See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/306357183

GYNAECOLOGINAL REVIEW: VAGINAL VAULT PROLAPSE – UNDERSTANDING

ITS COMPLEXITY AND SURGICAL OPTIONS FOR TREATMENT

Article · July 2009

CITATIONS READS

0 399

2 authors, including:

Sharifah Sulaiha Syed Aznal

International Medical University (IMU)
31 PUBLICATIONS 85 CITATIONS

SEE PROFILE

All content following this page was uploaded by Sharifah Sulaiha Syed Aznal on 22 August 2016.

The user has requested enhancement of the downloaded file.

 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12

GYNAECOLOGINAL REVIEW: VAGINAL VAULT PROLAPSE – UNDERSTANDING ITS

COMPLEXITY AND SURGICAL OPTIONS FOR TREATMENT

Sharifah Sulaiha Aznal, Zainur R Zainuddin

ABSTRACT

Vaginal vault prolapse is increasingly seen in women in Malaysia due to the increasing
number of them having some form of pelvic surgery. Its correction requires surgery as it
is noted that conservative management is rather suboptimal. However the options could
only be selected appropriately for a patient depending on the identification of the
specific defect of pelvic structures and its severity affecting the patient’s life. The
techniques available vary from the latest using grafts and mesh to the traditional sling
methods which performed vaginally or abdominally. The bottom-line is any option
chosen for a patient should aim to correct the anatomical defects, preserve vaginal
function and alleviate her symptoms to improve quality of life.

Keywords: Vaginal vault prolapses, vaginal prolapse, pelvic floor surgery, vaginal sling
surgery, mesh –sling vaginal surgery, abdominal sling surgery
________________________________________________________________________

ADDRESS OF CORRESPONDENCE
Assoc. Prof Sh Sulaiha Aznal,
Obstetrics & Gynaecology Dept.
International Medical University,
Clinical School, Seremban, Negeri Sembilan, Malaysia.
Shsulaiha_sydaznal@imu.edu.my

INTRODUCTION

Incidence of vaginal vault prolapse is increasing in Malaysia now that many women had
undergone hysterectomies and due to the extended longevity of women. Although it is
said that the condition occurs only in about 1% of hysterectomies, some studies have
quoted much higher incidence which is up to five-fold 1. MacLennan et al reported that
46.2% of women aged 15 to 97 experience pelvic floor dysfunction. By age 80,
approximately 11–12% of women will have undergone surgery for pelvic floor
dysfunction Thirty percent of this group will require more than one procedure 2. Post
hysterectomy vault prolapse often requires a surgical approach since non surgical
management in the form of a pessary may be ineffective 3.

The management of vaginal prolapse can be challenging as surgical failure is the most
fretful disaster in a woman. This is perhaps due to the least understanding of vaginal

1
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
support which maintenance relies on the interrelationships of intact pelvic floor
nueromusculature, ligaments and fascia. Vaginal vault prolapse occurs when the upper
part of the vagina sags or bulges down into the vaginal canal or outside the vagina. Two
thirds of women have concomitant cystocele and/or rectocele 4.

Pelvic Anatomy and Its Defects

The vagina maintains its anatomy with the support of important structures including
ligaments and endopelvic fascia. Vaginal apex represents a site where they coalesce.
The cervix on the other hand serves as the strong obvious attachment point 5

Anterior support

The pubocervical fascia extends from the pubis anteriorly to the cervix posteriorly. It
acts like a hammock to support the bladder in the correct position. It maintains the
integrity of the anterior and posterior vaginal walls in which if torn will lead to
herniation of the underlying tissue or organs 6

Middle support

The paracolpium and parametrium are the connective tissues surrounding the vagina
and the uterus where they fuse at the midvagina with the pelvic wall and the fascia
laterally to form the cardinal ligaments 7. Uterosacral ligaments on the other hand are
attached to the cervix and upper vagina posterolaterally. These two structures are the
anchor of the supports of uterus and upper vagina 8. Defect in the ligaments results in
descent of the middle structures.

Posterior support

The posterior vaginal wall is supported by paracolpium from the sides which fused with
rectovaginal fascia and pelvic diaphragm. The fascia is found mostly at the sides and
very thin in the midline 7. A posterior rectovaginal septum however has also been
described consisting of fibromuscular tissue extending from the peritoneal reflection to
the perineal body 9. It is adherent to the undersurface of the posterior vaginal wall and
forms a potential space, the rectovaginal space. An intact and normal septum permits
independent mobility of the rectal and vaginal walls.

