Enterocele and Massive Vaginal Eversion 

Updated: Apr 05, 2021
Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD 

Overview

Practice Essentials

Vaginal vault prolapse refers to significant descent of the vaginal apex following a hysterectomy. Although the term enterocele refers to a hernia in which peritoneum and abdominal intestinal contents are in direct contact with and displace the vaginal epithelium, with massive vaginal eversion it is often difficult to determine what lies behind the vagina (bladder, small intestine, colon, or rectum). The terms anterior vaginal wall prolapse, vaginal vault prolapse, and posterior vaginal wall prolapse are preferred for this reason.[1]

Pelvic organ prolapse (POP) is a common healthcare problem that many women live with for years, causing discomfort and affecting quality of life. Massive vaginal eversion, rare compared with mild to moderate POP, can lead to devastating consequences if not handled appropriately. This article will discuss the presentation, diagnosis, and treatment of POP, with a focus on massive vaginal eversion and enterocele (also known as advanced posthysterectomy pelvic organ prolapse).

Signs and symptoms

Symptoms include the following:

  • Prolapse: Vaginal bulging, pelvic pressure, vaginal bleeding, infection, discharge, tenderness, low back pain
  • Anorectal: Constipation, feeling of incomplete bowel emptying, straining to defecate, splinting or digitation, fecal urgency
  • Urinary: Incontinence, occult incontinence, urgency, frequency, recurrent urinary tract infection, slowed urinary stream, hesitancy, intermittent stream, splinting to micturate, dysuria 
  • Sexual: Dyspareunia, obstructed intercourse, vaginal laxity, loss of or decreased libido

The following are characteristic signs:

  • Advanced stage III C or IV C on the pelvic organ prolapse quantification system (POP-Q)
  • Breaks in the rectovaginal fascia often noted on digital rectovaginal examination
  • Levator and pelvic floor muscle defects, often with decreased Kegel strength
  • Occult urinary incontinence with prolapse reduction
  • Postvoid residual urine

See Presentation for more detail.

Presentation and diagnosis

The history and physical examination are generally all that are needed to obtain a diagnosis of vaginal vault eversion. Questions about the quality and duration of prolapse and urinary, fecal, and sexual symptoms should be asked and validated questionnaires given. The physical examination should focus on the stage of prolapse based on the POP-Q examination along with any obvious pathology, such as abdominal masses or ascites, vaginal wall breakdown, fistulas, or infection.

Imaging may be used to determine which organs are behind the vaginal wall prolapse or to examine for intra-abdominal pathology but should not routinely be employed.

See Workup for more detail.

Management

Conservative options are observation, pessary placement, and pelvic floor physical therapy.

The following are surgical treatment options:

  • Reconstructive: Sacrospinous ligament, uterosacral ligament, iliococcygeal fixation, sacral colpopexy
  • Obliterative: Colpocleisis of the vaginal vault

See Treatment for more detail.

 

 

 

Background

Massive vaginal vault prolapse is a devastating condition, with discomfort and genitourinary and defecatory abnormalities as the primary consequences. Pelvic organ prolapse is prevalent and associated with significant health-related quality of life and economic impact.[2] References to prolapse of the womb were first made in ancient Egypt, dating back to 1550 BC. Vaginal vault prolapse refers to significant descent of the vaginal apex following a hysterectomy (see the image below), whereas uterovaginal prolapse denotes apical prolapse of the cervix, uterus, and proximal vagina.  

Enterocele and massive vaginal eversion. Massive v Enterocele and massive vaginal eversion. Massive vaginal eversion in a patient with post hysterectomy vaginal vault prolapse.

These apical failures are often accompanied by anterior and/or posterior vaginal compartment prolapse with or without enterocele. While the term enterocele refers to a hernia in which peritoneum and abdominal intestinal contents are in direct contact with and displace the vaginal epithelium, with massive vaginal eversion it is often difficult to determine what lies behind the vagina (bladder, small intestine, colon, or rectum).  The terms anterior vaginal wall prolapse, vaginal vault (or apical) prolapse, and posterior vaginal wall prolapse are preferred for this reason, as they are descriptive of what is being observed.[1]   

Although this is not a new condition, apical prolapse is thought to be increasingly common as life expectancy increases. According to population projections from the US Census Bureau from 2010 to 2050 and published age-specific prevalence estimates for bothersome, symptomatic pelvic floor disorders and pelvic organ prolapse, the number of women with uterovaginal prolapse is expected to increase from 3.3 to 4.9 million from 2010 to 2050.[3]

Whereas complete vaginal eversion is obvious on physical examination, lesser degrees of prolapse and the presence of enterocele are more difficult to discern and require careful evaluation of all anterior, posterior, and apical compartment defects. Also, associated functional abnormalities, whether concurrent or potential, must be properly explored, evaluated, discussed with the patient, and considered in the context of management.

Problem

The International Urogynecological Association and International Continence Society define pelvic organ prolapse as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of vagina (vaginal vault or cuff scar after hysterectomy).[1, 4]  Indeed, a degree of uterine/vaginal descensus is present in many, if not most, women who are multiparous. Not all patients with prolapse are symptomatic, and the degree of prolapse often does not correlate with the degree of symptoms reported by the patient. Furthermore, pelvic floor–related symptoms do not predict the anatomic location of the prolapse especially in women with mild to moderate prolapse.[5] A systematic and comprehensive description of pelvic organ prolapse is useful to help document and communicate the severity of the problem, to establish treatment guidelines, and to improve the quality of research to standardizing definitions.

The pelvic organ prolapse quantification (POP-Q) system was developed to address deficiencies in measuring and reporting the extent of prolapse. Specific sites are defined separately on the anterior, posterior, and apical vaginal compartments and are measured with respect to a fixed reference point, the hymen. These measurements can then be categorized into an ordinal staging system ranging from 0-4:

  • Stage 0 denotes no prolapse (the apex can descend as far as 2 cm relative to the total vaginal length).
  • Stage 1 means that the most distal portion of the prolapse descends to a point more than 1 cm above the hymen.
  • Stage 2 denotes that the maximal extent of the prolapse is within 1 cm of the hymen (outside or inside the vagina).
  • Stage 3 means that the prolapse extends more than 1 cm beyond the hymen, but no more than within 2 cm of the total vaginal length.
  • Stage 4 denotes complete eversion, which is defined as extending to within 2 cm of the total vaginal length.

The POP-Q staging system has been validated and demonstrates good interobserver and intraobserver reliability.[4]  Although POP-Q staging adequately addresses the extent of prolapse, assumptions about which organ is behind the visualized bulge should be made with caution and should be made only after a complete evaluation.

Regarding enterocele, the definition is somewhat more difficult. Previous texts have defined enterocele as a hernia in which peritoneum and abdominal contents displace the vagina and is palpable within the cul-de-sac, as evaluated during a rectovaginal examination in the erect position. Patients with such findings may have a deep cul-de-sac and thus represent a normal variant.  A more anatomic definition was proposed by Richardson, who suggested that enterocele occurs when endopelvic fascia does not intervene between the peritoneum and vagina (see the image below).[6]  

Enterocele and massive vaginal eversion. Large api Enterocele and massive vaginal eversion. Large apical endopelvic fascial defect representing an enterocele demonstrated by the transabdominal route. Note the proximal cervicovaginal and rectovaginal fascia separate from the peritoneum.

 

 

Epidemiology

Prevalence

Pelvic organ prolapse (POP) when defined by symptoms has prevalence of 3-6% and up to 50% when based upon vaginal examination. Moreover, the prevalence of surgical correction of the prolapse varies widely from 6% to 18%, with the incidence of POP surgery from 1.5 to 1.8 per 1,000 women years and peaks in women aged 60-69 years.[7]

Swift reported on the frequency of different stages of pelvic organ prolapse in a routine gynecologic clinic population based upon the POP-Q staging system. Most women had stage 1 or stage 2 prolapse (43.3% and 47.7%, respectively), few women had stage 0 or stage 3 prolapse (6.4% and 2.6%, respectively), and none had stage 4 POP.[8]

Samuelsson et al reported a prevalence of 30.8% for any prolapse, using the Baden-Walker halfway system, in a study of the general population in Sweden.[9]  In a population-based Dutch study, the prevalence of POP based on POP-Q staging was as follows: stage 0 = 25.0%; stage I = 36.5%; stage II = 33%, stage III = 5.0%; stage IV = 0.5%.[10] .

