vault prolapse definition ,etiology and management

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Vaginal Vault Prolapse

Definition

Vaginal vault prolapse (also called apical vaginal prolapse) is the descent of the vaginal apex - the vaginal vault (cuff scar) following hysterectomy - toward or beyond the vaginal introitus. It is a form of pelvic organ prolapse (POP) involving failure of the apical compartment (Level I support).

More broadly, POP is defined as "the 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).

When the uterus is present: downward displacement of the cervix and uterus is called uterine prolapse or, when complete, procidentia.
After hysterectomy: descent of the vaginal cuff is specifically termed vault (apical) prolapse (ICD-9: 618.5 - posthysterectomy vault prolapse).
Complete vaginal vault prolapse = total eversion of the vagina, representing the most severe form.

Etiology and Risk Factors

Vault prolapse is multifactorial, resulting from attenuation or disruption of pelvic support structures at multiple levels.

Anatomical Basis - Three Levels of Support (DeLancey)

Level I - The uterosacral/cardinal ligament complex anchors the vaginal apex superiorly to the sacrum and lateral pelvic wall. Vault prolapse is primarily a Level I defect.
Level II - Paravaginal attachments of the lateral vagina to the arcus tendineus pelvis (anterior) and levator fascia (posterior) - maintains midline vaginal position.
Level III - Distal vaginal support via muscles and connective tissue of the perineum.

Key Etiological Factors

Obstetric:

Vaginal delivery is the most significant risk factor. Women with at least one vaginal delivery are twice as likely to develop POP as nulliparous women.
Birth-induced injury to the pubococcygeal portion of the levator ani muscles is seen in 55% of women with prolapse vs. 16% with normal support.
Prolonged second stage, instrumental delivery, perineal lacerations.

Hormonal:

Postmenopausal estrogen deficiency leads to loss of collagen and elastin in connective tissue, weakening the cardinal-uterosacral complex.

Age:

Prevalence of POP more than doubles in women aged 80+. Age-specific annual risk peaks at 4.3 per 1,000 women at age 73.

Surgical:

Prior hysterectomy is a major precipitating factor for vault prolapse specifically - the normal suspension of the apex is disrupted unless specifically repaired at the time of hysterectomy.
Following hysterectomy for prolapse, "the vaginal apex must be suspended or the patient will likely have posthysterectomy prolapse" (Berek & Novak's).
Previous prolapse operations (risk of recurrence ~10% at 5 years).

Increased Intra-abdominal Pressure:

Chronic constipation and straining
Chronic obstructive pulmonary disease
Obesity
Heavy physical labor

Connective Tissue Disorders:

Marfan syndrome, Ehlers-Danlos syndrome (intrinsic collagen defects)
Racial variation: higher risk in White women compared to Black or Asian women.

Pathophysiology Summary

The levator ani muscles normally provide a closed pelvic diaphragm. When muscular or neuromuscular damage (often birth-related) widens the levator hiatus, the apical connective tissue bears more load. Concurrent attenuation or actual "breaks" in the cardinal-uterosacral ligament complex (Level I failure) allows the vaginal apex to descend. Once the apex descends, the anterior and posterior compartments typically follow - correction of cystocele without addressing the apex significantly increases prolapse recurrence.

Classification (POP-Q System)

The Pelvic Organ Prolapse Quantification (POP-Q) system is the validated standard for staging:

Stage	Description
0	No prolapse
I	Most distal portion >1 cm above hymen
II	Within 1 cm above or below hymen
III	>1 cm below hymen, but less than total eversion
IV	Complete eversion (total vaginal vault prolapse)

Management

1. Conservative / Non-Surgical

Indications: Mild-to-moderate prolapse, patient preference, surgical risk too high, or as first-line therapy.

Pelvic Floor Muscle Training (PFMT):

Kegel exercises strengthen the levator ani group.
Effective for symptomatic relief in Stage I-II prolapse; less effective for advanced vault prolapse.

Pessary Therapy:

An intravaginal device provides mechanical support of the prolapsed structures.
For vault prolapse specifically, ring with support, Gellhorn, or donut pessaries are preferred (see Berek & Novak's Figure 30-11).
Requires regular follow-up (every 3-6 months) for cleaning and assessment.
Suitable for women who are poor surgical candidates or who decline surgery.

Vaginal Estrogen:

Improves connective tissue quality and mucosal health.
Used preoperatively to improve tissue for surgery, or as adjunct to pessary.

2. Surgical Management

Surgery is indicated for symptomatic prolapse (typically Stage II or higher) that has failed conservative management, or when the patient prefers surgery. The primary goal is to relieve symptoms while restoring anatomy and preserving sexual function.

Key principle: Apical support is the cornerstone of any successful prolapse repair. Failure to address the apex increases the risk of recurrence in all compartments.

