The vaginal vault


Dr Alfred S. Cutner, Urogynaecology Unit, Elizabeth Garrett Anderson Hospital, University College London Hospitals, Huntley Street, London WC1E 6DH, UK.


Pelvic organ prolapse in women is common, affecting 50% of parous women over 50 years of age, with a lifetime prevalence risk of 30%–50%.1 Perhaps the most challenging problem is that of vaginal vault prolapse. It is important to appreciate that the vaginal vault cannot be treated in isolation, as anterior or posterior compartment prolapse and/or surgery will invariably affect the vaginal vault. Indeed large epidemiological studies have shown that women who undergo any operation for incontinence or prolapse have a 29% chance of a further operation for one of these conditions.2


The underlying aetiology of vault prolapse is multifactorial, most notably previous surgery, with a significant contribution of the patient's genetic predisposition.3 Vault prolapse can only occur after hysterectomy and the rate of prolapse is greater where the hysterectomy is performed for prolapse (11.6%) rather than for other reasons (1.8%).4 The overall risk after hysterectomy is reported as 3.6 per 1000 person years.5 Various procedures have been tried at the time of vaginal hysterectomy in an attempt to reduce the chance of vault prolapse. These include sacrospinous fixation, as well as the Moschowitz, Halban and McCall Culdoplasty procedures, which aim to re-establish the continuity of the pubo-cervical fascia, recto-vaginal fascia and cardinal-uterosacral complex with the vagina. Of all the methods used, the McCall Culdoplasty has been shown to reduce the risk of vault prolapse most significantly from 30% to 6%.6 The genetic predisposition of patients to vault prolapse is often as a result of failure of the inherent soft tissue support structures of the pelvis.7,8 These are formed by the parametrium, which forms a bridge between the vagina and the bony pelvis and the cardinal-uterosacral formed by the condensation of the endopelvic fascia.9 The support of the vagina is symbiotically dependent on overall pelvic floor support. Hence, the insults that are exerted on the vagina and the pelvic floor throughout life affect the underlying strength, resulting in prolapse. An extreme example of this is uterosacral ligament division. Davis in 1996 reported several cases of uterine prolapse in these women where form of surgery had been performed for pelvic pain.10 Interestingly, in women with endometriosis, where a similar form of surgery is practised particularly when removing endometriotic nodules from the utero-sacral ligaments, prolapse does not seem to occur. Though both procedures are used in the treatment of pelvic pain, prolapse does not seem to occur in the endometriosis group. This may be as a result of extensive scarring that is associated with endometriosis, which may inadvertently contribute to the ‘tethering or support’ of the pelvic floor.


Typically patients with vault prolapse complain of one or all of the following symptoms: ‘something coming down’, ‘feeling something there’ (i.e. a bulge), urinary symptoms (such as urgency, incontinence or voiding difficulty), ano-rectal dysfunction (such as difficulty with evacuation with the need for digitation) and coital problems. Pain is rarely a symptom of prolapse and even if prolapse is present other causes for pain, e.g. pudendal neuropathy, should be excluded before surgery, as pain might become worse despite anatomical correction of the prolapse.

Patients might present to a gynaecologist, urologist or the colorectal surgeon, depending on their major symptom. Madjar et al.11 found that there is little interaction between these three groups of specialists despite the overlap of the patient's conditions. In the UK most patients present to gynaecologists where a detailed history and examination are undertaken; the latter in the left lateral or standing position using a Sim's speculum. Placing the Sim's speculum along the posterior vaginal wall and asking the patient to gently bear down can assess anterior vaginal wall prolapse. This enables the examiner to visualise the degree of anterior vaginal wall prolapse. Placing gentle traction on the forceps attached to the vault when the patient is awake can assess the extent of vault descent. The extent of vault descent can be easily determined. In some cases these examinations are carried out when the patient is anaesthetised; however, one must be cautious that the pelvic floor may also be ‘paralysed’ and this may affect clinical assessment. The preoperative assessment of the patient is important as it can be difficult to determine what the main prolapse symptom of some patients is, and their co-operation is essential to clarify the clinical situation. There are various grading systems for prolapse.12 Currently the assessment recommended is the Pelvic Organ Prolapse Questionnaire (POP-Q) produced by the International Continence Society.13 An objective assessment of the patient's prolapse is important if results of different treatment modalities are to be compared.