Vaginal vault prolapse is thought to occur postoperatively in 0.5% of hysterectomy cases.[9]  A study found only a small difference in the risk of POP repair after hysterectomy when comparing the different hysterectomy types after restricting the analyses to women without POP at the time of hysterectomy. In this study, patients who underwent a vaginal hysterectomy had a slightly higher risk (odds ratio [OR], 1.25) of requiring a POP repair in the future compared with laparoscopic or open abdominal hysterectomies.[11]

Etiology

Current evidence supports a multifactorial etiology of POP. Swift reported that significant trends for increasing prolapse were found with advancing age, parity, postmenopausal status, previous hysterectomy, and prior corrective surgery for prolapse.[8]  Multivariate analysis in a study performed by Samuelsson et al revealed independent statistical associations with age, parity, maximal birth weight, and pelvic floor muscle strength.[9]  Such associations were not found regarding weight or hysterectomy status. Some epidemiologic evidence contradicts the opinion that female pelvic organ prolapse worsens with age.[9] Furthermore, Sze et al demonstrated that vaginal birth is not associated with POP-Q stages III and IV prolapse, but it is associated with an increase in POP-Q stage II.[12]

Chronic obstructive pulmonary disease and constipation have been associated with the development of POP. The mechanism is likely from an increase in abdominal pressure due to chronic coughing or straining with bowel movements contributing to prolapse development.[13]  Several studies have found an association between obesity and POP, with a body mass index (BMI) greater than 30 increasing the risk of prolapse up to 75%.[14]

It is well recognized that POP runs in families, giving credence to a hereditary contribution to the phenotype with some evidence that loci on chromosomes 10q and 17q may contribute to the etiology of prolapse.[15, 16, 17, 18]  Additionally, a recent paper reported on the first set of genome-wide significant POP variants identified through genome-wide associate study (GWAS).[19]  This study showed a genetic overlap between POP and several traits with similar pathophysiology pointing toward a role of estrogen exposure and connective tissue metabolism in the etiology of POP.

Racial differences have been reported for pelvic organ prolapse, although is not yet clear whether the differences are biological or sociocultural. Whitcomb et al showed that compared with African American women, Latina and white women had a 4 to 5 times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse at or beyond the hymen.[2] More recently, data obtained from African American and Hispanic women who were enrolled in the Women’s Health Initiative Hormone Therapy, with available genotyping data from Women’s Health Initiative-SHARe, suggest that common germ-line variations may contribute to an increased risk of POP among African Americans and Hispanics; however, further research with larger minority sample sizes is necessary to confirm this finding.[20]

Pathophysiology

As discussed, genetic factors may play a significant role in development of uterovaginal prolapse. Current basic science research suggests a molecular etiology of pelvic organ prolapse. Some studies demonstrate an increased rate of apoptosis and significant depletion of mitochondrial DNA in uterosacral ligaments in women with uterovaginal eversion.[21, 22]

The precise etiology of pelvic organ prolapse remains elusive. Additional theories include diminished sacral nerve function and/or defects in collagen. The pelvic floor is a unique and complex system constructed of skeletal and striated muscles, support and suspensory ligaments, fascial layers and an intricate neural network. When this system is damaged, pelvic floor failure may occur and pelvic organ prolapse ensues.[23]

DeLancey describes the anatomy of vaginal vault prolapse in terms of 3 levels of support (see the image below).[24]

Enterocele and massive vaginal eversion. Levels of Enterocele and massive vaginal eversion. Levels of support as described by DeLancey (1992). Note that level I refers to apical (or uterovaginal) support.

The 3 levels of support shown in the image are as follows:

  • Level I refers to the support of the upper vagina and cervix or the vaginal cuff (in a woman who has undergone total hysterectomy) by the cardinal-uterosacral ligament complex.

  • Level II denotes the lateral support of the mid vagina to the arcus tendineus fascia pelvis (white line).

  • Level III is represented by the fusion of tissue along the base of the urethra and the distal rectovaginal septum to the perineal body.

The conditions of enterocele and vaginal eversion represent failures of level I support, although other compartments may be affected. Uterovaginal prolapse does not denote intrinsic uterine disease and, therefore, may not necessarily require a hysterectomy in all cases. It should be noted, however, that no evidence proves or disproves the benefit of hysterectomy at the time of apical suspension.

Apical prolapse occurs because of tearing (or attenuation) of the cardinal-uterosacral ligament complex. This results in failure to support the upper vagina and/or uterus over the pelvic diaphragm, which should be in a near-horizontal plane in a woman in the erect position. Level I support is considered primary in maintaining adequate overall pelvic support.

Richardson describes an enterocele in anatomic terms, as a break in the integrity of endopelvic fascia at the vaginal apex (see the image below).[25]

Enterocele and massive vaginal eversion. Normal po Enterocele and massive vaginal eversion. Normal posthysterectomy vaginal vault. Note the presence of continuity of the endopelvic fascia at the vaginal apex, resulting from the fusion of cervicovaginal and rectovaginal fascia, and their fusion with the uterosacral ligament portion of endopelvic fascia.

Normally, post-hysterectomy enterocele is precluded by the apposition of pubocervical and rectovaginal fascia (collectively termed endopelvic fascia) at the apex. Anterior, apical, and posterior enteroceles have been described based upon the location of the fascial defect and the location of the ensuing herniation of bowel.

Apical enterocele is the most common enterocele and is primarily associated with post-hysterectomy vaginal vault prolapse. Apical enterocele may present with or without vaginal vault prolapse (see the images below).

Enterocele and massive vaginal eversion. Early ent Enterocele and massive vaginal eversion. Early enterocele with no vault prolapse. Note contact of peritoneal contents with vaginal epithelium, with no intervening endopelvic fascia.
Enterocele and massive vaginal eversion. Progressi Enterocele and massive vaginal eversion. Progressive enterocele now demonstrating true vaginal vault prolapse.
Enterocele and massive vaginal eversion. Massive e Enterocele and massive vaginal eversion. Massive enterocele with total vaginal vault prolapse.

Anterior enteroceles are rare and may occur following sacrospinous ligament fixation, when the proximal vagina is displaced posteriorly, creating a potential space in the anterior compartment. Because they present as a protrusion of the anterior vaginal wall, they may be the true etiology of some cystoceles. In women with an intact uterus, posterior enteroceles have been described. These are thought to be due to tearing of the proximal rectovaginal fascia from its attachment to the cardinal-uterosacral ligament complex, which results in descent of the peritoneal contents down the posterior aspect of the vagina (see the image below). On examination, this is often associated with loss of posterior vaginal rugae proximally.

Enterocele and massive vaginal eversion. Posterior Enterocele and massive vaginal eversion. Posterior enterocele in a patient with a uterus. Note that peritoneal contents have dissected between the vaginal skin and rectovaginal fascia through a proximal defect.

Posterior enterocele is usually accompanied by significant uterovaginal prolapse and prolapse of other compartments as well.[25]

Histologic studies by Tulikangas et al failed to find breaks in the fibromuscular layer in women who underwent surgical correction for enterocele compared with controls (women who did not have pelvic organ prolapse).[26] Admittedly, the authors' findings did not correlate with their subjective clinical findings of thinning of the vaginal wall in enteroceles. Hsu et al similarly found a lack of difference in vaginal wall thickness on MRI studies of patients with prolapse and their normal controls.[27] The numbers in these studies, however, were small and further investigation is needed before this controversy is fully resolved.  Nonetheless the authors believe that considering this theory in the context of surgical correction has merit and aids in properly managing these conditions.

Presentation

Patients may present with an obvious vaginal bulge that is visualized or felt by the patient. Patients may complain of the feeling that they are "sitting on a ball." Conversely, the patient may report a vague sense of pelvic heaviness, back pain, or a sensation that something is about to fall out. The bulging is often noted to be worse toward the end of the day, as compared with when the patient first wakes up, or when the patient is straining at defecation, urination, or with exercise. When vaginal epithelium remains exteriorized, it undergoes cornification and, often, ulceration, which can result in significant pain, vaginal bleeding, discharge, and infection.

Functional difficulties may be encountered during coitus, especially with massive vaginal eversion. Dyspareunia and obstructed intercourse may lead to decreased libido given negative body image. Defecation may be difficult; associated constipation is very common and patients may push inside the vagina (splinting/digitation) to evacuate their bowels. Patients may have to strain in order to complete a bowel movement or empty their bladder.

Incomplete bladder emptying also is common, and in severe cases, complete obstruction may occur. Voiding dysfunction may result in frequent urinary tract infections and urinary urgency or frequency with or without incontinence due to incomplete emptying. A slow stream with intermittent urine flow or hesitancy may be described by the patient and there may be a need for splinting to void. Due to kinking of the urethra, occult (potential) stress incontinence and even intrinsic sphincter deficiency may be present. A history of stress incontinence that spontaneously improved and/or resolved as the prolapse progressively worsened is especially concerning for the presence of occult stress incontinence. In a cross-sectional study, urinary urge incontinence was associated with anterior wall prolapse, whereas stress urinary incontinence was strongly linked to posterior wall prolapse.[5] Advanced pelvic prolapse may result in ureteral kinking with the potential for hydroureter.[28]

A systematic review showed that with stage II prolapse or higher, the risk of hydronephrosis can be up to 63.1%.[29]  This review concluded that hydronephrosis was more common in patients with more severe prolapse, in those with uterovaginal prolapse as opposed to vaginal vault prolapse, and in those with a longer duration of prolapse.

