Vaginal Vault Prolapse
Vaginal Vault Prolapse
Vaginal Vault Prolapse
Review Article
Vaginal Vault Prolapse
Azubuike Uzoma and K. A. Farag
Barnsley Hospital, NHS Foundation Trust, Gawber Road, Barnsley S75 2EP, UK
Correspondence should be addressed to Azubuike Uzoma, [email protected]
Received 9 December 2008; Revised 30 March 2009; Accepted 17 June 2009
Recommended by Anthony O. Odibo
Introduction. Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on womens
quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism
for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualised,
taking into consideration the surgeons experience, patients age, comorbidities, previous surgery and sex life. Result. Preexisting
pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have
been advanced at hysterectomy to prevent vault prolapse. Studies have shown the McCalls culdoplasty under direct visualisation
to be superior. Vault prolapse repair rely on either the use of patients tissue or synthetic materials and can be carried out
abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures, with
literature in favour of abdominal sacrocolpopexy over sacrospinous fixation due to its reported higher success rate of about 90%.
Other less commonly performed procedures include uterosacral ligament suspension and illiococcygeal fixation, both of which
are equally eective, with the former having a high risk of ureteric injury. Colpoclesis will play a greater role in the future as the
aging population increases. Mesh procedures are gaining in popularity, and preliminary data from vaginal mesh procedures is
encouraging. Laparoscopic techniques require a high level of skill and experience. There are many controversies on the mechanism
of prolapse and management techniques, which we have tried to address in this article. Conclusion. As the aging population
increases, the incidence of prolapse will also rise, older techniques using native tissue will continue, while new techniques using
the mesh needs to be studied further. The later may well be the way forward in future.
Copyright 2009 A. Uzoma and K. A. Farag. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
1. Introduction
Vaginal vault prolapse has been defined by the International
Continence Society as descent of the vaginal cu below a
point that is 2 cm less than the total vaginal length above
the plane of the hymen [1]. It occurs when the upper vagina
bulges into or outside the vagina.
Coexistent pelvic floor defects which may be a cystocoele,
rectocoele or enterocoele are present in 72% of patients with
vault prolapse [2]. Prolapse does have a negative impact on
these womens quality of life due to associated urinary, anorectal, as well as coital dysfunction. It is therefore important
to counsel these women and carefully assess the defects of the
various vaginal compartments before planning management.
A clear understanding of the supporting mechanisms for
the uterus and the vagina is important in order to make
the right choice of the corrective procedure and also to
30.3%
33
6.1%
34
39.4%
2. Anatomic Background
The upper vagina, cervix, and uterus are attached to the
pelvic sidewalls by broad sheets of endopelvic fascia. These
sheets of tissue are usually referred to as the cardinal and
utero-sacral ligaments. They originate over the region of
the greater sciatic foramen and lateral sacrum, and insert
into the side of the cervix as well as the upper one-third
of the vagina. Although the cardinal and the utero-sacral
ligaments have separate names, they are actually a single
unit. The endo-opelvic fascia in this region consists mainly
of perivascular collagen and elastin but also contains a
considerable amount of nonvascular smooth muscle and the
autonomic nerves to the uterus and bladder. Below the level
of the uterus, the endo-opelvic fascia attaches the upper onethird of vagina to the pelvic sidewalls in the same way that
the cardinal and utero-sacral ligaments provide attachment
for the uterine cervix [5]. The middle one-third of the vagina
is attached more directly to the lateral pelvic sidewalls by
the pubocervical and rectovaginal fasciae, which are nothing
more than downward continuations of the cardinal and
uterosacral ligaments. These structures attach the lateral
margins of the vagina to the pelvic sidewalls on each side,
stretching the vagina from one side of the pelvis to the other
so that its anterior wall forms a horizontal sheet on which
the bladder rests. The posterior attachment of the vagina
to the pelvic sidewalls creates a similar sheet that prevents
the rectum from prolapsing forward. This is the rectovaginal
fascia.
On the other hand the muscular levator plate provides
indirect support for the upper genital tract by acting as
a platform against which the upper vagina and other
pelvic viscera are compressed during rises in intraabdominal
pressure. The levator plate is formed by the fusion of the right
and left bellies of the levator ani muscle behind the rectum
and anterior to the coccyx. Sublaxation of the levator plate
will cause it to act like a slide, down which the rectum and
upper genital tract may descend with rises in intraabdominal
pressure.
