Vaginal Vault Prolapse: Symptoms and Treatment
What is vaginal vault prolapse?
Vaginal vault prolapse is the downward displacement of the upper part of the vagina after hysterectomy (removal of the uterus). When the uterus is removed, the upper end of the vagina is closed; this area is called the vaginal vault or vaginal crest. If the supporting tissues that hold the upper part in place weaken, the vault can descend into the vagina, and in advanced cases, outside the vaginal opening. The problem is not simply an excess of tissue, but related to the function of the pelvic support system.
Mild prolapse may not cause any symptoms. However, some women experience a feeling of fullness, downward pulling, or a palpable bulge in the vagina. The severity of symptoms is not always the same as the degree of prolapse seen during examination. Therefore, the decision for treatment is not based solely on anatomical measurements. The individual's daily life, urinary and bowel functions, sexual life, and expectations from treatment are evaluated. Not every woman who has had a hysterectomy develops a prolapse; a history of surgery alone does not necessarily indicate a future prolapse.
What causes vaginal prolapse after a hysterectomy?
The pelvic organs are supported by muscles, ligaments, and connective tissue. Pregnancies, vaginal deliveries, age-related tissue changes, pre-existing prolapse, and certain individual connective tissue characteristics can affect this support. Constipation, chronic cough, and excess weight, which lead to persistent straining, are also considered in the assessment. Usually, there is a combination of factors rather than a single cause.
Pelvic floor prolapse can be noticed shortly after a hysterectomy (removal of the uterus), or it may become apparent years later. The reason for the hysterectomy, whether prolapse was present before the surgery, and any previous pelvic floor procedures are important. The development of prolapse alone does not prove that the surgery was performed incorrectly. Reviewing previous surgical records helps to understand the current anatomy. Instead of searching for a blameworthy explanation, the focus of the evaluation is on the location of the current loss of support, the patient's symptoms, and appropriate options.
What are the symptoms of vaginal vault prolapse?
A feeling of a lump, bump, or fullness at the vaginal opening is among the most frequently reported complaints. Some women experience an increasing pulling sensation towards the end of the day; prolonged standing or physical exertion can exacerbate these symptoms. Relief may occur upon lying down. Friction against underwear, discomfort while walking, or tenderness in the vaginal tissue may also develop. However, lower back or groin pain should not always be assumed to be caused by prolapse; other causes should also be investigated.
Weakened urine flow, a feeling of incomplete emptying, urgency, or incontinence may accompany the symptoms. Difficulty with bowel movements and discomfort during sexual intercourse are also seen in some patients. Not all of these symptoms are present in every woman. It is helpful to describe not only the palpable bulge but also changes in bowel habits to the doctor. Identifying which symptom is most bothersome provides a starting point for evaluating the success of treatment.
Are vaginal prolapse and uterine prolapse the same thing?
In uterine prolapse, the uterus and cervix shift downwards. Vaginal vault prolapse, on the other hand, is the downward displacement of the upper end of the vagina in a woman who has had her uterus removed. Both belong to the group of pelvic organ prolapses, but the existing anatomy and some surgical options differ. Therefore, the idea that "my uterus has been removed, so prolapse will no longer occur" is incorrect. The need for support continues even after the uterus is removed.
Information about the treatment of uterine prolapse should not be applied in the same way as for prolapse of the dome of the uterus. During the examination, it is necessary to determine which structure has descended. Whether the entire uterus or only a portion of it was previously removed is also important. If the patient is unaware of the details of the surgery, obtaining the relevant reports can be helpful. Correct diagnosis is not merely a technical detail; it is fundamental to discussing the available treatments and expected outcomes.
Do cystocele and rectocele accompany vaginal vault prolapse?
The support provided by the upper vaginal section and the support provided by the anterior and posterior walls are not entirely independent of each other. Therefore, prolapse of the vaginal vault may be accompanied by anterior or posterior vaginal wall prolapse. Downward displacement of the bladder along with the anterior wall is called cystocele. Bulging of the posterior wall in relation to the rectum is considered rectocele, and in some cases, downward displacement of the small intestine is considered enterocele. It is possible for more than one region to be affected.
Cystocele treatment and rectocele and enterocele evaluation are planned, along with upper section support as needed. Focusing only on the externally visible area may not explain the entire support problem. If surgery is considered, which sections will be intervened and the reasons should be clearly discussed. Not every wall needs to be corrected to the same extent; examination findings and the patient's complaints determine the scope of treatment.
How is a vaginal prolapse examination performed?
The evaluation begins with a discussion of the patient's complaints and previous surgeries. The examination assesses the upper, anterior, and posterior parts of the vagina; coughing or straining may be requested. In some patients, findings observed while lying down may not fully reflect the prolapse felt in daily life. In this case, evaluation in a different position or standing may be necessary. The aim of the examination is not only to determine the degree of prolapse but also to understand which areas are affected and their relationship to the symptoms.
Standardized systems can be used to measure prolapse. However, the numbers themselves do not determine the necessity of treatment. The condition of the vaginal tissues, irritation, bleeding, or other lesions are also checked. If the diagnosis is clear through examination, routine imaging is not necessary for everyone. The NICE guidelines also state that imaging is not an automatic step in the case of clear examination findings. If the symptoms and findings do not match, or if another problem is suspected, additional investigations are selected on an individual basis.
How are urinary and bowel complaints evaluated?