 

Indications

Treatment of pelvic organ prolapse is indicated if it is symptomatic or is causing associated morbidity. Asymptomatic prolapse, with minor degrees of protrusion that cause no other problems, must be discussed with the patient, but does not necessarily require treatment after ruling out significant associated functional problems (urinary retention, obstipation, etc). In the older population, even extensive prolapse may be reported as asymptomatic by the patient herself, but questioning her family or caregiver may reveal troublesome symptoms, and further evaluation may reveal significant resultant morbidity.

Offer conservative management to these patients as the initial management option. Conservative management may include observation with mild degrees of asymptomatic prolapse or a pessary fitting. Pelvic floor physical therapy is another conservative option and may be utilized with some success in mild to moderate prolapse for both objective and subjective symptoms.[30, 31, 32]  It should be noted that massive vaginal eversion cannot be treated or reversed with the use of pelvic floor exercises or physical therapy. Surgical management may be considered in appropriate candidates if conservative therapies fail or are declined by the patient.

Relevant Anatomy

The cardinal-uterosacral ligaments are localized thickenings of the peritoneum and connective tissue that invest the pelvic organs. The endopelvic fascia that is anterior to the vagina is called pubocervical; posteriorly, it is termed rectovaginal fascia or Denonvilliers fascia. Laterally, the endopelvic fascia attaches the vagina to the arcus tendineus fascia pelvis (white line) to provide lateral support to the mid-vaginal compartment, whereas the distal rectovaginal fascia attaches laterally to the aponeurosis of levator ani.[33]

The integrity of the vaginal apex following hysterectomy depends on the fusion of the pubocervical fascia with the rectovaginal fascia and support provided by the uterosacral ligaments. As described above, it is the gap between these two layers of fascia, no longer connected by the strength of the pericervical ring that allows for bowel to slip between the layers leading to an enterocele.[24]  Surgically, the uterosacral ligaments lie medial to the ureters in the pelvis. The proximal uterosacral ligament fans out and attaches to the lateral aspect of the sacrum. MRI studies show slight variations in the attachment of the uterosacral ligament, although most overlay the sacrospinous ligament/coccygeus muscle. The proximal vagina usually points into the hollow of the sacrum towards S3 and S4 and maintains a near-horizontal plane when the woman stands erect.

Although the term fascia is frequently used to denote the surgically significant layer used for pelvic reconstruction, histologically, it is a fibromuscular layer with varying amounts of smooth muscle, collagen, and elastin that is located deep to the epithelium.

Contraindications

Regarding treatments, pessary use is contraindicated in the presence of vaginal ulceration and breakdown or in the presence of an active vaginal infection. Severe vaginal atrophy is best treated prior to starting pessary use, in the absence of contraindications for estrogen use. Additionally, if a patient or caregiver is unable to remove and reinsert the pessary or bring the patient in for periodic vaginal examinations, a pessary should not be placed. Pelvic floor physical therapy has no absolute contraindications; however, it has not been found to be successful for high-grade prolapse. See Treatment/Medical Therapy for more details on treatment options.

The medical evaluation of a patient for surgical repair is a topic that is too broad for this article. However, one should tailor the proposed operation to the specific defects noted preoperatively, taking into consideration the patient's overall health and prior surgical history. The chosen approach, whether vaginal, abdominal, laparoscopic, or robotically assisted, should be selected with careful consideration of these patient-related points, in addition to the surgeon's level of skill and available local resources. Appropriate consultations and referrals during the preoperative evaluation can ensure the highest degree of success and safety.

Prognosis

The natural history of pelvic organ prolapse has been studied in prospective observational studies in postmenopausal women.[14]  In one study, there was both regression and progression of the prolapse in older women, but rates of vaginal descent progression were greater than regression. Increasing BMI and grand multiparity increase the risk of progression. A longitudinal analysis also suggested that vaginal descent progression over time is positively associated with various bladder, bowel, and prolapse symptoms in postmenopausal women with stage I-II prolapse.[34]

It should be noted that most studies following the natural history of pelvic organ prolapse focus on early-stage prolapse, and it is highly unlikely that massive vaginal eversion will regress with time. As mentioned above, if massive vaginal eversion is not treated appropriately, more severe sequelae such as ulceration, bleeding, hydronephrosis, and kidney damage, as well as vaginal vault evisceration, are possible.[35]

Massive vaginal eversion may present with acute findings that necessitate operative urgent/emergent management. Generally, complications such as ulceration, vaginal epithelial bleeding, and tenderness are likely to occur with long-standing advanced-stage prolapse.

Patient Education

Patients should be educated about their suspected etiology and physical examination findings. Often patients are reluctant to bring up issues such as pelvic organ prolapse to their primary care providers who would be able to refer them to a urogynecologist. If they have not had a vaginal examination, many patients may live with this condition for years with a great impact on their quality of life. It is important to validate their concerns and to provide both conservative and surgical options for treatment. 

The American Urogynecologic Society and the International Urogynecological Association have a large volume of patient resources that can be found at the following websites:

 

 

 

Presentation

History

A detailed history is required to evaluate the patient who presents with massive vaginal eversion. See Overview/Practice Essentials for a description of the symptoms with which a patient typically presents.

The duration of symptoms of the prolapse, with any information regarding functional problems that may be caused by the prolapse, should be ascertained. Ask patients about prior treatments they have attempted for the prolapse (conservative or surgical). Patients should be questioned about their urinary, bowel, and sexual function symptoms. This includes evaluation of urinary incontinence, storage and voiding dysfunction symptoms, accidental bowel leakage (previously known as fecal incontinence), and defecation dysfunction symptoms, as well as difficulties with sexual intercourse. The patient’s desire for future sexual activity should also be brought up, as this may guide future treatment or concomitant procedures. A detailed medical and surgical history should be obtained with a focus on prior pelvic surgeries and any significant gynecologic pathology. 

Essential to the preoperative evaluation and surgical decision-making is the review of any prior pelvic surgery, including obtaining operative reports, especially if surgery was performed for prior pelvic floor dysfunction. It is imperative to evaluate and stabilize the patient’s general health to assess for and mitigate any increased surgical risks. The patient's general medical comorbidities may be important in the decision of how to proceed with treatment options.

Validated standardized questionnaires should be used to assess the degree of bother from the prolapse as well as urinary, bowel, and sexual function and symptoms. While an in-depth discussion of the questionnaires is beyond the scope of this article, they are a useful adjunct to a history obtained in the office and are helpful for gauging pre- and post-treatment success as well as for research purposes.

Physical Examination

A commitment to treat all associated and relevant pelvic floor defects requires a careful and comprehensive urogynecologic examination.

A diligent search for all pelvic support defects and repair of these defects increases the likelihood of overall surgical success and patient satisfaction. The apical, anterior, and posterior compartments are evaluated separately, with and without straining and/or coughing in the supine position and again in the erect position if needed.

It is our preference to examine patients with a full bladder upon arrival to test for stress urinary incontinence with and without the prolapse reduced. The patient is then asked to void and the postvoid residual urine volume is measured either by straight catheterization or ultrasound (bladder scan). An abdominal examination should be performed because intra-abdominal masses or ascites may be a risk factor for or exacerbate existing pelvic organ prolapse (POP).[36] A comprehensive pelvic examination is then performed.

A standardized examination should be performed and documented. This examination begins on the outside of the vagina by examining the vulva, introitus, perineum, anal opening, urethral meatus, and any exteriorized prolapse. The prolapse should then be reduced and a careful speculum and bimanual examination performed. The authors prefer to use a half speculum to examine the anterior and posterior vaginal walls individually. The vaginal canal should be examined for evidence of prior surgical procedures such as scarring, suture or mesh exposure, and tenderness.

In cases of massive vaginal eversion, it may be difficult to reduce the prolapse. Use of lubricant or having the patient lie supine for a period of time before the examination may help with reduction. If it is not possible to reduce the prolapse in the office, an examination under anesthesia may be necessary. 

The pelvic organ prolapse quantification system (POP-Q) examination is helpful for quantifying the extent of prolapse and accurate follow-up (see Overview/Problem for more detail). Carefully evaluate the rectovaginal and pubocervical fascia for integrity, strength, and thickness along its entire length. Look for any signs of enterocele, such as bowel peristalsis, along the posterior vagina or near the apex. In addition, look for any obvious pubocervical/rectovaginal detachments at the periphery of an apical bulge as well as localized loss of rugations. Evaluate the cul-de-sac in the supine and standing positions, with and without Valsalva maneuvers. The levator muscles should be palpated for any tenderness and Kegel strength measured. A rectal examination should be performed to evaluate for any rectal masses, sphincter tone, and the presence of rectovaginal fistula defects. 

