Post-Hysterectomy Vaginal Vault Prolapse
Definition and Epidemiology
Post-hysterectomy vaginal vault prolapse (PHVP) is descent of the apex of the vagina (the vaginal vault, or cuff scar after hysterectomy) — corresponding to point C on the Pelvic Organ Prolapse Quantification (POP-Q) system. It arises from inadequate reattachment of the vault's supporting structures at the time of hysterectomy, or from weakening of pelvic support over time. Reported incidence varies widely across historical case series (0.2–43%); more recent data put it at 11.6% following hysterectomy for prolapse versus 1.8% for hysterectomy for other benign disease. Surgical repair rates are estimated at 6–8%.
Diagnosis and Investigation
- Classification: standardised classification systems should be used for assessment/documentation of prolapse, including vault prolapse [Grade D]. The ICS POP-Q system is the most comprehensive and widely used.
- Urodynamics: routine urodynamic testing is not recommended in women with PHVP [Grade B] — clinical assessment remains the most important tool, and preoperative testing does not reliably predict postoperative stress urinary incontinence (SUI).
- Clinicians should work within a pelvic floor multidisciplinary team (MDT) [good practice point].
- Quality-of-life assessment should use standardised tools [Grade C].
Prevention at Hysterectomy
- McCall culdoplasty at vaginal hysterectomy is effective in preventing subsequent PHVP [Grade B].
- Suturing the cardinal and uterosacral ligaments to the vaginal cuff is effective in preventing PHVP after both abdominal and vaginal hysterectomy [Grade B].
- Sacrospinous fixation (SSF) at vaginal hysterectomy should be considered when the vault descends to the introitus during closure [Grade C].
- Subtotal hysterectomy is not recommended as a means of preventing PHVP [Grade A] — it reduces some perioperative complications but is associated with more urinary incontinence and prolapse.
- Evidence on permanent versus absorbable sutures for vault support is inadequate/conflicting; permanent sutures carry high exposure rates [Grade C].
Conservative Management
- Pelvic floor muscle training (PFMT) is effective for stage I–II vaginal prolapse, including PHVP [Grade B] (evidence extrapolated from the POPPY trial, not PHVP-specific).
- Vaginal pessaries are an alternative treatment for stage II–IV PHVP [Grade B]. Gellhorn and ring pessaries show similar symptomatic improvement (PESSRI trial). Consider sexual function, need for regular changes, and complication risks (ulceration, bleeding, rare fistula).
Surgical Management
- Surgery should be offered to symptomatic women after appropriate counselling, and performed by an RCOG-accredited subspecialist urogynaecologist or equivalent.
- Open abdominal sacrocolpopexy (ASC) vs vaginal sacrospinous fixation (SSF): both are effective for primary PHVP [Grade A]. ASC has significantly lower rates of recurrent vault prolapse, dyspareunia, and postoperative SUI than SSF [Grade A], without lower reoperation rates or higher satisfaction. SSF allows earlier recovery [Grade A] but may be unsuitable in women with a short vagina or pre-existing dyspareunia.
- Laparoscopic/robotic sacrocolpopexy (LSC/RSC): LSC can be as effective as ASC in selected women [Grade B]; robotic sacrocolpopexy has limited evidence and should only be done within research/audit governance [Grade C].
- High uterosacral ligament suspension (HUSLS): first-line use only within research or prospective audit [Grade B]; risk of ureteric injury, especially laparoscopically [Grade C].
- Transvaginal mesh (TVM) kits: limited evidence does not support first-line use [Grade B]; if used, women must be counselled on the permanent nature of mesh and potential serious, long-term complications, with results audited nationally (e.g. BSUG database) and complications reported to the MHRA.
- Colpocleisis is a safe, effective option for frail women and/or those not wishing to retain sexual function [Grade C].
- Concomitant continence surgery: colposuspension at the time of sacrocolpopexy reduces postoperative symptomatic SUI in previously continent women [Grade B], but colposuspension at ASC is not effective treatment for pre-existing overt SUI [Grade B]; concomitant mid-urethral sling may be considered with vaginal approaches.
- Recurrent vault prolapse should be managed through a specialist MDT.
High-Yield Exam Points
- PHVP = descent of vault/point C on POP-Q; incidence ~11.6% after hysterectomy for prolapse vs 1.8% for benign disease
- Routine urodynamics NOT recommended in PHVP (Grade B) — clinical assessment is key
- McCall culdoplasty and cardinal/uterosacral ligament suture to the vault at hysterectomy both PREVENT PHVP (Grade B each)
- Subtotal hysterectomy does NOT prevent PHVP and is not recommended for this purpose (Grade A) — classic distractor
- ASC vs SSF: ASC = lower recurrence/dyspareunia/SUI but SSF = quicker recovery, avoid SSF in short vagina
- TVM kits are NOT first-line (Grade B) — mesh complications must be MHRA-reported and outcomes BSUG-audited
- Colpocleisis is reserved for frail women/those not wishing to retain sexual function
Source: RCOG Green-top Guideline No. 46 (RCOG/BSUG Joint Guideline) (July 2015 (2nd edition; first published 2007 as "The Management of Post Hysterectomy Vaginal Vault Prolapse"). No update published since — check the RCOG website to confirm this is still the current version.)
Read the original on rcog.org.uk
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