De Lancey described three levels of vaginal support Figure 1 6.Defect in Level 1 support
which is the suspension of the vaginal apex by suspensory ligaments can lead to vaginal
prolapse. Disruption to level II supports (pubocervical or rectovaginal fascia) can lead to
the development of cyctocele or rectocele. However the distal portion of the vagina
always remains attached at the region of level III supports as the attachment of the
levator ani muscles is dense and may be disrupted by collagen weakness due to ageing 7.

2
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12

Over the years, the pelvic complexity of anatomic support is becoming better
understood. The importance of an accurate pelvic examination cannot be
overemphasized. It provides an idea to the surgeon as to planning of surgical therapy.
Identification of the area of defect and evaluation of its degree of damage is imperative
when managing a patient.

Clinical presentations

The symptoms of vaginal prolapse (picture1) depend on the type and severity. There are
general symptoms like pressure in the vagina, dyspareunia, backache or recurrent
urinary tract infection. Other symptoms are specific to certain types of prolapse.
 Difficulty in emptying the bowel – indicates defect in the posterior wall
causing herniation of the small bowels onto the upper part of the wall or
rectum onto the lower part.
 Difficulty in emptying the bladder – there is defect in the anterior wall
causing both the bladder and urethra to protrude and kink the flow of urine.

3
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
 Difficulty in controlling urination – Anatomical changes, injuries to bladder
and pelvic innervations could be the cause of incontinence. Prolonged
urethral kinking, urethral compression and pressure dissipation from a
cystocele enhances urethral closure pressure. Thus occult stress incontinence
can be evident when the herniation is corrected. 8
 Sexual dysfunction – the close anatomical proximity of the urinary and
genital tracts allows an association between urinary tract dysfunction and
sexual difficulties. Causes and effects are bidirectional. 9

Picture 1: Vaginal Vault Prolapse

CORRECTION WITH SURGICAL OPTIONS

The goals for repair is to restore the anatomy as near normal to optimize sexual, bladder
and bowel function including alleviating clinical symptoms. 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. Currently the
assessment recommended is the Pelvic Organ Prolapse Questionnaire (POP-Q) produced
by the International Continence Society.10 Reconstructive surgeries are now preferably
performed via vaginal approach as to abdominal.

VAGINAL APPROACH

This approach is favourable to some surgeons because it avoids the need for laparotomy
thus results in fewer complications, less blood loss, shorter hospital stay, less
postoperative discomfort and more cost effective.11 Vaginal approaches to repair
include:

 Sacrospinous fixation
 Iliococcygeal fixation
 High uterosacral ligament suspension
 McCall culdoplasty
 Obliterative procedure such as colpocleisis
 Intravaginal slingplasty (IVS)

4
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12

The most popular is still sacrospinous fixation best performed with an anterior
approach as it has been shown to result in better lengthening of the vagina. 12 It fixes
the apex of the vaginal vault to one or both of the sacrospinous ligaments. The most
notable modification is the Miyazaki technique, which substitutes the Miya hook for the
DesChamps ligature carrier. The Miya hook is reportedly safer for the pudendal complex.
13 The path of the Miya hook avoids Alcock’s canal and its neurovascular pudendal

bundle. Follow-up studies in women undergoing this procedure report a roughly 20%
incidence of recurrent or persistent anterior vaginal wall relaxation, or symptomatic
cystocele, within 1 year after the surgery. Alteration of the vaginal axis in an
exaggerated posterolateral direction after this procedure is thought to place undue
tension on the anterior segment of the vaginal wall and predispose women to prolapse
at a site opposite the repair14. Patient satisfaction however was shown higher with
sacrospinous fixation compared to illiococcygeal fixation although the outcomes are
similar.

In iliococcygeal fixation, the everted vaginal apex is secured to the iliococcygeal fascia
bilaterally, just below the ischial spine. Shull and colleagues15 studied 42 women whom
2 (5%) of them had recurrence, one of whom required further surgery. Six additional
patients had loss of support at other sites in the follow-up period, one of whom
required repeat surgery. 95% of women experienced no persistence or recurrence of
cuff prolapse 6 weeks to 5 years after the procedure. In comparison with sacrospinous
ligament fixation, iliococcygeus fixation is otherwise technically easier and places less
tension on the anterior vaginal wall.