A neurologic examination to assess sacral dermatomes and reflexes is often performed.

 

Workup

Approach Considerations

Generally, the workup for massive vaginal eversion is based on the history and physical examination. Laboratory and imaging studies, procedures, and consultation with other specialties may be necessary at times, and they are discussed below. 

Laboratory Studies

A urinalysis is routinely performed to rule out infection and/or hematuria depending on the patient's symptoms when she initially presents for consultation. Culture is done as needed based on the urinalysis results and the patient's symptoms.

In the case of massive vaginal eversion, blood urea nitrogen (BUN) and creatinine levels may be elevated because of obstruction and therefore may need to be evaluated.

A standard preoperative laboratory evaluation should be performed to screen for anemia, metabolic abnormalities, and clotting problems depending on the patient's age and medical history. Surgical procedures for the repair of massive prolapse frequently involve elderly patients, and the operations are often prolonged, involving the Trendelenburg position with the legs elevated in stirrups. It is important to pay special attention to the effects on patients with cardiac or pulmonary conditions, and appropriate tests such as an electrocardiogram (ECG), complete blood cell (CBC) count, and clotting studies are warranted.

Imaging Studies

Imaging studies to consider for the workup of enterocele and massive vaginal eversion, but in our experience seldom used are the following:

  • Intravenous pyelogram (IVP)
  • Renal ultrasound scan
  • Computed tomography (CT) urogram

Intravenous pyelogram (IVP) for cases of severe prolapse to rule out hydronephrosis has been traditionally performed. A renal ultrasound scan is the least invasive modality to rule out significant hydronephrosis. A CT urogram can be obtained if further evaluation of the upper urinary tract and bladder is needed.·  

Controversy exists regarding the utility of other imaging studies. These may include dynamic cystoproctography, magnetic resonance imaging (MRI), 3D and 4D transperineal ultrasound, and even peritoneography (ie, the injection of radiographic dye into the peritoneal cavity).[37] These studies may be reserved for difficult and inconclusive cases, especially for the diagnosis of enterocele and sigmoidocele but are not routinely necessary.

In cases of massive vaginal eversion, MRI or ultrasound may be used to determine which organ (bladder, small or large bowel) lies behind the prolapsed vagina. In patients with lower stage prolapse, these studies may be used to evaluate the levator muscles, to predict recurrence risk after pelvic reconstructive surgery, or for research purposes.[38]

If intra-abdominal pathology is suspected, a CT scan of the abdomen and pelvis may be ordered to evaluate for ascites or a mass.

Diagnostic Procedures

Although controversial, multichannel urodynamic studies with prolapse reduction may be used to further evaluate the preoperative patient with significant prolapse.[39]  In the case of massive vaginal eversion, the urethra may be kinked by the prolapse, obstructing urinary incontinence, and prolapse reduction with a cough stress test (CST) should be performed in the office during the initial examination.

Studies often include initial uroflowmetry (with the prolapse not reduced) followed by insertion of a pessary or other methods to reduce the prolapse (speculum, Procto Swabs, etc), performance of complex cystometry, and a pressure-voiding study with or without electromyography (EMG). Although uroflowmetry is ideal, measuring the patient's voided volume and a subsequent postvoid residual by ultrasound or catheterization should suffice for the vast majority of cases. Postvoid residual volumes of less than 50-100 mL are considered normal range, if the patient voids at least 200 mL.[40]

With the prolapse reduced and pessary placement checked so it is not obstructing the urethra, complex cystometry with provocative maneuvers can be used to assess for occult stress incontinence.

When initial uroflowmetry is combined with a pressure-voiding study, information regarding the potential for postoperative obstructed voiding is obtained and may influence the choice of procedures.

Simple cystometry may also be performed in the office if multichannel urodynamics are not available.

Several diagnostic procedures are available for the assessment of accidental bowel leakage, which often coexists with prolapse and urinary incontinence and is beyond the scope of this article.

 

Treatment

Approach Considerations

The general approach to treatment should be based on the patient's medical and surgical history as well as symptoms, goals of care, and desire for sexual function. It is the clinician's responsibility to explain the various options that are available and guide patients toward a treatment that is best for the individual patient.

If necessary, consultation for bladder or bowel issues may be managed in a multidisciplinary effort with urology and colorectal surgery.

Conservative treatment with observation, pelvic floor physical therapy, or a pessary is often used as first-line management, with surgical options for those who fail or do not desire these options.

Currently, no medications are used to reverse the process of pelvic organ prolapse. Medications such as vaginal estrogen, lubricants, and barrier ointments may be used to alleviate symptoms and to prevent the breakdown of the vaginal epithelium.

Surgical options include reconstructive and obliterative procedures. Vaginal approaches, traditionally using native tissue, have good results and may be offered to patients, especially those who have a complicated surgical history or who may not tolerate an abdominal procedure. These approaches include the uterosacral ligament, sacrospinous ligament, and iliococcygeus fixation. Abdominal sacral colpopexy is considered the gold standard for reconstructive repair, with minimally invasive sacral colpopexy shown to be as effective.[41]

Obliterative procedures have excellent results, but patients will not have functional use of the vagina for penetrative intercourse. This option may be offered to all patients but is particularly useful in older patients with high surgical risk, which reduces the likelihood of subsequent regret.

Although transvaginal mesh with or without kits gained popularity during the mid 2000s, many products were removed from the market following the 2011 US Food and Drug Administration (FDA) announcement that identified serious safety and effectiveness concerns.[42]  In 2016, surgical mesh products for transvaginal repair of pelvic organ prolapse (POP) were reclassified as class 3 products (high risk).

In April 2019, manufacturers of all transvaginal mesh products indicated for transvaginal repair of POP were ordered by the FDA to halt the sale and distribution of these products in the United States.[43]  It was determined that the premarket approval applications failed to demonstrate an acceptable long-term benefit-to-risk profile for surgery compared with transvaginal native tissue prolapse repair, which is the standard for class 3 surgical devices. This FDA announcement does not apply to transabdominal mesh for prolapse repair (eg, sacral colpopexy) nor mesh placed transvaginally for the treatment of stress urinary incontinence (also known as midurethral slings).

Medical Therapy

Supporting the epithelial environment in the vagina with estrogen, if no contraindication exists, helps minor symptoms of vaginal irritation and discomfort. Estrogen assists the healing process if ulceration is present and prepares the vagina for subsequent pessary use. Topical preparations are preferred because of their rapid effect and limited systemic absorption. The authors use conjugated equine estrogens or estradiol cream 2-3 times a week for at least 4-6 weeks until an effect can be noted. This will only help with symptomatology and does not treat the prolapse itself. 

A pessary may be offered as primary treatment or to temporize until surgery for the prolapse can be completed. The primary indication for fitting a pessary is the nonsurgical relief of symptoms associated with pelvic organ prolapse. In a long-term assessment of quality of life, Tenfelde et al report improved quality of life with the use of pessaries over a mean of 4½ years (range of 1-15).[44]

Many different types of pessaries are available and used for prolapse (see image below).

Enterocele and massive vaginal eversion.  A variet Enterocele and massive vaginal eversion. A variety of pessaries that are available for the treatment of pelvic organ prolapse.

In a survey among American Urogynecologic Society (AUGS) members, 78% of providers tailored their choice of pessary to the specific pelvic support defect. Most respondents generally favored a space-occupying rather than supportive pessary.[45]  Supportive pessaries are defined as those that involve a spring mechanism (ring, Gehrung, lever-type pessary) and are thought to be supported by the symphysis pubis. Space-occupying pessaries are defined as supported by the creation of suction between the pessary and vaginal wall (eg, cube) or by providing a diameter larger than the genital hiatus (donut, InflatoBall, Shaatz) or by both mechanisms (Gellhorn).

