The vaginal vault, also known as the vaginal apex, is the uppermost section of the vagina and the deepest point of the canal within the pelvis. It provides significant anatomical support for surrounding organs. In individuals with an intact uterus, the cervix projects into this area, creating recesses called fornices. The vault’s structural integrity keeps the upper vagina in its correct position.
Anatomical Location and Structure
The vaginal vault is positioned deep within the pelvic cavity. Its stability relies on a complex arrangement of ligaments, fascia, and muscles that anchor the apex to the bony walls of the pelvis. This primary support is classified anatomically as Level I support of the pelvic floor.
Level I support is provided by the dense connective tissue of the uterosacral and cardinal ligament complex. These ligaments extend from the upper vagina and cervix, connecting to the sacrum and pelvic side walls, suspending the vault. The entire vagina is enveloped by the endopelvic fascia, a supportive layer of fibromuscular tissue that maintains the organ’s shape. The levator ani muscles, which form the bulk of the pelvic floor, reinforce this suspension.
The Vaginal Cuff Following Hysterectomy
The term “vaginal vault” often refers specifically to the “vaginal cuff” following a total hysterectomy, which involves the complete removal of the uterus and cervix. When the cervix is removed, the surgeon closes the top opening of the vagina to prevent abdominal contents from entering the canal.
This closure forms a scar or suture line called the vaginal cuff, which becomes the new apex of the vagina. It is created by stitching together the edges of the vaginal tissue where the cervix was attached. This structural change significantly alters the original support system, replacing the cervix’s anchor point with a surgical closure.
Surgeons often reattach support ligaments, particularly the uterosacral ligaments, to the vaginal cuff during the procedure to maintain its position and prevent prolapse. Despite these efforts, the cuff can become a point of weakness. A rare but serious complication is vaginal cuff dehiscence, where the closure separates, requiring immediate surgical repair.
Vaginal Vault Prolapse
Vaginal vault prolapse is a specific type of pelvic organ prolapse that occurs when the apex loses support and descends down the vaginal canal. This condition is almost exclusively seen after a hysterectomy and can be a delayed complication. The descent can range from a slight drop to a complete eversion, where the top of the vagina protrudes outside the body.
The condition involves damage or stretching to the Level I support structures and the pelvic floor. Childbirth, especially multiple vaginal deliveries, contributes to this weakening. Other factors include chronic straining from severe constipation or coughing, which increases downward pressure on the pelvic organs.
Aging and the associated loss of estrogen also play a role, as lower levels can lead to thinning and weakening of supportive tissues. Symptoms often include a feeling of pressure or heaviness in the pelvis, which worsens throughout the day or with physical activity. Individuals may report feeling a bulge or a sense that something is falling out.
Vault prolapse is frequently accompanied by other types of prolapse. These include a cystocele, where the bladder pushes into the anterior vaginal wall, or a rectocele, where the rectum bulges into the posterior wall. The condition allows surrounding organs to shift and descend, and it can also lead to sexual dysfunction or difficulty with bowel and bladder movements.
Treatment Options for Vault Prolapse
Management is determined by the severity of symptoms and the individual’s overall health. Non-surgical options are typically the first approach for mild to moderate cases, including using a pessary. A pessary is a removable device placed into the vagina to physically support the prolapsed tissue.
Pelvic floor physical therapy is another non-surgical option, focusing on strengthening the levator ani muscles to improve overall pelvic support. If symptoms are severe or conservative measures are unsuccessful, surgical intervention is considered. The goal of surgery is to re-suspend the vaginal apex to a stable structure within the pelvis.
Two common surgical procedures are sacrocolpopexy and sacrospinous fixation. Sacrocolpopexy is an abdominal procedure, often performed laparoscopically or robotically, that uses synthetic mesh to attach the vaginal cuff to the sacrum. Sacrospinous fixation is a vaginal procedure that attaches the apex to the sacrospinous ligament in the lower pelvis, offering a shorter operating time and faster recovery.