Culdoplasty (picture 2) being described in late 1950’s and later modified is still a
technique which helps prevent post hysterectomy prolapse in 85% of cases. It often
performs at vaginal hysterectomy as it plicates the remnant of uterosacral ligaments
intervening cul-de-sac peritoneum and full thickness apical vaginal mucosa. Care must
be taken not to injure or kink the ureters during placement of the sutures 16, 11.

Picture 2: McCall culdoplasty

Colpocleisis may still have a role in older sexually inactive women. It is a relatively easy
procedure which could be performed under local anaesthesia. However many
5
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
postoperative complications like bowel and urinary functions have not been properly
addressed. It is expected though that complications easily occur in this group of patients
whom also have had repeated surgeries 17.

Intravaginal slingplasty (IVS) is a newer minimally invasive, transperineal approach to

vaginal vault prolapse with so far quite encouraging results. It is an outpatient technique
where a narrow tunneling device is used to pass a synthetic non absorbable tape
through each pararectal space via a small perineal incision, and make a small vaginal
incision to secure the tape to the vault. Farnsworth 18 has reported a symptomatic cure
rate of about 91% in 93 women with grade 2 or 3 vault prolapse with IVS. However the
use of mesh in the procedure has raised concerns about its potential morbidity.

The recent introduction use of grafts (picture 3) in vault suspension or vaginal wall
reinforcement has received numerous positive and negative feedback from surgeons.
Although series of small studies on the usage has shown promising results, the question
of graft extrusion is most alarming as the morbidity could have large impact onto the
patient’s sexual and social ability. Similarly the issues on type of mesh, tension applied
and the fixation points are still amidst 19.

Picture 3: graft or mesh

6
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12

Picture 4: Perigee system

The Apogee system and prolift system (picture 4) are the two major pedigrees which
have received admixture of response. Long term trial on its usage is required to justify
the use in reconstructive surgery 20.

ABDOMINAL APPROACH

The abdominal surgical approach can also be used but it has not been in favour due to
its associated complications and longer recovery time. However, a range of clinical
conditions can suggest an abdominal approach for vaginal vault prolapse procedures.

These include, but are not limited to:

 Prior unsuccessful vaginal attempts

 Obligate need for adnexal access
 markedly foreshortened vagina
 pelvic bony architectural limitations
 high risk for surgical failure (eg, athleticism, obesity, chronic obstructive
pulmonary disease, congenital connective tissue disorder)
 desire for uterine preservation

A common and gold standard procedure is sacrocolpopexy (picture 5) with interposing

mesh between the vagina and sacrum. It is also performed laparoscopically which in
centers where it is widely used, good results and low morbidity have been reported.
Success rate has been recorded as 78% to almost 100% at 5 years but the postoperative

7
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
graft extrusion, vaginal rupture and intestinal obstruction (if the mesh is not buried) are
the worrying complications 21, 22 .The most concerning complications includes bleeding
from the sacral promontory and postoperative ileus.

Picture 5: Sacrocolpopexy

Other technique which can also be performed vaginally is high uterosacral ligament
suspension. It is applicable best with mild to moderate prolapse. It suspends the corners
of the apical prolapse to the respective remnant of the uterosacral ligaments. Success
rates range from 87% to 90% but ureteral injury is as high as 11% 23.

CONCLUSION

Reconstructive surgery should be performed with an intention of improving the

anatomical and functional outcome of the vagina and related organs. Successful pelvic
surgery should achieve effective and sustained vault support, obliteration of the
enterocele sac and repairs of the cyctocele and rectocele. Most utilized techniques can
be most effective in suspending the vaginal apex. The surgeon should be familiar with
the identification of areas of defect and treatment of such prolapse.

8
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
Key points:

1. Incidence of vaginal vault prolapse (VVP) is between 1 – 15%, higher in women

who have had hysterectomies
2. Conservative management is ineffective thus surgical therapy is essential
depending on the need of the patient
3. Understanding the pelvic anatomy i.e.: anterior, middle and posterior supports
and its relation to the defect is vital before performing any form of pelvic repair
work
4. VVP is often associated with other presentations i.e.: incontinence, sexual
dysfunction, cystocele, rectocele or enterocele.
5. Surgical options would be either abdominally or vaginally. Though abdominal
approaches are the gold standard but vaginal surgeries are favoured as it carries
less complication.
6. The most popular vaginal surgery is sacrospinous fixation as it results in better
lengthening of the vagina and shows higher patient satisfaction.
7. Older techniques like Culdoplasty and Colpocleisis are still useful in some patients.
8. Recent use of graft or mesh in the repairs has received conflicting responses from
surgeon since complication from graft extrusion is alarming though the results are
quite promising.
9. Abdominal technique like sacrocolpopexy could also be performed
laparoscopically and success rates differ from centre to centre i.e.: 68 -100% with
low morbidity.