The cardinal and uterosacral ligaments form a complex
of visceral supporting tissues to the upper vagina and cervix
and, after hysterectomy, to the vaginal cu. They pull the
upper vagina horizontally back toward the sacrum and thus
3. Risk Factors
The risk of genital prolapse increases with increasing parity
and advancing age. Previous surgery to correct pelvic organ
support defects has been consistently identified as risk
factors for the development of pelvic organ prolapse. Several
other factors have also been implicated, including vaginal
versus abdominal delivery for term infant, hysterectomy,
congenital defects, races, lifestyle, and chronic disease that
increase intrabdominal pressure (e.g., chronic constipation,
pulmonary disease, and obesity). However the role of some
of these factors is not fully understood.
4. Childbirth
Women who had 4 or more vaginal deliveries have 12 times
more risk of genital prolapse [6]. From the literature, it
appears that vaginal delivery causes damage to the pudendal nerve and promotes the development of pelvic organ
prolapse. There are suggestions that instrumental vaginal
delivery, especially forceps delivery increase the risk [7].
Also it was demonstrated that Caesarean section can avoid
the pudendal nerve damage caused by vaginal delivery [8].
Inspite of the absence damage to the pudendal nerve at
caesarean section Maclennan et al. [9] showed that there was
no significant dierence in pelvic floor dysfunction between
caesarean section and vaginal delivery. However pelvic floor
dysfunction was significantly commoner following Instrumental delivery.
5. Age
Many literatures show increasing prevalence of pelvic organ
prolapse in an aged population [10]. It has been shown that
there is a 12% increase in the incidence of severe pelvic
organ prolapse with each year of advancing ae, or roughly
a doubling of the incidence for every decade of life [11].
7. Hysterectomy
There is no consensus on the role of hysterectomy as a cause
of subsequent development of pelvic organ prolapse.
The incidence of prolapse, which required surgical
correction following hysterectomy, is 3.6 per 1000 personyears of risk. The cumulative risk rises from 1% three years
after a hysterectomy to 5% 15 years after hysterectomy. Also
the risk of prolapse following hysterectomy is 5.5 times in
women whose initial hysterectomy was for genital prolapse
as opposed to other reasons. Some studies have reported an
incidence of up to 43% [3, 13].
Dallenbach et al. conducted a case control study involving 114 women who required pelvic organ prolapse surgery
after initial hysterectomy and found that risk factor included
preopertional prolapse grade 2 or more, 95% CI 1.348.2 and
history of vaginal delivery, 95% CI 1.319 [14]. Marchionni
et al. after following up 2670 women over 913-years (mean
11 years) also concluded that incidence of vaginal vault
prolapse was low when hysterectomy is performed in the
absence of defect in the pelvic support [15]. These support
the view that vault prolapse following hysterectomy is more
likely if there was pre-existing pelvic floor defect or prolapse.
3
physician may be dicult or inaccurate. There are validated,
reliable, and easily comprehensible questionnaires designed
to assess the severity of symptoms of prolapse and their
impact on quality of life. One very useful questionnaire is the
prolapse Quality-of-life Questionnaire [17].
Type
McCall culdoplasty (n = 33)
Moschcowitz (n = 33)
Simple closure of peritoneum (n = 34)
1 year
Stage 1 = 0
Stage 2 = 0
2 years
Stage 1 = 2
Stage 2 = 0
Stage 1 = 3
Stage 2 = 0
Stage 1 = 4
Stage 2 = 4
Stage 1 = 3
Stage 2 = 2
Stage 1 = 5
Stage 2 = 4
3-years
Stage 1 = 2
Stage 2 = 0
(P = .004)
Stage 1 = 4
Stage 2 = 6
Stage 1 = 8
Stage 2 = 5
5
The technique comprises a transverse incision on the
posterior vaginal wall 1.52 cm below the hysterectomy scar
line and opened anteroposteriorly. The enterocele sac is
placed backwards and allowed access to the laterally displaced
uterosacral ligaments. At this point the enterocele sac is
reduced with a purse string suture. The next step is making
bilateral incisions 0.5 cm long in the perianal skin at 4 and
8 oclock, halfway between the coccyx and external anal
sphincter. Having slid the conical head of the tunneller
subdermally to the level of 3 and 9 oclock, the handle
is lifted upward 90 degrees so that the head is parallel to
the floor. The shaft of the tunneller is then thrust forward
into the ischiorectal fossa. This action penetrates the levator
plate and brings the conical head into a position behind
the uterosacral ligament. Under direct vision, with finger
placed in the rectum to locate the position of the rectal wall,
the conical tip of the tunneller is gently inclined medially
towards the vaginal vault. The tip is then penetrating the
fascia adjoining the vagina and rectum. A 6 mm woven
nylon tape was threaded into the eye of the plastic insert
and brought into the transverse incision. The procedure is
repeated on the contralateral side, leaving the tape as a U
entirely unfixed at the sacral end. The tape is then sutured
to the vault at each corner at the estimated insertion site of
the uterosacral ligament. The tape is then gently stretched
by pulling on each perineal end, and left entirely free and
unfixed.