A. Vaginal Approaches

1. Sacrospinous Ligament Fixation (SSLF)

The vaginal apex is suspended to the sacrospinous ligament (the tendinous component of the coccygeus muscle), typically unilaterally on the right.
Extraperitoneal approach via the rectovaginal space.
Disadvantage: deflects the vagina posteriorly, which may increase the incidence of anterior compartment (cystocele) recurrence.
Complications: buttock/thigh pain (pudendal/sciatic nerve proximity), hemorrhage from pudendal/gluteal vessels.

2. Uterosacral Ligament Suspension (High ULS)

The vaginal apex is re-suspended to the remnants of the uterosacral ligaments bilaterally, restoring the natural vaginal axis.
Access via the peritoneum; sutures placed at the sacral-intermediate portion of the ligament (near S2-S3, approximately 1 cm posterior to the ischial spine).
Key risk: ureteral kinking/obstruction (the ureter approaches to within 0.9 cm of the uterosacral ligament near the cervix) - cystoscopy is mandatory post-suture placement.
Preserves vaginal axis and addresses both the anterior and posterior compartments simultaneously.

3. Iliococcygeal Suspension

The apex is fixed to the iliococcygeus fascia just anterior to the ischial spine.
Used when the uterosacral ligaments are not identifiable or are of poor quality.

4. McCall Culdoplasty

Plication of the uterosacral ligaments to close the posterior cul-de-sac and elevate the vaginal apex.
Typically performed at the time of vaginal hysterectomy.

5. Vaginal Obliterative Procedures (Colpocleisis)

LeFort colpocleisis or total colpocleisis: narrows/obliterates the vaginal canal.
Reserved for elderly, high-surgical-risk women who do not desire sexual intercourse.
Highly effective (~90-95%) with low morbidity.

B. Abdominal / Laparoscopic / Robotic Approaches

1. Abdominal Sacrocolpopexy (Gold Standard for Apical Repair)

The vaginal apex is attached to the anterior longitudinal ligament of the sacrum (S1-S3) via a synthetic mesh graft (Y-shaped polypropylene mesh).
Restores the natural vaginal axis and provides durable, long-term support.
Can be performed open, laparoscopically, or robotically (laparoscopic sacrocolpopexy - LSC).
A 2023 systematic review (PMID: 37766917) comparing LSC vs. vaginal reconstructive procedures and abdominal sacrocolpopexy confirms LSC as an effective minimally invasive option.
Disadvantages: longer operative time, mesh erosion risk (~3-10%), sacral osteomyelitis (rare), ileus.
Concomitant Burch colposuspension may be added for stress urinary incontinence.

2. Laparoscopic/Robotic Sacrocolpopexy

Minimally invasive version of the above.
Comparable anatomical outcomes to open sacrocolpopexy with reduced recovery time.

3. Laparoscopic Pectopexy

Emerging technique: mesh fixation to the iliopectineal ligament (Cooper's ligament) bilaterally.
A 2025 meta-analysis (PMID: 40024596) comparing laparoscopic pectopexy vs. sacrocolpopexy showed comparable efficacy with potentially lower sacral injury risk.

C. Uterine-Sparing Options (When Uterus is Present)

Manchester procedure (amputation of cervix + cardinal ligament plication)
Sacrohysteropexy (mesh attachment from cervix/uterus to sacrum)
Cervical sacrospinous hysteropexy
Evidence suggests uterine preservation reduces mesh erosion risk, operative time, and blood loss vs. hysterectomy + suspension, without significantly altering short-term recurrence rates.

D. Posterior Compartment Concurrent Repair

Vault prolapse is frequently accompanied by enterocele (herniation of peritoneal sac and bowel, more common after hysterectomy) and/or rectocele, which must be repaired simultaneously:

Enterocele repair: excision or reduction of the peritoneal sac + closure of fibromuscular defect (Halban or McCall sutures).
Posterior colporrhaphy for rectocele.

Summary Table: Surgical Options for Vault Prolapse

Procedure	Route	Best For	Key Risk
Sacrospinous ligament fixation	Vaginal	Good surgical candidates, narrow pelvis	Buttock pain, anterior recurrence
Uterosacral ligament suspension	Vaginal	Bilateral apical suspension	Ureteral injury
McCall culdoplasty	Vaginal	At time of hysterectomy	Recurrence in advanced prolapse
Abdominal sacrocolpopexy	Abdominal	Severe/recurrent prolapse	Mesh erosion, longer recovery
Laparoscopic sacrocolpopexy	Laparoscopic	Most patients; minimally invasive	Same as abdominal; longer OR time
Colpocleisis	Vaginal	Elderly, no desire for coitus	Irreversible
Pectopexy	Laparoscopic	Alternative to sacrocolpopexy	Less long-term data

References:

Berek & Novak's Gynecology (Chapter 30: Pelvic Organ Prolapse)
Campbell-Walsh-Wein Urology (Chapter 124: Apical Vaginal Vault Prolapse Repairs)
Ciortea R et al. Front Med 2023 [PMID: 37766917] - Systematic review: LSC vs. vaginal/abdominal sacrocolpopexy
Parsaei M et al. J Minim Invasive Gynecol 2025 [PMID: 40024596] - Meta-analysis: Pectopexy vs. sacrocolpopexy

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