A prospective study conducted by Wu et al identified younger age, higher parity, a history of pelvic surgery, and stress urinary incontinence as characteristics associated with initial failure of pessary fitting. Interestingly, the degree of pelvic organ prolapse, hormone replacement therapy, and adequacy of perineal body did not predict failure of initial fitting, but a short vagina was a risk factor for unsuccessful pessary use.[46, 47] Maintaining pessary rates vary from 41% to 64%, and the reasons for discontinuation are usually associated with inconvenience or inadequate relief of symptoms (40%), difficulty in removal (23%), pessary fell out (6%), and inability to urinate (5%).[48]

Longitudinal data from the US Centers for Medicare and Medicaid Service over a 9-year period on 4,019 women with diagnosed pelvic organ prolapse demonstrated a pessary continuation rate of 69%, with 3% developing vesicovaginal or rectovaginal fistulas and 5% having a mechanical genitourinary device complication. Twelve percent of women underwent surgery for prolapse repair by 1 year, with 24% by 9 years.[49]  Studies have shown that the duration of use is longest with Gellhorn pessaries, in older patients, and with the use of vaginal estrogen.[50]

Evaluation of vaginal epithelium to assess estrogen status is necessary and vital in order to prevent pessary-associated erosion and ulceration in an atrophic vagina. Thus, the use of concurrent vaginal estrogen therapy is recommended in the absence of contraindications.[45]  

Patients who choose a pessary as treatment of their prolapse may be followed closely and examined at regular intervals. Common complications of long-term pessary use include vaginal discharge and bleeding, and epithelial erosion/abrasion. Serious complications of pessary use are usually seen in neglected patients and can include infections, fistulas, complete erosions, or incarcerations.  With that said, it is safe for patients to maintain their own pessaries if they have the dexterity and desire.[51]

As previously stated, pelvic floor physical therapy is also a conservative treatment for pelvic organ prolapse in the early stages; however, it is unlikely to help in cases of massive vaginal eversion. 

Surgical Therapy

Surgery to repair enterocele and apical prolapse should address the underlying defect-specific pathophysiology of the patient's condition and should restore normal anatomy. This includes addressing all 3 levels of vaginal support as discussed previously (see Overview/Pathophysiology), with restoration of the normal vaginal axis and the integrity of the endopelvic fascia in all of its compartments.

There are several options for the treatment of vaginal eversion. Changes and modifications have been made to the original procedures; however, the paramount principles are still present and include the attachment of the vaginal apex to level I support. Therefore, this manuscript is limited to discussing these surgical principles as they relate to management of the failure of level I (apical) support.

Pelvic reconstructive procedures can be vaginal, abdominal, laparoscopic, robot-assisted, or a combination of these. Surgical techniques can be reconstructive, with the aim of restoring anatomy and maintaining the potential for coitus, or can be obliterative that by definition eliminate prolapse at the expense of future coital function.

The goals of surgical treatment of vaginal eversion include, but are not limited to improvement of quality of life, restoration of anatomy (with the exception of colpocleisis of the vaginal vault), and prevention of reoccurrence of prolapse.

Preoperative Details

Preoperative workup is dependent on patient medical comorbidities and is beyond the scope of this article.  This has been discussed briefly in Workup/Laboratory Studies and Workup/Imaging Studies.

Preoperative bowel preparation was historically employed. However, a single-blind, randomized, controlled trial of mechanical bowel preparation conferred no benefit regarding surgeons' intraoperative assessment of the operative field. Furthermore, it noted decreased patient satisfaction, and increased abdominal symptoms in the postoperative period in patients who underwent bowel preparation before reconstructive vaginal prolapse surgery.[52]

A first-generation cephalosporin is administered as a preoperative antibiotic prior to the time of the first incision; alternatives exist in the case of allergies.[53]  Patients are typically placed in lithotomy position with stirrups to allow access to the vaginal canal and/or abdomen depending on the procedure. All reconstructive procedures begin with careful examination under anesthesia, and a Foley catheter is placed after the patient is appropriately prepped and draped. 

Intraoperative Details

When including hysterectomy as a treatment modality for uterovaginal prolapse, preservation, restoration, and strengthening of pelvic support is of primary importance in order to avoid future vaginal vault prolapse.[54] Attention should be paid to reattachment of the cardinal-uterosacral ligament complex to the posterolateral vaginal apex, with a uterosacral ligament attachment thus reestablishing its continuity with the rectovaginal fascia. The use of permanent sutures for the uterosacral ligament colpopexy has been traditionally advocated. Another option is to use prolonged delayed absorbable suture, which can avoid some of the post-surgical problems encountered with suture exposure and formation of granulation tissue at the vaginal apex. If the uterosacral ligaments are of insufficient strength, one may consider a sacrospinous ligament fixation or abdominal sacral colpopexy instead.

Culdoplasty

Culdoplasty is performed per surgeon preference. Traditional culdoplasties include the McCall, Moschcowitz, and Halban methods. Although not idescribed in detail in this article, the McCall culdoplasty approximates (plicates) the uterosacral ligaments in the midline. The external McCall stitch also incorporates the posterior vaginal apex. The Moschcowitz culdoplasty closes the pelvic peritoneum with purse-string sutures that incorporate both anterior and posterior peritoneum along with the uterosacral ligaments. The Halban culdoplasty shortens each uterosacral ligament using a reefing stitch, with vertical purse-string sutures interposed between the uterosacral sutures. Other procedures exist but are generally variations of these procedures. Culdoplasty serves to close the posterior cul-de-sac and further direct the vaginal apex toward the hollow of the sacrum. It does not, however, address the underlying endopelvic fascial defects at the vaginal apex, as discussed previously and therefore have been abandoned by some.

Adequate closure of the cuff serves to reestablish continuity of the endopelvic fascia at the apex by reapproximating pubocervical fascia with rectovaginal fascia at the most proximal end. The combined effect of proper orientation of the upper vagina in a near-horizontal plane (in the erect position) and the reestablishment of endopelvic fascial integrity as described constitutes both the treatment and prevention of enterocele. All significant pelvic floor defects need to be addressed during this surgery to decrease the likelihood of recurrence. Repair of other pelvic floor defects may be performed vaginally and may include anterior repair, paravaginal repair, posterior repair, rectovaginal septal reconstruction, and/or perineal repair as needed.

Vaginal approaches

Vaginal approaches to reconstruction of the prolapsed vaginal vault (following prior hysterectomy) include sacrospinous ligament fixation (unilateral or bilateral), bilateral iliococcygeus fascia suspension, or uterosacral vaginal vault suspension. Each of these reconstructive procedures addresses level I (apical) support. 

Sacrospinous ligament fixation begins with incision of the vagina along the anterior or posterior wall, or at the apex depending on the technique.[55, 56]  If an enterocele is encountered, it may be completely dissected and opened. The bowel contents are reduced, and the redundant peritoneum is excised. Alternatively, the sac may be left as is, since the most important part of the repair is the proper identification and reapproximation of the endopelvic fascial defect at the apex. Regardless of vaginal incision (anterior, posterior, apical) the vaginal epithelium is dissected away from the underlying connective tissue and the pararectal space is entered in a position overlying the ischial spine. The space is developed, the sacrospinous ligament within the coccygeus muscle is palpated, and the surrounding area is cleared off gently.  Several instruments are available to penetrate the ligament for adequate suspension, including the Deschamps ligature carrier, the Miya Hook, the Nichols-Veronikis ligature carrier, the Capio device (see image below), and the EndoStitch.

Enterocele and massive vaginal eversion. Sacrospin Enterocele and massive vaginal eversion. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier.

Take care to avoid injury to the inferior gluteal artery, pudendal neurovascular bundle, and the sciatic nerve (see image below) by staying inferior and medial along the ligament.

Enterocele and massive vaginal eversion. The anato Enterocele and massive vaginal eversion. The anatomy surrounding the right ischial spine.

Avoid dissection superior to the coccygeus muscle and lateral to the ischial spine. Do not place retractors beyond the sacrospinous ligament and never pass the ligature carrier/needle posterior to the ligament because of risk of vascular injury of the inferior gluteal artery. The ligature carrier should pierce the ligament 1.5-2 finger breadths (2-3 cm) medial to the ischial spine, without encircling the coccygeus muscle (see image below).

Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the pudendal neurovascular bundle at the lateral aspect of the sacrospinous ligament. Also note the proper penetration of the suture into the body of the coccygeus muscle.

Permanent, delayed absorbable, or a combination of both suture types (see image below) may be used. They are sutured to the vagina, incorporating endopelvic fascia.  If permanent sutures are used, excluding vaginal epithelium is important because of the high incidence of granulation tissue at the site of the surgical knots.  Avoid suture bridging when tying down these sutures.

Enterocele and massive vaginal eversion. Following Enterocele and massive vaginal eversion. Following penetration of the sacrospinous ligament, the permanent suture (on the left) is attached to the posterior vagina by a figure-eight stitch, incorporating rectovaginal fascia but not penetrating the epithelium. Once this stitch is tied, a pulley has been created whereby the vagina can be drawn up to the ligament by pulling on the free suture and then tied down. The delayed absorbable suture is driven through-and-through and is tied on the vagina.