In his series of 75 patients Petros reported 5% recurrence
of vault prolapse at a follow up between 14 years, 16%
de novo anterior wall prolapse, and 4% partial rectocele
[42]. Rectal perforation during insertion of the tape was
reported in 2 patients, identified during the procedure and
had no long-term sequel. Current evidence on the ecacy
and safety of this procedure is inadequate. Few clinical data
are available on the success rate of this procedure, though a
recent report quoted a 75% improvement in vault prolapse
[43].
The National Institute for Health and Clinical Excellence
recommends that this procedure should only be used with
special arrangement in a clinical governance or research
setting [44].
6
of the vagina and distribution of tension over a larger
surface area. Previous authors have reported severe and
occasionally life-threatening haemorrhage from the preexistingsacral vessels, when sutures were placed in the hollow
of the sacrum [48, 49]. To reduce this risk the operative
technique was therefore modified and sutures placed more
proximally over the sacral promontory. Contrary to previous
reports, the point of sacral attachment does not aect the
vaginal axis and attachment to the sacral promontory allows
eective restoration of vaginal support, while maintaining
both vaginal capacity and coital function. [50, 51]. Most
surgeons will bury the mesh under the peritoneum to avoid
bowel erosion, while some do not and others will tunnel
the mesh from the vaginal vault to the sacral promontory
without dissecting the peritoneum. Which method is best
is still controversial. Dierent methods of mesh attachment
to the vagina have been described and to date these remain
very controversial. These include attaching a full length
of mesh to the whole length of the rectovaginal septum.
Another method involves a double attachment of the mesh
to the anterior and posterior vaginal surfaces with reported
good results. There are usually other associated defects like
anterior or posterior vaginal wall defect in varying degrees
with divided opinion and debate amongst surgeons on
completing it either vaginally or abdominally [34]. There
is no simple answer, but every patient has to be considered
individually and the associated defects assessed properly, so
that a clear plan of surgical repair can be agreed with the
patient bearing in mind other factors like coital function.
Consistent cure rate of more than 90% has been reported
[52], with some studies reporting up to 95% [53].
Mesh erosion following the use of polypropylene graft
was reported to complicate 22.7% of cases [54, 55]. This will
necessitate revision or removal of the mesh. In most of the
cases, this occurs at the vaginal vault resulting in dyspareunia
and vaginal discharge within the first six months. Mesh
erosion is usually predisposed to by marked scarring and
thinning of the vagina from previous vaginal repairs or a
combined abdominal hysterectomy and sacral colpopexy.
This problem can be eliminated by the use of donor fascia
lata or a xenograft.
This procedure has added advantage over the traditional
procedures because it maintains the normal axis of the
vagina, with preservation of maximal vaginal length which
is desirable for optimal sexual function. It also provides a
source of strength in patients with weak tissue or recurrent
prolapse [56]. For these reasons it is quite a fairly common
operation with 38% of surgeons in a national survey carrying
it out for vault prolapse [57]. It is further associated
with a lower rate of recurrent prolapse and dyspareunia
[58] which makes it popular choice amongst surgeons
especially in fit patients. Part of its drawback includes
the fact that it is performed via laparotomy with all the
associated risk of internal organ injury, longer operation
time and hospital stay, so these need to be balanced against
the benefits. In the very elderly with coexisting medical
pathology, the risk of laparotomy coupled with the extra risk
of general anaesthesia will make this procedure unsuitable
[56].
7
Table 3
Hb change g/dl
Number transfused
Dyspareunia
Febrile morbidity
Incontinence
Catheter duration >5 days
Time of recurrence in months
Vaginal (n = 42)
2.6 1
0
15%
(Sexually active n = 26)
4%
44%
75%
11.2 11.5
Abdominal (n = 38)
31
2
0%
(Sexually active n = 15)
8%
23% (P < .05)
48% (P < .05)
22.1 16.2 (P < .05)
14. Conclusion
Vault prolapse repair is based on use of native tissues or
synthetic materials. There is no consensus on the mechanism
and management of vault prolapse, but what is accepted
by all is the need to properly assess these patients, involve
them in the management and to agree on the type of surgery
that will be suitable for their own peculiar circumstance.
The mesh is gaining in popularity, but there are no studies
yet on its long term ecacy though initial results are very
encouraging.
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