Investigations are tailored to the individual with the aim of establishing whether bladder, ano-rectal or indeed neurological function has been compromised as a result of the prolapse or is the cause of the prolapse. The investigations, which may be required, include urodynamic tests, defecography, ultrasonography and magnetic resonance imaging of the pelvic floor. Perhaps one of the common problems seen with complex vault prolapse is occult stress urinary incontinence. A recent study confirmed this by looking at abdominal leak point pressures in association with vault prolapse. They showed there was a 50% incidence of occult stress incontinence with the prolapse in situ.14 However, a mean decrease of 59% of the leak point pressure was noted following the reduction of the prolapse.14 Traditionally the prolapse is reduced by inserting a pessary, but an extensive study by Bump et al.15 showed that there was a high false positive rate for incontinence following pessary testing. This is an important point as these patients with ‘positive leak point pressures’ may have further continence procedures performed at the same time as vault surgery, which may be unnecessary. Patients with vault prolapse need good assessment of their bladder function with the prolapse reduced to ensure that occult stress incontinence is detected, but not necessarily to have concomitant surgery. It is perhaps wise in some patients to defer treatment until the primary vault surgery is completed before contemplating continence procedures.



Conservative treatment with pelvic floor exercises or cones may initially be tried; however, in most cases of vault prolapse the fascial supports are torn and therefore it is unlikely that exercises will be of benefit. There is no published evidence to show whether pelvic floor exercises may be helpful in prolapse. Repository devices may be used but most patients find that the long-term nature of their use makes them unacceptable. In addition, if the pelvic floor gives little support then the ring may not be able to be retained. In these situations shelf pessaries may be better and some workers have tried using two rings at the same time.16 However, vaginal pessaries remain useful in the management of elderly patients who are unfit for or not keen on surgery, in women who have not completed their family, and in those women awaiting surgery or who wish to ‘trial’ the surgery. The patient has to be motivated and understand that hygiene and vaginal skin condition is important for long-term use of pessaries. Patients also have to be aware that there is a need to replace the pessary at least every 6 months. If this is not done then there is a risk of patients developing vaginal erosions and possibly genital tract fistulas. In some cases hormone replacement therapy may be used to ensure good vaginal skin condition. However, there is lack of scientific evidence as to the role of hormone replacement creams in the vaginal condition and the replacement intervals of the pessary.17


Surgery is often the only suitable treatment. The aims of surgery are to restore anatomy, whilst preserving bladder, bowel and sexual function. The surgery can be performed either vaginally or abdominally. The abdominal approach can be either via laparotomy or laparoscopy. Laparoscopic surgery should not be thought of as a different operation to that carried out via laparotomy but rather as traditional surgery carried out through small incisions. Various operations have been described for the treatment of vault prolapse. These include the high posterior repair, colpocleisis, culdoplasty procedures (such as Moschowitz, Halban and McCall), sacro-spinous fixation, sacro-colpopexy and posterior intravaginal slingoplasty. Laparoscopically, several operations for prolapse have been reported, notably ventrosuspension,18 cervicopexy,19 suspension of the vault to rectus fascia,20 high McCall,21 sacro-spinous fixation,21 sacro-colpopexy22 and laparoscopic suture hysteropexy.23 Currently there are three widely established and accepted surgical approaches adopted for the treatment of vault prolapse: sacro-colpopexy, sacro-spinous fixation and the posterior intravaginal slingoplasty. There are other novel procedures used in the support of the vaginal vault, though not necessarily widely accepted, such as uterosacral suspension24 and rectus fascial sling.25

