Pelvic organ prolapse occurs when one or more pelvic organs, such as the bladder, uterus, or rectum, shift from their normal position. These organs are typically held in place by the pelvic floor, a supportive network of muscles and connective tissue. When this support system weakens or is damaged, the organs can descend into the vagina, creating a sensation of a bulge or pressure. Vaginal vault prolapse is a specific form of this issue, frequently affecting women who have undergone a hysterectomy.
Defining Vaginal Vault Prolapse
Vaginal vault prolapse occurs when the apex, or uppermost part, of the vagina descends toward the vaginal opening. In women who have had a hysterectomy, this area is often referred to as the vaginal cuff scar. This condition is classified as an apical prolapse, meaning it involves the top of the vagina. Normal support for the vault comes from strong ligaments and fascia, such as the uterosacral and cardinal ligament complexes, which tether the apex to the pelvic walls.
When these support structures lose integrity, the vaginal vault collapses into the vaginal canal. This descent can cause the vagina to turn inside out, and in severe cases, the tissue may protrude outside the vaginal opening. Vault prolapse is frequently accompanied by the prolapse of adjacent organs, such as the bladder (cystocele) or the rectum (rectocele), because the loss of apical support destabilizes the entire pelvic floor structure.
Identifying Causes and Risk Factors
The most significant factor increasing the risk of vaginal vault prolapse is a previous hysterectomy, the surgical removal of the uterus. The uterus provides a major structural anchor for the upper vagina, and its removal eliminates this support, leaving the vault vulnerable to descent. This risk is heightened if the supporting ligaments are not adequately reattached during the original procedure.
Chronic strain and pressure on the pelvic floor also contribute to the weakening of supportive tissues. This includes conditions that repeatedly increase intra-abdominal pressure, such as chronic constipation, persistent coughing, and regular heavy lifting. Another major risk factor involves a history of multiple vaginal deliveries, which can stretch and damage the pelvic floor muscles and nerves.
Advancing age and hormonal changes associated with menopause further contribute to the condition’s development. The decrease in estrogen levels following menopause can lead to a thinning and weakening of vaginal wall tissues, making them less resilient. Additionally, being overweight or obese places continuous stress on the pelvic floor, and some women may have a genetic predisposition for weaker connective tissue.
Recognizing the Symptoms
Symptoms of vaginal vault prolapse vary significantly, with some women experiencing no symptoms at all, especially in mild cases. The most common sensation is a feeling of pelvic pressure, heaviness, or a chronic dragging in the lower abdomen. Patients often describe this as feeling like they are sitting on a small ball or that something is falling out of the vagina.
As the prolapse progresses, a noticeable bulge or mass may appear inside or outside the vaginal opening. This manifestation often becomes more pronounced after prolonged standing or walking, as gravity increases the descent. Prolapse can also interfere with sexual function, causing discomfort or pain during intercourse (dyspareunia).
While the primary issue is the descent of the vaginal apex, the condition can also lead to secondary urinary and bowel issues due to the shifting of adjacent organs. These symptoms may include difficulty emptying the bladder, urinary urgency, increased frequency, or a sensation of incomplete bowel evacuation. In severe cases, women may need to physically push the bulging tissue back to allow for urination or a bowel movement.
Treatment Approaches
Management of vaginal vault prolapse is tailored to the severity of symptoms, patient’s age, and overall health. For women with mild symptoms, a watchful waiting approach combined with lifestyle modifications may be appropriate. Non-surgical options are the first line of treatment for those seeking to alleviate symptoms without undergoing surgery.
One common non-surgical intervention is the use of a pessary, a removable silicone device inserted into the vagina to physically support the prolapsed vault. Pessaries come in various shapes and sizes, such as ring or shelf types, and offer immediate symptom relief. They can serve as a long-term solution or a temporary measure before surgery. Pelvic floor physical therapy, including exercises like Kegels, is also used to strengthen surrounding muscles, though its effectiveness for advanced vault prolapse can be limited.
For more severe cases or when non-surgical treatments fail, surgical repair is recommended to restore the vault to its proper anatomical position. The surgical goal is to re-suspend the apex of the vagina to strong, supportive structures in the pelvis. The gold standard technique is abdominal sacrocolpopexy, which involves attaching the vaginal vault to the sacrum (tailbone), typically using a synthetic mesh for durable support.
Alternatively, procedures like sacrospinous ligament fixation are performed through a vaginal approach, attaching the vaginal apex to the sacrospinous ligament. The choice between a vaginal or abdominal approach depends on factors like the patient’s health and the surgeon’s experience. The aim of any surgical technique is to provide long-lasting support and improve the patient’s quality of life.