Pelvic organ prolapse (POP) is a common condition where one or more pelvic organs descend from their normal position. This occurs when the pelvic floor—a structure of muscles, ligaments, and connective tissues—loses its ability to provide adequate support. The pelvic floor holds the bladder, uterus, rectum, and vagina in place. When this support weakens, the organs can bulge into the vaginal canal. Vaginal Vault Prolapse (VVP) is a specific type of POP characterized by the descent of the upper portion of the vagina.
Understanding Vaginal Vault Prolapse
The “vaginal vault” refers to the uppermost, closed end of the vagina, where the cervix or uterus was formerly attached. In individuals who have not had a hysterectomy, this apex is supported by the uterus and a complex network of ligaments (e.g., uterosacral and cardinal ligaments). Vaginal Vault Prolapse (VVP) is the abnormal dropping of this apex or cuff scar toward the vaginal opening.
The condition almost exclusively occurs in women who have had a prior hysterectomy (surgical removal of the uterus). When the uterus is removed, the main central support structure and its strong suspensory ligaments are disconnected from the apex. Over time, the resulting vaginal cuff loses its tethering and begins to descend into the vaginal canal. This descent can cause the vagina to turn inside out, sometimes protruding completely outside the body.
VVP must be differentiated from other forms of prolapse defined by the bulging organ. A cystocele is the prolapse of the bladder into the anterior vaginal wall, while a rectocele is the prolapse of the rectum into the posterior vaginal wall. VVP, also known as apical prolapse, is the descent of the top of the vagina itself, and it frequently occurs alongside a cystocele or rectocele due to widespread loss of fascial support.
Primary Causes and Contributing Risk Factors
The single most significant causal factor for Vaginal Vault Prolapse is a previous hysterectomy. The uterus provides a strong anchor for the top of the vagina, and its removal leaves the vaginal apex vulnerable to descent. The risk of requiring surgical repair for VVP follows a significant percentage of hysterectomies, particularly those done for pre-existing prolapse.
Several other factors increase the risk by weakening pelvic support tissues or raising abdominal pressure. Advanced age and the loss of estrogen following menopause can weaken the collagen and connective tissues that provide structural integrity to the pelvic floor. Conditions that cause chronic straining or increased pressure repeatedly stress the weakened vaginal cuff.
This repeated pressure can come from chronic respiratory conditions that lead to persistent coughing (e.g., COPD). Chronic constipation, which requires forceful bearing down during bowel movements, is a major contributor to the breakdown of pelvic support. Obesity is another risk factor, as the excess weight places constant downward force on the pelvic organs. Genetic factors, specifically an inherent weakness in collagen, can also predispose an individual to VVP.
Recognizing Symptoms and Clinical Diagnosis
VVP symptoms vary based on the degree of descent and typically worsen throughout the day, particularly with physical activity. Patients often describe a feeling of pressure, heaviness, or a sensation that something is falling out of the vagina. In advanced cases, a visible or palpable bulge of tissue may be present at or outside the vaginal opening.
Many individuals experience discomfort during sexual intercourse (dyspareunia). Associated urinary and bowel symptoms are common because the prolapsing vault can distort the surrounding anatomy. These include difficulty completely emptying the bladder, a slow or weak urinary stream, or the need to manually support the prolapse to pass stool or urine (splinting).
Clinical diagnosis begins with a thorough pelvic examination. The examiner uses a speculum to visualize the vaginal walls and apex, often asking the patient to strain or cough to demonstrate the descent. The severity and location of the prolapse are objectively graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, which measures the descent of specific points relative to the hymen. Imaging, such as an MRI or ultrasound, may be used in complicated cases to assess for an associated enterocele (herniation of the small intestine into the top of the vagina).
Treatment Options for Restoration and Relief
Treatment for Vaginal Vault Prolapse is tailored to the individual’s symptoms, overall health, and the severity of the condition. Non-surgical management is typically the first approach for mild to moderate prolapse or for patients who wish to avoid surgery. Lifestyle modifications, such as achieving weight loss and managing chronic constipation through diet or medication, are crucial for reducing downward pressure on the pelvic floor.
Pelvic floor muscle training (Kegel exercises) can help strengthen the supporting muscles, though they are most effective for mild prolapse or as an adjunct to other therapies. A pessary is a common and effective non-surgical treatment; this removable silicone device is inserted into the vagina to physically support the prolapsed vault.
For significant or highly symptomatic VVP, surgical correction is the definitive treatment, aiming to suspend the vaginal vault back to its proper position. Sacrocolpopexy is one of the most successful and durable procedures, typically performed through an abdominal approach (often laparoscopically or robotically). This technique uses a synthetic mesh or tissue graft to attach the vaginal apex to the sacrum, providing strong, long-lasting suspension.
Alternatively, a transvaginal approach may be used, such as Native Tissue Repair, which attaches the vaginal cuff to strong, existing pelvic ligaments. Sacrospinous Ligament Fixation is a common example, where the apex is sutured to the sacrospinous ligaments. The choice of surgical method depends on the surgeon’s expertise, the patient’s anatomy, and whether other types of prolapse require concurrent repair. Recovery requires avoiding heavy lifting and strenuous activity for several weeks to allow proper tissue fixation.