REFERENCES

Barber MD, Visco AG, Weidner AC et al. Bilateral uterosacral ligament vaginal vault
suspension with site – specific endopelvic fascia defect repair for treatment of pelvic
organ prolapse. Am J Obstet Gynecol 2000; 183: 1402-10

Barrington JW, Edward G. Post hysterectomy vault prolapse. Int Urognecol J pelvic
Floor Dysfunct 2000; 11:241-5.

Cosson M, Caquant F, Collinet P, Rosenthal C, Clave H, Debodinance P. et al. Prolift

(Mesh (Gynecare) For Pelivc Organ Prolapse. Surgical Treatment Using the TVM
Group Technique: A Retrospective Study of 687 Patients. ICS 2005 Presentation.

Cosson M, Rajabally R, Bogaert E et al. Laparoscopic Sacrocolpopexy, hysterectomy

and burch colposuspension: feasibility and short term complications of 77
procedures. JSLS 2002; 6: 115-9

9
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet
Gynecol 1992; 166:1717– 1728

Farnsworth BN. Posterior intravaginal slingplasty (infracoccygeal sacropexy) for

severe posthysterectomy vaginal vault prolapse—a preliminary report on efficacy
and safety. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13: 4-8

FitzGerald MP, Richter HE, Siddique S. et al. Colpocleisis: a review. Int Urogynecol J
(2006) 17: 261–271

Guerette N, Davila GW. Sacrospinous fixation: Does reinforcement of the vaginal

vault improve outcome? Int Urogynecol J 2003; 12(1): S69

Hall, A. F., Theofrastous, J. P., Cundiff, G. W., Harris, R. L., Hamilton, L. F., Swift S. E.
et al: Interobserver and intraobserver reliability of the proposed International
Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic
Society pelvic organ prolapse classification system. Am J Obstet Gynecol 175: 1467,
1996

Huebner M., Hsu Y., Fenner. The use of graft materials in vaginal pelvic floor surgery.
Int J Gynaecol Obstet 2006; 92: 279—288

MacLennan AH, Taylor AW, Wilson DH et al. The prevalence of pelvic floor disorders
and their relationship to gender, age, parity, and mode of delivery. Br J Obstet
Gynecol. 2000; 107:1460–1470.

Mahendra P. Vault Prolapse. J Obstet Gynaecol India 2005; 5: 20-1

Marinkovic SP, Stanton. Incontinence and voiding difficulties associated with

prolapse. J Urol 2004; 171: 1021-28

Miyazaki FS. Miya hook ligature carrier for sacrospinous ligament suspension. Obstet
Gynaecol 1987; 70:286-89.

Morley G, DeLancey JO. Sacrospinuos ligament fixation for eversion. Obstet Gynecol
1988; 158: 872 - 78

Norton PA, Baker JE, Sharp HC, Warenski JC. Genitourinary prolapse and joint hyper
mobility in women. Obstet Gynecol 1995; 85:225–228

Nygaard IE, McCreery R, Brubaker L et al. Abdominal Colpopexy: a comprehensive

review. Obstet Gynecol 2004; 104: 805-23

10
 Malaysian Journal of Obstetrics & Gynaecology
July-Dec, 2009; Vol.8, No.18: 1-12
Shull BL. Pelvic organ prolapse: anterior, superior and posterior vaginal segment
defects. Am J Obstet Gynecol 1999; 181: 6

Shull BL, Capen CV, Riggs MW. Bilateral attachment of the vaginal cuff to
illococcygeus or sacrospinous fixation for vaginal vault prolapse. Obstet Gynaecol
2001; 98: 40 – 44

Stepp K, Barber MD. Genital anatomic correlates; In: Pelvic Floor Dysfunction: A
Multidisciplinary Approach. London: Springer Verlag; 2005

Symmonds RE, Williams TJ, Lee RA. Posthysterectomy enterocele and vaginal vault
prolapse. Am J Obstet Gyaecol 1981; 140: 852- 59

Sze E H M, Karram M M. Transvaginal repair of vault prolapse: a review. Obstet

Gynaecol 1997; 89: 466-75

Tunuguntia H S, Gousse A E. Female Sexual Dysfunction Following Vaginal Surgery: A

Review. J Urol 2006; 175: 439-446

11

View publication stats