Vault Prolapse

What is a vault prolapse?

When the upper part of the vagina drops down from its usual position because of a failure of its supports, it is known as a vault prolapse. This is most often seen after a hysterectomy, although rarely it can be seen with the womb (uterus) still present. It occurs in 1-5 women out of a 100 after a hysterectomy and is 2-3 times more common when a hysterectomy has been performed for uterine/uterovaginal prolapse. Vault prolapse can occur months to years after the operation

Imagine a sock being turned inside out (see figure) and the top of the sock is the top of the vagina (vault). When the top of the vagina drops, depending on the degree it descends usually determines the grade of vault prolapse.

Often the bladder or bowel may be dragged down at the same time. So along with the vault prolapse, there may be associated vaginal prolapse known as a cystocele/urethrocele when the bladder is involved or an enterocele or rectocele when the bowel is involved. This may be seen in as many as 9 out of 10 women with a vault prolapse.

What are the symptoms of a vault prolapse?

In the early cases, there may be no symptoms at all. However, as the upper part of the vagina bulges out of the hymenal opening (introitus), symptoms are almost always present. These symptoms can sometimes cause a great deal of inconvenience and/or embarrassment to women.

There may be symptoms of feeling a lump down below, worse on prolonged standing or at the end of the day. The woman may notice that the lump reduces itself on lying down and that she sometimes has to replace this lump to be able to empty her bladder or bowel completely. The lump may cause difficulty in walking and standing and sometimes can bleed because of vaginal skin ulceration. Rarely, the entire vagina may turn itself inside out dragging the bladder or bowel with it (complete vaginal inversion).

There may be bladder symptoms, including urgency, urge or stress incontinence (involuntary loss of urine), frequency of passing urine and a feeling of incomplete emptying.

Bowel symptoms include urgency and a feeling of incomplete evacuation.

There may be difficulty in having satisfactory sexual intercourse.

Backache and a dragging heaviness may also be presenting symptoms.

Why does vault prolapse occur?

In a small number of women, especially after a hysterectomy, the supports of the upper vagina (uterosacral and cardinal ligaments) give way but the exact cause for this has not been determined. A number of risk factors, however, have been identified. These include age leading to reduction in tissue elasticity and collagen, the menopause causing lack of oestrogen hormone, having several vaginal deliveries, especially difficult labours, increased body weight which increases abdominal pressure making vaginal vault prolapse worse. A number of techniques exist to reduce the risk of vault prolapse at the initial surgery, but in spite of all measures taken to prevent this condition, vault prolapse can still occur because of a pre-existing pelvic floor defect, which is why vault prolapse is most common after hysterectomy for prolapse.

Is surgery the only answer?

Vault prolapse does not usually respond well to correction with a pessary. This is a plastic ring or shelf pessary that can sometimes be used to hold the upper vagina up. As the supports for the upper vagina have failed, it is not surprising that a pessary can’t help support the vaginal walls and the top of the vagina manages to drop down inspite of the pessary. It is usually not suitable for younger women and sexually active women, as it can interfere with sexual activity. The ring needs to be changed regularly every few months to avoid ulceration and vaginal discharge.

What about pelvic floor exercises?

Pelvic floor exercises need to be continued as far as possible to strengthen the pelvic floor before and after surgery, but just doing them on their own will not reverse the vault prolapse.

What is a sacrospinous fixation?

This is an operation to surgically correct a vault prolapse by hitching the top of the vaginal wall (vault) or the cervix to a stable ligament (sacrospinous ligament) that runs from the pelvic bone (ischial spine) to the backbone (sacrum) and is part of the pelvic floor. This allows the procedure to be done without any external cuts and is done through the vaginal approach, hence allowing quicker recovery. A cut is made in the posterior vaginal wall to allow access to the sacrospinous ligament and delayed absorbable sutures are placed carefully in the ligament, avoiding important nerves and blood vessels.

Will any other repair be carried out at the same time?

Depending on the findings at surgery, repair of other associated prolapse such as a cystocele/rectocele or enterocele will be undertaken.

What is the failure rate of sacrospinous fixation?

The operation is successful in over 80% of women. The usual failure rate quoted in literature is 20%. That is 2 out of 10 women will need further surgery for a recurrent vault prolapse. This failure rate will depend upon individual surgeon’s experience and may be much lower.

Usually, a different approach is chosen to correct recurrent vault prolapse and may involve an open abdominal or keyhole (laparoscopic) approach, often using a mesh.