Sacro-spinous fixation involves placing nonabsorbable or long-term absorbable sutures from the vaginal vault to the sacro-spinous ligament. Either unilateral or bilateral fixation can be carried out. It was popularized by Randall and Nichols in the early 1970s.26 Sze and Karram performed a review of 34 papers involving 1062 patients.27 There was an 18% recurrent prolapse rate, which included 32 vault eversions, 81 cystoceles, 24 rectocoeles and 56 unspecified types of vaginal wall prolapse. Colombo and Milani in their paper found a 27% recurrence rate.28 There was one randomised study in the literature comparing vaginal sacro-spinous fixation with abdominal sacro-colpopexy.29 However, after interim analysis this study was stopped due to the high failure rate in the unilateral sacro-spinous fixation arm. The vaginal arm had a 12% vault eversion rate requiring further surgery, whilst the abdominal arm only had a rate of 2.6%. There are other notable risks associated with sacro-spinous fixation (see Guner et al. for a review).30

Petros first described the posterior intravaginal slingoplasty, when he reported on 75 patients.31 In the final analysis, one patient had severe pain and four patients had a tape erosion. A further report of these techniques on a larger series of 93 patients had a 91% cure rate.32 The main advantage of this operation is that it is a vaginal procedure, which can be combined with other prolapse repairs. It is relatively easy to learn and suitable for women who have a short vagina, which is a problem in patients with previous prolapse surgery. A short vagina makes a sacro-spinous fixation unsuitable. In addition, sacro-spinous fixation results in a less natural axis than the posterior intravaginal slingoplasty. Potential disadvantages of this operation are possibly the type of nonabsorbable mesh used, the fact that the vagina is opened (which may increase the erosion rate) and the fact that it is only a thin strip of mesh that is used to give support to the vaginal wall. There is no current evidence to support these statements as there is no long-term follow-up data and very few published case series. Therefore, more data are needed before it can be recommended for widespread use.

Hence, abdominal surgery for vault prolapse remains the ‘gold standard’. It involves suspending the vaginal vault from the sacral promontory using a mesh. Arthur and Savage first described this procedure in 1957 when the uterus was sutured to the anterior sacral ligaments in order to prevent uterine prolapse.33 Lane in 1962 defined the first formal sacro-colpopexy, when he inserted an arterial graft from the vaginal vault to the anterior sacral ligaments, and thus suspended the vaginal vault.34 Various adaptations have been described, but the method used by most surgeons today is that described by Timmons et al.35 The laparoscopic version of this operation was first reported in 1994.22 Sacro-colpopexy entails using a nonabsorbable mesh and therefore several factors need to be taken into consideration. These include mesh type, suture type and whether staples are used.

There are no randomised studies comparing the laparoscopic and open approach in performing sacro-colpopexy. There have been a few case series for the laparoscopic approach.22,36–38 The surgical technique and length of follow up varies between the series. Overall, however, the success rates reported are similar to those of the open procedure. Although as stated, there are no randomised studies, there is a randomised study of laparoscopic and open rectopexy (a similar operation).39 The laparoscopic arm had less pain, quicker discharge from hospital and greater mobility. Patients having the laparoscopic approach also had less respiratory morbidity although the operating time was longer (153 compared with 102 minutes).

The specific risks of sacro-colpopexy are that of bleeding,40 sacral osteomyelitis41 and mesh erosion. The overall risk of erosion is 5.6% but 4.1% if the mesh is inserted abdominally and 20% if placed vaginally.42 The type of synthetic mesh used appears to affect the rate of erosion. Polypropylene meshes, which have a low erosion rate, have a very large pore size, which allows for active phagocytosis of debris between the pores.43 The other mesh products, such as polytetrafluorethylene (PTFE), expanded PTFE, or polyethylene tetraphtalate have smaller pore sizes, which do not allow for active phagocytosis, and hence are more commonly associated with infections and possibly erosion.43

In patients with concomitant anterior vaginal wall weakness, supporting the vault alone may aggravate the anterior vaginal wall prolapse postoperatively, and may also be associated with urinary stress incontinence.37 One option is to extend the placement of mesh down the anterior vaginal wall. However, there are reports of mesh erosion into the bladder from anteriorly placed mesh, as well as the development of overactive bladder symptoms.44 Other surgical options include a paravaginal repair or a colposuspension.

