors

Management

A. Conservative (Non-Surgical)

1. Pelvic floor muscle training (PFMT) - first-line; may improve mild symptoms and delay surgery.
2. Pessary - mechanical intravaginal device to reduce prolapse. Ring, Gellhorn, cube, and donut pessaries can all be used for vault prolapse. Particularly useful for women who are poor surgical candidates or who decline surgery.
3. Vaginal estrogen (topical) - improves tissue quality preoperatively; used especially in postmenopausal women.
4. Observation - appropriate for asymptomatic or mildly symptomatic (Stage I-II) prolapse.

B. Surgical Management

1. Reconstructive (native tissue) - uses endogenous support structures.
2. Compensatory/Augmentation - replaces deficient support with permanent graft/mesh.
3. Obliterative - closes the vagina; reserved for women who do not desire sexual function.

Vaginal (Transvaginal) Procedures

Abdominal / Laparoscopic / Robotic Procedures

• The cuff/apex must be resuspended posteriorly and cephalad toward the sacrum - anterior apical suspension changes the vaginal axis and predisposes to posterior compartment defects.
• Concomitant cystocele/rectocele repair should address anterior and posterior compartment defects.
• Concurrent anti-incontinence procedure (midurethral sling) should be considered given high coexistence of stress urinary incontinence.
• 6-year recurrence rates using strict composite definitions may be as high as 40% (Campbell-Walsh).

Obliterative Procedures

• Colpocleisis (Le Fort's procedure) - partial vaginal closure; most effective with lowest recurrence (~95%+ success), but permanently prevents penetrative intercourse. Reserved for elderly/frail women who do not desire sexual function.

Recent Evidence (PubMed, 2023-2025)

• A Cochrane systematic review (Maher et al., 2023 - PMID 37493538) on apical vaginal prolapse surgery provides the highest-level summary of operative options.
• A systematic review and meta-analysis (Ciortea et al., 2023 - PMID 37766917) found laparoscopic sacrocolpopexy has comparable or superior outcomes to vaginal reconstructive procedures.
• A 2025 meta-analysis (Parsaei et al. - PMID 40024596) found laparoscopic pectopexy is a viable, comparable alternative to laparoscopic sacrocolpopexy with potentially fewer presacral complications.