Are there any other surgical procedures available to repair the vault prolapse?

Yes, there are procedures such as abdominal or laparoscopic (keyhole) sacrocolpopexy which use the abdominal route and often use a mesh (artificial material) to strengthen the prolapse. Very old or infrm women may have a procedure where the vagina is closed off (Colpocleisis). There is no absolute best surgical operation to correct a vault prolapse and the choice of surgery depends upon the patient’s age, risk factors, need for sexual function, anaesthetic risks and the surgeon’s experience.

What would happen if I did not have surgery?

Surgery to repair vault prolapse is elective surgery and should be considered only if the woman is symptomatic and fully understands the operative procedure and its attendant risks. Sometimes, a mild vault prolapse will need no intervention and may never become symptomatic, especially if normal body weight is maintained, heavy lifting avoided and pelvic floor exercises are done regularly. However, most women usually present only when they have already developed symptoms and these can get worse with time. Timing and decision for surgery will be carefully considered by detailed consultations between the patient and the surgeon, weighing the benefits and risks of surgery.

What are the possible risks of surgery?

Sacrospinous fixation is a safe procedure, but like any other major operation, comes with some risks. There may be a risk of infection, heavy bleeding (especially pudendal blood vessels) or nerve injury (damage to pudendal or sciatic nerves) but these risks are uncommon and usually occur in less than one in a hundred cases. A blood transfusion or an open operation (laparotomy) may be needed to control the bleeding. This is very rare. Very rarely, the stitch may have to be removed.

There is also a risk of bladder, ureter and bowel injury because of close proximity of these structures to the vagina. However, all possible precautions are taken to keep complications to a minimum (less than one in a hundred cases)

Some women (1 in 10 women) may have hip or buttock pain after the stitch is placed in the sacrospinous ligament. This will usually subside with painkillers and over 8-10 weeks after the operation.

If there is heavy bleeding or an offensive discharge after you return home and you are concerned, you must contact the hospital or your doctor, as you may need further attention or antibiotics.

Sexual function is usually much improved after a sacrospinous fixation as the length of the vagina is restored and maintained. However, very rarely it may be difficult to have successful intercourse because of too tight a repair.

Sometimes, a few months or years after the operation, an anterior wall prolapse (cystocele) may be revealed that was not apparent at the time of the surgery. This may need a further operation if it becomes symptomatic. Also, urinary stress incontinence that was previously not a problem may be revealed post operatively on correction of the vault prolapse. This will then need to be managed appropriately, depending on the symptoms.

Will I need to have a general anaesthetic for the sacrospinous fixation?

This will depend on a discussion between the anaesthetist and yourself, taking into account your risk factors, your wishes and your general health. It is possible to do this operation successfully using a regional anaesthetic (Spinal or epidural). This is especially recommended when women are not particularly suited to have a general anaesthetic, for example elderly infirm women, chronic smokers or very overweight women. Most women however opt to go to sleep but they then also have a caudal anaesthetic (injection in your lower back) which helps with pain relief and to reduce blood loss.

Will I need a catheter and a vaginal pack after the sacrospinous operation?

Yes, an indwelling catheter will be left in the bladder for 1-2 days, depending on the extent of the repair. It will be checked that you are passing urine normally before you are discharged home. A vaginal pack to apply pressure and prevent post operative oozing may be inserted and is usually removed in 24 hours.

An intraoperative antibiotic is usually given to reduce your risk of infection.

A laxative may also be prescribed after surgery to avoid constipation and you should resume a healthy diet rich in fruit and vegetables to reduce your risk of developing recurrent prolapse in the future.

Early mobility after the operation and avoiding chronic cough will also help recovery. Stopping smoking will reduce coughing and hence reduce future risk of recurrence of prolapse.

What can I do to help myself before the operation?

Before any major surgery, it is advisable to try and get as fit for surgery as possible.