A similar problem occurs with rectocoele formation after sacro-colpopexy. This is as a consequence of enhanced support of the front vaginal wall and the apex of the vagina, resulting in lack of lower posterior vaginal wall support. The options are concomitant vaginal rectocoele repair, placing mesh low down on the vaginal wall and attaching it to the perineal body or obliteration of the pouch of Douglas. The potential problems of placing mesh low down the posterior vaginal wall are the risks of dyspareunia. The laparoscopic approach enables easier placement of the mesh low down on the posterior vaginal wall. In the authors' experience this obviates the need for vaginal repair of the rectocoele at the time of the sacro-colpopexy. Hence, the increased risk of mesh erosion associated with the vagina being opened is avoided.

Appropriate management of vault prolapse is a problem in the elderly. With the increase in the longevity of the general population, there will be an increasing demand for care of patients with complex vaginal prolapse. In the past conservative management and colpocleisis were the only therapies offered to this group of patients, but this does not always resolve the problem. Furthermore, prolapse remains a major cause of morbidity.45 Prolapse limits the social activities of the elderly making them less mobile, and in turn affects their psychological ability to cope with their condition, and general well-being. This may result in their having to be institutionalised. An alternative operation in the form of sacro-spinous fixation can be offered, but this carries an increased risk of bleeding in the elderly, and has a high recurrence rate of apical prolapse as well as de novo cystocoele formation.46 We have assessed the laparoscopic approach in the very elderly and have found it to be a satisfactory approach with low morbidity and fast restoration of mobility. These data are yet to be published.

The reconstructive procedures for vaginal vault prolapse remain controversial. It is evident that different routes and procedures need to be considered when assessing any one particular patient's clinical condition. It is essential to consider the patient's age and any existent comorbidity, sexual activity, reproductive history and previous surgery. Bladder and bowel function also needs to be taken into consideration when determining the procedure to be performed. It is therefore critical that every clinician dealing with complex vaginal prolapse should be well versed with all surgical modalities.

Vault prolapse cannot be treated in isolation to other compartments of the pelvic floor. The management needs to individually tailored. Where possible preventative surgical techniques, such as the McCall Culdoplasty, should be employed at the time of hysterectomy, to reduce the risk of developing vault prolapse and its associations. In cases where this has failed then patients should be offered a range of conservative and surgical options. The aims of the surgery should remain the same: to correct the anatomical problem whilst maintaining or restoring bladder, bowel and sexual function. At the same time one should aim to achieve a long-term result, whilst ensuring no deterioration in the patient's general condition. The two surgical options, in our opinion, which should be available, include the posterior intravaginal slingoplasty and abdominal sacro-colpopexy. The posterior intravaginal slingoplasty will probably replace those situations where a sacro-spinous fixation is offered but long-term data are still pending, especially with regards to mesh erosion rates (bowel trauma and as yet other unknown complications). The abdominal sacro-colpopexy is our operation of choice and it should not be denied to the women based on their age (provided they are fit for surgery). As we operate increasingly on the elderly, the laparoscopic approach appears to be superior to laparotomy. This is similar to findings by general surgeons carrying out abdominal cholycystectomy in the elderly, who showed that patients who underwent the laparoscopic procedure had a better recovery from surgery and were discharged home sooner. Though data in the literature on laparoscopic sacro-colpopexy are sparse, in our opinion this approach not only offers them a better surgical outcome to other forms of surgery, but also a better medical recovery from the procedure.