This repair was traditionally performed in a unilateral fashion to the right sacropspinous ligament. Newer techniques such as the Michigan Four-Wall technique expand upon traditional principles with some new modifications.[55]  Some physicians have advocated bilateral sacrospinous ligament fixation.[57] The authors prefer bilateral sacrospinous attachment in defect-directed repair and reconstruction of the rectovaginal septum when adequate uterosacral ligaments are not found. Exercise clinical judgment intraoperatively to determine whether this can be accomplished without undue tension. Consider the potential benefits in view of the potential increase in risk, both from intraoperative injury and the long-term effect on vaginal anatomy. If bilateral sacrospinous ligament fixation is utilized, the anterior and posterior transverse fascial edges should be approximated in the midline to complete the repair eliminating and preventing future enterocele.

Uterosacral vaginal vault suspension with fascial reconstruction aims to restore normal level I anatomy and is almost always done bilaterally (see image below).

Enterocele and massive vaginal eversion.  Uterosac Enterocele and massive vaginal eversion. Uterosacral ligament suspension.

This does not result in lateral deviation of the proximal vagina or in the posterior displacement observed with sacrospinous ligament fixation. Uterosacral ligament reattachment may be performed vaginally by the transperitoneal approach as depicted below, but it can also be accomplished retroperitoneally without the need to open the enterocele sac.[58, 59] It may be used immediately following a vaginal hysterectomy or for post-hysterectomy vaginal prolapse.

In posthysterectomy vaginal vault prolapse, the posterior vagina is opened, the enterocele sac is identified and excised, the peritoneal cavity is entered and the bowel packed away. It is the author's preference to utilize a lighted retractor to help with intraperitoneal visualization. The uterosacral ligaments are identified first distally and then more proximally, noting the level of the ischial spine. Identification may be aided by inserting a finger rectally and palpating the proximal rectovaginal fascia or by grasping the vaginal cuff with an Allis clamp and applying gentle traction toward the contralateral leg. The proximal aspect of the ligament at the level of the ischial spine is used for resuspension to exclude the defect that is responsible for the prolapse and constitutes a "high uterosacral ligament suspension (colpopexy)." Permanent or delayed absorbable sutures are used to grasp and hold each ligament separately; in our practice, 2 are placed on each side. 

After assessing for the integrity of ureteral function, the ligaments are sutured to the rectovaginal fascia laterally near the apex and also incorporated into the proximal lateral pubocervical fascia anteriorly with or without midline plication depending on defects present. The authors prefer at least 2 sutures in each uterosacral ligament with reapproximation of the pubocervical and rectovaginal fascia across the vaginal apex to correct and prevent enterocele. Posterior and perineal repair may be performed as needed. Take care to ensure the integrity of the ureters by carefully palpating the uterosacral ligament, staying medial and inferior to the ureter, and liberally using cystoscopy to verify adequate urine efflux.

Iliococcygeus fixation suspends the vaginal apex to the unilateral or bilateral parietal fascia of the iliococcygeus muscle (see image below).[60]  Because this procedure is carried out caudad to the ischial spine, there is minimal risk to the ureter and neurovascular structures in the pelvis.[61]  Similar to the sacrospinous ligament suspension, the pararectal space is approached through an incision in the posterior vaginal epithelium. The epithelium is dissected away from the underlying connective tissue with entry into the bilateral pararectal spaces. Once the ischial spine is identified, sutures can be placed through the fascia of the iliococcygeus muscle caudad to the ischial spines. The vaginal epithelium and underlying endopelvic fascia are then sutured bilaterally to the iliococcygeus fascia and the apex tied down. The authors prefer to use this technique if access to the sacrospinous ligaments is limited from scarring or if the vaginal epithelium is shortened. 

Enterocele and massive vaginal eversion. Iliococcy Enterocele and massive vaginal eversion. Iliococcygeus fixation.

Colpocleisis without hysterectomy (LeFort)

Colpocleisis without hysterectomy (LeFort) involves retention of the uterus, and therefore, although controversial, it is the author's preference to sample the endometrium either with dilatation and curettage (D&C) or preoperative endometrial biopsy.[62]   The procedure is relatively contraindicated in patients with postmenopausal bleeding. This procedure may be performed under local or regional anesthesia to accommodate a patient who is frail.

Rectangular strips of both anterior and posterior vagina are obtained, extending from 2 cm distal to the cervix to the level of the bladder neck anteriorly and similarly on the posterior vaginal wall. Sufficient vagina is left laterally to fashion bilateral canals for drainage (see image below).

Enterocele and massive vaginal eversion. LeFort co Enterocele and massive vaginal eversion. LeFort colpocleisis begins with dissection and excision of a rectangular patch of epithelium on both the anterior and posterior vagina. Gradual inversion of the vaginal tube is accomplished by interrupted sutures that approximate anterior to posterior. Reapproximation of the lateral vaginal edges serves to maintain the tunnels on either side of the repair. From Thompson JD. Surgical correction of defects in pelvic support. In: Rock JR, Thompson JD, eds. TeLinde's Operative Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997.

Dissection should be broad and leave adequate endopelvic fascia anteriorly and posteriorly to retain strong tissue for reapproximation. Excellent hemostasis is required and achieved by judicious electrocautery.

The anterior and posterior denuded vaginal walls are sutured with either an interrupted or continuous delayed absorbable suture in a progressive manner to invert the prolapsed vagina. The lateral vaginal edges are reapproximated so that lateral tunnels are formed throughout the length of the vagina on either side. If actual or occult incontinence has been demonstrated preoperatively, a retropubic or transobturator midurethral sling may be performed by adding a separate midline vaginal incision at this time and continuing as per routine for these procedures. 

For posthysterectomy vault prolapse, a colpocleisis of the vaginal vault is performed in a similar fashion, except that no epithelium-lined tunnels are created. Therefore the entire vaginal epithelium may be dissected off in strips, and the vaginal endopelvic fascia is progressively inverted by concentric purse-string sutures of delayed absorbable material once meticulous hemostasis is achieved. The urethra and bladder neck are managed in the same way as described for a LeFort procedure. 

Whether performing a LeFort or a colpocleisis of the vaginal vault, care must be exercised to not carry the anterior epithelial excision too far distal for fear of opening the bladder neck and urethra by the posterior displacement the anterior segment will undergo when the colpocleisis is complete. Severe postoperative urinary incontinence may result if this occurs.

Transvaginal mesh for POP repair

Trocar-based vaginal kits were previously popular in the management of vaginal vault prolapse in the beginning of this century and were advocated as a safe and durable treatment option for vaginal prolapse. Many of these kits were removed from the market in 2008, and trocar-less mesh kits were still being used. As noted above (see Treatment/Approach Considerations), the selling and distribution of all of these products was stopped by the FDA in April 2019.

It is still possible for a surgeon to fashion his or her own mesh to be placed transvaginally to augment a repair in the anterior or posterior compartment. This mesh is typically anchored to the sacrospinous ligaments. The topic of detailed mesh-based repairs is beyond the scope of this article.

Biologic grafts

Biologic grafts have also been employed for augmentation of pelvic organ prolapse. While these grafts are more commonly used in anterior or posterior repairs, they may be used as an adjunct during an apical vaginal vault repair.  Their use in anterior and posterior vaginal wall prolapse is beyond the scope of this article. These grafts may be categorized as follows[60] :

  • Autologous: From the patient's own tissue, typically rectus fascia or fascia lata
  • Allografts: From post-mortem tissue banks of human tissue
  • Xenografts: From other species such as porcine dermis, porcine small intestine, and bovine pericardium

Abdominal approaches

Abdominal approaches to vaginal vault suspension include sacral colpopexy or uterosacral reattachment. The abdominal approach allows for concomitant abdominal procedures to be performed, such as paravaginal repair, Burch colposuspension, or removal of adnexa (depending upon associated pelvic floor defects, preoperative urodynamics, concomitant pelvic pathology, and medical history). Occasionally, concurrent vaginal surgery is required to complete adequate reconstruction. In either technique, carefully exclude enterocele and repair the enterocele if found. When performing defect-specific repair, this is accomplished abdominally by incising the peritoneum at the vaginal cuff and identifying the endopelvic fascia. If a break is found, it is repaired with interrupted sutures (see image below). Conversely, a traditional Moschcowitz or Halban procedure may be completed, though this is non-anatomic and not our preferred technique.

Enterocele and massive vaginal eversion. Transabdo Enterocele and massive vaginal eversion. Transabdominal repair of the large enterocele noted in Image 2. Note interrupted permanent sutures used for repair.

Abdominal sacral colpopexy is defined as suspension of the vaginal apex to the anterior longitudinal ligament of the sacrum using a graft, with possible incorporation of the graft into the fibromuscular layer of the anterior and/or posterior vaginal walls.[60]   This may be performed with a biologic graft but is most often performed with a permanent type 1 polypropylene mesh.[63]  This is typically configured in a "Y" configuration, with the distal end of the graft attached to the anterior and posterior aspects of the vaginal cuff, the crux of the "Y" at the vaginal cuff, and the proximal (tail) end attached to the anterior longitudinal ligament. (see image below). There are several premade "Y" grafts available, or it may be fashioned in the operating room by multiple pieces of mesh and suture.