  • Getting Fit: Try to do regular exercise including swimming, walking or going to the gym as this will go a long way in helping your recovery after your operation. This also means trying to lose weight if you are overweight (this helps post operative recovery and reduces complications such as infection and anaesthetic problems that occur more frequently in overweight patients). Do take the advice of your doctor before you start any exercise programme so that you don’t hurt yourself.
  • Healthy Diet: Do make an effort to eat healthily (please refer to the leaflet on Dietary advice for Men and Women), increasing your intake of water, vegetables and fruit. Take iron rich foods such as nuts, broccoli and spinach.
  • Do stop smoking, seeking advice from your doctor, as this affects healing as well as increases your chance significantly of anaesthetic problems, especially lung infections and breathing problems post operatively.
  • Do stop medications such as blood thinning agents (Aspirin or Warfarin etc) only after discussion with your surgeon and your general practitioner as this can affect your surgery.
  • It is recommended that Hormone Replacement Therapy or hormone containing medications is stopped usually a month before any surgery, as this can increase your risks of developing Thrombosis after your operation. Do discuss details with your surgeon.
  • Do let your surgeon and anaesthetist know about the medications you are taking including homeopathic or alternative medicines as these can affect your operation adversely. You may need to stop them before your operation.
  • Do let your surgeon and anaesthetist know about any medical/anaesthetic or surgical information regarding yourself, as this may be helpful in avoiding problems during surgery and afterwards.

How long will I stay in hospital?

You will usually be discharged home in a few days after your operation; usually 48 to 72 hours, provided there have been no untoward complications. During your time in the hospital, you will be monitored for bleeding, infection and the nurses will help you become mobile as soon as possible. This reduces your risk of thrombosis.

Will I need Blood Thinning Injections and why do I need to wear stockings?

You will be usually given a blood thinning injection (for example Clexane), some hours after any major or long operation as well as stockings provided by the hospital, to try and reduce your risk of developing a clot after your operation. You must wear your stockings properly (the nurses will advise you) while you are in hospital and for at least 6 weeks after, until you have recovered fully from your operation and are fully mobile.

Do I need to fast before the operation?

Yes, if you are having a General anaesthetic, no food, even chewing gum for at least 6 hours before your procedure.

  • Evening Operation: No food or chewing gum after 10 am in the morning. You can drink water up to midday.
  • Morning Operation: No food or chewing gum after midnight before your procedure. You can drink water up to 6 am of the morning of your procedure.

Please take your essential medications as normal with a sip of water, unless advised by nurse or doctor.

Please click on this link to view frequently asked Anaesthetic questions

What can I expect after a Sacrospinous Fixation?

Vaginal bleeding

Some amount of vaginal bleeding and discharge is to be expected, usually for 6-8 weeks. Avoid tampons to reduce the risk of infection. As long as the bleeding is not heavy, or has an offensive smell or causes you concern, this is normal. If you are concerned, you must contact your own doctor or the hospital where you were operated on.

Pain

You will have very effective pain relief prescribed by your anaesthetist after the surgery. You will also be discharged with painkillers to take home with you. You must take these regularly as prescribed to keep pain under control, so that you can become mobile and active sooner rather than later.

Nausea

You may feel slightly nauseous or groggy just as you are coming out of your anaesthetic. This will pass soon and if needed, medication will be given to you to make you feel better. You will feel better once you start drinking and eating normally, which should usually be in a few hours after surgery, if all goes well.

Returning to work

You have had major surgery and it is recommended that you take at least 8 weeks off after surgery and see your GP before you return to work. Some women may need longer, as healing can depend on a number of factors. You must avoid heavy lifting during this time as also constipation and any factors that make coughing a problem, such as smoking. These will increase your risk of need for future surgery.

Other issues

You will be able to resume sexual intercourse usually in 6-8 weeks, after you have stopped bleeding and have no significant vaginal discharge. You may wish to wait to see your doctor first.

Other physical activities

You will be able to resume other activities such as sport, gardening and swimming usually 8 weeks after surgery. Do see your doctor before you commence any strenuous activity. Do avoid lifting heavy weights, constipation both of which can affect the success rate of your surgery. You can do gentle exercises, abdominal and pelvic floor exercises. You will usually be advised by your doctor or the physiotherapist.

When will I know the results of the procedure?

Following your operation, the findings will be discussed with you. Any necessary appointments will usually be made before you leave the hospital.

You will usually be seen in clinic for a follow up but you should contact the hospital if you have any urgent problems or your doctor or surgeon via the secretary if there are any queries prior to your appointment.

The operation and findings will be discussed in detail with you, usually in the clinic after your surgeon has checked your recovery and asked you regarding any symptoms. You will usually be examined to check healing and to assess success of the operation.

Your GP will be sent a letter with the findings from your procedure, and any results. You can be copied into this, if you so wish.

Nitu Bajekal (Consultant Gynaecologist, June 2010)