Enterocele and massive vaginal eversion. Mesh conf Enterocele and massive vaginal eversion. Mesh configuration for abdominal sacral colpopexy. Mesh may come preformed or made in the operating room from two pieces of polypropylene mesh. If so, the crux of the Y is formed by permanent sutures with the knots tied down on the side that faces the sacrum, not the vagina.

After entry into the peritoneal cavity, whether via laparotomy, laparoscopically, or robotically assisted, relevant landmarks are identified, including ureters, rectosigmoid, and bladder reflection. The rectosigmoid is retracted to the left side of the peritoneal cavity to gain access to the sacrum. The sacral promontory is identified, and the retroperitoneal space is entered with a window created over the anterior longitudinal ligament. Dissection is carried down to the S1-S2 vertebral level. At this point the peritoneum may be divided along the right pelvic side wall down to the vagina or a tunnel to the vaginal apex can be created. Care must be taken during these steps to avoid the rectosigmoid and the right ureter. Cautiously proceed with the dissection in the presacral space and pay attention to avoid damage to the middle sacral vessels. The bladder and rectum are then dissected from the anterior and posterior vagina, respectively. This vaginal dissection may be done prior to the sacral dissection depending on intra-abdominal pathology and surgeon preference.  

Each arm of the mesh is attached to the vagina with a variable number of interrupted permanent or delayed absorbable sutures, taking care to incorporate endopelvic fascia in each bite. The posterior mesh arm may be attached as low as the perineum for extra support termed "sacral colpoperineopexy."[60]  The proximal aspect of the mesh is attached to the anterior sacral fascia at the level of S1-S2 with 2-3 permanent sutures (see images below).

Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the anatomy of the lower presacral space. Take care to adequately mobilize the sigmoid colon and ensure the safety of the right ureter. Identification of the middle sacral vessels is important to avoid hemorrhage.
Enterocele and massive vaginal eversion. Note adeq Enterocele and massive vaginal eversion. Note adequate bites taken into the anterior sacral fascia at sacral level 2 (S2). Take care not to attach the mesh too high (towards the sacral promontory) so that the normal vaginal axis is maintained. Also, take care to avoid excess tension on the vagina.
Enterocele and massive vaginal eversion.  Note the Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum.

Attachment of the mesh to the sacral promontory may minimize vascular and/or neurologic injuries, but it also results in an unnatural anteflexion of the vaginal apex. Some have felt that this predisposes the posterior compartment to development or recurrence of enteroceles. There is also concern about the increased risk of spondylodiscitis if the promontory is chosen as the attachment site, and we avoid this level in our own practice. The anterior longitudinal ligament is 2 mm thick, and the sacral nerve roots are located 2.5 cm below the promontory and 2 cm to the right of midline; therefore, placement into the center of the ligament is critical while avoiding the middle sacral vessels.[64]

Reperitonealization is used to avoid subsequent entrapment of the bowel within the mesh. This may be accomplished by approximating the 2 sides of peritoneum previously dissected or by placing the mesh through the previously created tunnel, then fixing it to the sacrum with sutures. Ensure that there is no undue tension on the vagina with the mesh in place.

Data from the Colpopexy and Urinary Reduction Efforts (CARE) randomized trial evaluated the use of Burch colposuspension at the time of sacrocolpopexy in women who were stress continent. Patients who received a prophylactic Burch colposuspension were about half as likely to develop stress urinary incontinence after the surgery. No differences were noted in the development of postoperative urgency symptoms in the 2 groups.[65]

As mentioned above, sacral colpopexy has been reported via the laparoscopic approach with or without robotic assistance. These are useful surgical approaches if the surgeon takes care not to alter the operation in a way that would fundamentally change and weaken the reconstruction.

Advantages of robotic surgery include improved (3-dimensional) visualization of the operative field with increased dexterity allowing more precise movements.[66]  Data suggest that this approach combines the advantages of open sacrocolpopexy with decreased hospital stay, less blood loss, low complication and conversion rates, and high rates of patient satisfaction.[67, 68]

Studies showed that when the robotic approach is compared with traditional (“straight stick”) laparoscopy, it has similar outcomes but is noted to take longer and to be associated with significantly increased cost.[69]  

High uterosacral reattachment is performed using the same principles discussed previously under vaginal approaches. Reconstruction of the continuity of endopelvic fascia is the cornerstone of therapy. Maintain an adequate hiatus between the sacrum and vagina after the sutures are tied by allowing 2 finger breadths to leave sufficient space for the sigmoid colon. Avoid upward tension on the vagina.

As discussed previously, the uterosacral vaginal vault suspension with fascial reconstruction may be performed vaginally or abdominally. Using the same principles, this procedure is amenable to the laparoscopic approach as well (see image below).

Enterocele and massive vaginal eversion. Bilateral Enterocele and massive vaginal eversion. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus.

 

Postoperative Details

The authors strongly recommend following all reconstructive surgical procedures with cystoscopy for evaluation of bilateral ureteral patency and bladder integrity. Intraoperative identification and immediate repair of ureteral/bladder injury is associated with reduced morbidity and improved outcomes. A rectal examination should also be performed to evaluate for defects and to be sure there are no sutures in the rectum.

Traditionally, patients undergoing laparotomy for vaginal vault prolapse repair would spend at least 2 nights in the hospital, with slow return of feeding, ambulation, and removal of the Foley catheter. With advances in minimally invasive surgery and enhanced recovery protocols, patients now often spend 1 night in the hospital or are discharged home the same day of surgery without increased risk of complications.[70, 71]

Although postoperative care should be tailored for each patient based on her medical history and the procedure performed, enhanced recovery protocols should be employed during complex pelvic reconstruction or obliterative procedures.[71]  Some aspects of these protocols involve the use of multimodal anesthesia to avoid opioid use, maintaining euvolemia and basal body temperature, early feeding and catheter removal, and ambulation on the day of surgery.

Follow-up

Patients are usually seen 1-6 weeks after surgery for prolapse repair. It is our practice to have patients follow up in the office for a 2-week postoperative check followed by a 6-week visit. Typically, after this visit, they may be cleared to resume full functional activities, including intercourse. It is important to tailor follow-up based on a patient's medical/surgical history, the procedure performed and any complications encountered, and her ability to access the office. Telephone and telemedicine have been used in urogynecology with success; however, more robust data on postoperative outcomes are needed.[72, 73] For long-term follow-up, patients are observed every 6-12 months, as needed. This follow-up with pelvic organ prolapse quantification (POP-Q) examinations is important for research purposes in order to document long-term success rates and possible long-term complications.

For excellent patient education resources, see the Women's Health Center. Also, see the patient education article Prolapsed Uterus.

Diet

Dietary changes and the addition of fiber supplementation may be initiated based on patient bowel symptoms as an adjunct to medical or surgical management of prolapse. The details of these changes are beyond the scope of this article. After surgical treatment of prolapse, it is our practice to prescribe daily use of stool softeners for 1-2 months and laxatives as needed to avoid constipation and straining in the immediate postoperative period. After the resolution of the prolapse, there may be changes in bowel habits that can be addressed in subsequent visits. 

Complications

Hemorrhage; operative site infection; and damage to the bowel, bladder, and ureters are the most common complications during reconstructive pelvic surgery, regardless of the route or method chosen. Dyspareunia also may develop, especially when posterior vaginal incisions are employed. Additional complications shared by all pelvic surgeries, such as thromboembolism, ileus/bowel obstruction, cardiac events, or pneumonias, require meticulous preoperative and postoperative management and adequate prevention strategies. Of particular concern to the urogynecologist is the development of postoperative urinary retention and severe constipation, which are less affected by the actual vault suspension and more affected by the preoperative and postoperative management and concurrent surgical procedures.

Sacrospinous ligament fixation can result in severe hemorrhage from the inferior gluteal artery, internal pudendal vessels, or the hypogastric venous plexus. Damage to these structures is best avoided as delineated above (see Treatment/Intraoperative Details). In the event of such hemorrhage, initial packing is most beneficial, with individual and careful ligation using clips or suture. Hypogastric artery ligation is only helpful if the internal pudendal artery is hemorrhaging. The most common vessel injured is the inferior gluteal artery. Interventional radiology may also be useful for treatment of pelvic hemorrhage.[74]

Another complication of sacrospinous ligament fixation is buttock pain on the side of fixation. This occurs in 15% of patients and usually resolves spontaneously by 6 weeks, requiring reassurance and nonsteroidal anti-inflammatory agents, though persistent pain may occur in 4.3% of patients.[75]

Other possible complications of sacrospinous ligament fixation include damage to the sciatic nerve, rectal injury, vaginal stenosis, and subsequent defects of anterior compartments. Damage to the sciatic nerve is possible and necessitates removal of the offending suture. Rectal injury may occur and is best avoided by adequate medial retraction of the rectum during the procedure. Vaginal stenosis may occur if excessive amounts of the vagina are removed during anterior and/or posterior colporrhaphy concurrent with sacrospinous ligament fixation. Because of the posterior displacement of the upper vagina, patients are prone to subsequent anterior prolapse to the hymen at a rate of up to 13%.[75]

Postoperative pain is also a complication in uterosacral ligament suspension. In a large study, up to 6.9% of patients had pain in the immediate postoperative period; however, this percentage decreased to 0.5% at 6 weeks. Ureteral obstruction during the operative procedure is another possible complication of uterosacral suspension. This complication is typically caused by a kinking of the ureter with traction on the uterosacral ligament and surrounding peritoneum. The incidence has been found to be as high as 11% in some studies but is typically around 3-4%.[75]

Colpocleisis is a relatively safe procedure and, in fact, is used in patients who otherwise may not be good surgical candidates for more extensive reconstruction. The most common adverse event was urinary tract infection (34.7%) in a recent study. In this study, major adverse events were uncommon.[76] Immediate complications are rare but may include bleeding, infection, urinary retention, and urgency. Postoperative stress incontinence may occur in 10% of cases when the vesical neck and/or urethra are not adequately supported. To avoid this complication, if true occult or obvious stress urinary incontinence exists preoperatively, a midurethral sling may be included in the procedure.[77, 78]

Reported complications from vaginally placed mesh include infection, bleeding, and rectal lacerations. In addition, dyspareunia and mesh exposure through the vagina and erosions into adjacent organs may also occur.[79]  A complete description of these complications and their management is beyond the scope of this article. 

Abdominal sacral colpopexy may result in life-threatening hemorrhage from the presacral venous plexus, middle sacral, or iliac vessels. Such bleeding may be particularly difficult to control because of extensive anastomosis, lack of venous valves, and retraction of the vessels into the sacral bone when they are completely severed. Because of the likelihood that packing with laparotomy packs may exacerbate bleeding upon their removal and further shearing of these delicate veins, careful application of pressure with a gloved finger is the initial maneuver to arrest such hemorrhaging. Bleeding may be stopped by clips, cautery, or suture; maintain keen awareness of the location of the iliac vessels, ureters, and rectum. If these measures are unsuccessful, sterile stainless steel or titanium thumbtacks may be used at the point of bleeding from a retracted presacral vessel. Bone wax has also been used successfully in the management of such bleeding.[80]

Other early complications of abdominal sacral colpopexy include mesh infection/erosion, bowel obstruction, and ileus. Mesh erosion is a late complication and had previously been cited to occur in as many as 10% of cases.[81]  However, more recent studies using minimally invasive techinques and lightweight type 1 polypropylene mesh have shown these complications to be much lower.[82]  Suspect the diagnosis of mesh infection in a patient following abdominal sacral colpopexy with mesh at any interval when the patient reports persistent vaginal discharge, bleeding, and/or dyspareunia.

Conservative measures for mesh exposure, including applications of estrogen vaginal cream, may be attempted first. Partial mesh excision is also possible. Some physicians advocate an abdominal approach to remove the entire mesh. Dissection in this circumstance tends to be quite difficult because of scarring and should be attempted only if a more conservative vaginal approach has failed or is associated with postoperative infection. If possible, leaving the sacral attachment is prudent because of the potential for severe hemorrhage from the scarred presacral space. Vaginally excising the eroded mesh as deep as is safely accessible, undermining and freshening the edges of the involved vagina, and closing it primarily with delayed absorbable sutures generally is preferable. Recurrence of apical prolapse usually is not observed following mesh excision, although it may be related to close temporal proximity to the original surgery. Nevertheless, do not delay management of mesh erosion.[79]

An emerging, significant but rare complication of sacral colpopexy is spondylodiscitis. This is thought to be due to infection of the disc, bone, periosteum, or other surrounding spinal structures near the proximal attachment of the graft following sacral colpopexy.  It has been postulated that placement of suture at the promontory corresponds to the L5-S1 disc.[83] For that and other anatomical reasons, the authors suggest placing these proximal sutures lower down at around S1-S2.

Outcome and Prognosis

A large multicenter randomized trial of women undergoing surgery to treat apical vaginal prolapse and stress urinary incontinence showed that sacrospinous ligament and uterosacral ligament fixation had similar success rates at 63.1% and 64.5%, respectively, 2 years after surgery.[75]  It should be noted that < 6% of patients in each group had stage IV prolapse; thus, these results may not be applicable to women with massive vaginal eversion. Sacrospinous ligament fixation was reviewed by Sze and Karram.[84] They reported an overall failure rate of 19%, a reoperation rate for recurrent prolapse of 2.7%, and a reoperation rate for apical recurrence of 1.8%.

Previous studies showed that sacral colpopexy has an overall failure rate of 10-24% depending on the criteria used and length of follow-up. Indeed, based on extended follow-up of the CARE trial, 2-year cure rates may range from 19% if perfect anatomic support is the criterion, to 97% if the criterion is absence of subsequent treatment for pelvic organ prolapse. Similarly, failure rates increased from years 2 to 7 following surgery.[85]  A study by Culligan et al with a minimum of 5-year follow-up data showed improved success rates (>90%) with minimally invasive sacral colpopexy.[82]

Obliterative operations, such as the colpocleisis procedure, tend to have a success rate of over 90%.[77, 76]  In these studies, the majority of patients had stage IV prolapse. It is the authors' opinion that this is an excellent procedure for older patients with high stage prolapse.

Benson et al reported the first randomized comparison between abdominal and vaginal approaches to pelvic floor defects.[86] They reported a reoperation rate of 12% (5 of 42) for recurrent apical prolapse when performed vaginally and a reoperation rate of 2.6% (1 of 38) when performed abdominally. They reported unsatisfactory results leading to reoperation in 33% of the vaginal group versus reoperation in 16% of the abdominal group, with a mean follow-up of 2.5 years (range of 1-5.5 years).

Maher et al also performed a randomized prospective trial comparing sacrospinous ligament fixation with abdominal sacral colpopexy in post-hysterectomy vaginal vault prolapse.[87] Follow-up averaged 2 years postsurgery and showed a subjective success rate of 94% in the abdominal group and 91% in the vaginal group with objective cure rates of 76% in the abdominal group and 69% in the vaginal group. These differences were not statistically significant. The abdominal approach showed longer operative times, slower return to normal activity, and increased costs compared with the vaginal approach.

A Cochrane review determined the effects of different surgeries used in the management of pelvic organ prolapse from 56 randomized controlled trials (5954 women). The authors concluded that for upper vaginal prolapse (uterine or vault), abdominal sacral colpopexy was associated with a lower rate of (1) recurrent vault prolapse on examination and (2) painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach. In single studies, the sacral colpopexy had a higher success rate on examination and lower reoperation rates than high vaginal uterosacral suspension and transvaginal polypropylene mesh.[88]

Future and Controversies

Few well-controlled comparative studies regarding the treatment of apical prolapse are available in the literature with long-term follow-up. The concept of defect-specific repair in female pelvic reconstructive surgery is one that has been embraced by many, but not all, urogynecologists and pelvic surgeons. Whether long-term outcomes are improved using this concept remains to be determined through well-designed studies with long-term follow-up.

The implications of minimally invasive approaches in the treatment of apical prolapse, specifically laparoscopic and robotic-assisted sacrocolpopexy, present potential improvements in the correction of impaired native tissue. Systemic review and meta-analysis yielded estimated success rate for robotic sacrocolpopexy of 98.6% (95% confidence interval [CI], 97.0-100%) with a mesh exposure rate of only 4.1% (95%CI, 1.4-6.9%), and a rate of reoperation for mesh revision of 1.7%. The rates of reoperation for recurrent apical and nonapical prolapse were 0.8% and 2.5%, respectively.[89]  As more long-term data emerge with consistency in type 1 mesh placement, it is likely that outcomes will improve and complications will decrease.[82]

Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. High-volume surgeons had the lowest complication rates, and they were most likely to perform an apical suspension procedure as well as address the anterior and/or posterior compartments and to use intraoperative cystoscopy. It was noted that the high-volume surgeons operated on patients with higher degrees of prolapse and those who had prior prolapse or anti-incontinence surgery. The finding that intermediate-volume surgeons had the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and complications and may be reflective of the likelihood of requesting further assistance.[90] Moreover, high-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and preoperatively evaluate for stress urinary incontinence.[91]