If there is difficulty emptying the bladder, measuring the residual urine after urination may be considered. It should also be investigated whether incontinence occurs with coughing or sudden urges to urinate. In some women, prolapse can alter the behavior of the urethra; previously unnoticed incontinence may occur when the prolapse is supported. Discussing this possibility before surgery provides more realistic expectations regarding potential symptoms later on. Not all patients require the same tests.
From a bowel perspective, constipation, excessive straining, and a feeling of incomplete emptying are evaluated. Not all of these complaints may be related to prolapse. Whether urinary incontinence treatment and prolapse treatment are addressed simultaneously or separately is determined on an individual basis. The patient's priority, the benefits of additional procedures, and potential risks are discussed together. It should not be stated that a single surgery will definitively resolve all bladder and bowel complaints.
How to choose the right treatment for vaginal vault prolapse?
The primary determinants of treatment are the severity of symptoms, physical examination findings, general health, previous interventions, and the individual's preference. Observation may be appropriate for some asymptomatic or mildly bothersome prolapses. Lifestyle modifications to reduce symptoms, pelvic floor physiotherapy, and pessary options may be discussed. Surgery is considered for individuals with significant discomfort, those who have not benefited sufficiently from other methods, or those who prefer surgery after being informed about the procedure.
| Choice | Main purpose and point of focus |
|---|---|
| Monitoring and lifestyle adjustments | Monitor changes in mild cases and manage factors that increase the burden. |
| Pelvic floor physiotherapy | Improving muscle function and managing symptoms; it is not expected to completely reverse advanced sagging. |
| Vaginal pessary | Providing mechanical support through the vagina requires appropriate size and regular check-ups. |
| Vaginal support surgery | The dome is secured to the supporting tissues; the individual benefits and risks are evaluated. |
| Sacrocolpopexy | Re-establishing upper vaginal support via the abdominal approach; materials used and risks are discussed. |
Treatment options should not be evaluated like a competition ranking. A person who doesn't want surgery using a pessary doesn't necessarily mean they've received incomplete treatment. Similarly, choosing surgery in a suitable patient doesn't require trying all options for an extended period beforehand. It's important that the decision is made with clear information and through mutual discussion. Improvements in quality of life should be considered as much as anatomical appearance.
Do pelvic floor exercises correct vaginal prolapse?
Pelvic floor exercises can improve muscle support and symptom management in suitable patients. A supervised program may be particularly beneficial in mild prolapse. However, it should not be promised that a severely depressed vaginal vault will completely return to its original position through exercise alone. RCOG and NICE resources consider exercise as part of a conservative approach in the appropriate patient group. The duration and content of the program are determined through individual assessment.
Using the correct muscles, learning to relax, and moving without holding your breath are important. It's not enough to give every woman the same number of repetitions. The program can be adjusted if there is pain or excessive muscle tension. Managing constipation, evaluating chronic cough, and reviewing lifting habits are also added to the plan. The goal is not to restrict all movement, but to help the person live more comfortably in their daily life by recognizing the conditions that worsen their symptoms.
What is a vaginal pessary and who can use it?
A pessary is a medical device inserted into the vagina to support sagging tissues. They come in various shapes and sizes; the appropriate model is determined by examination. They may be an option for those who do not want surgery, want to postpone surgery, or have additional risks associated with surgery. Suitability is not solely determined by age. While some women are comfortable with a pessary for a long time, others may need to try different sizes or models.
Pessary use requires monitoring. Evaluation should be sought if there is discharge, discomfort, falling out, bleeding, or irritation of the vaginal tissue. The frequency of removal and cleaning is planned according to the model and the individual's ability to perform self-care. Random insertion without training is not appropriate. Compatibility with sexual intercourse also varies depending on the model and should be discussed beforehand. Keeping up-to-date with follow-up appointments is important to ensure that the device is understood not as a treatment to be simply inserted and forgotten.
Vaginal tissue care and local treatments during menopause.
Postmenopausal vaginal dryness and sensitivity can develop. These changes, along with prolapse, can increase discomfort due to friction or pessary use. Local vaginal treatments may be considered in suitable patients. However, addressing tissue dryness is not the same as anatomically correcting the prolapsed vault. Vaginal estrogen or other local care options should not be presented as methods that alone eliminate the loss of support.
In evaluating vaginal dryness during menopause, unexplained bleeding and pre-existing conditions should be considered. New bleeding, in particular, requires examination and should not be attributed solely to pessary friction or dryness. The contents and application method of any products used should be reported to the doctor. Random antiseptics or irritating products applied intravaginally do not replace proper care. Treatment is tailored to the condition of the tissues and the individual's history.
How is vaginal vault prolapse surgery performed?
The goal of surgery is to restore support to the upper part of the vagina. In methods such as sacrospinous fixation performed vaginally, the dome is secured to appropriate supporting tissues with sutures. In some patients, different sling methods using other connective tissues may be chosen. Sacrocolpopexy performed abdominally, using open or minimally invasive techniques, is also among the options. The choice of method depends on the existing anatomy, previous surgeries, general health, and the surgeon's assessment.
In sacrocolpopexy, support is provided to the upper part of the vagina, often using synthetic material. The benefits of this method, as well as the risks associated with the material, should be openly discussed. Prolapse mesh placement via the vaginal route is not the same as sacrocolpopexy performed via the abdominal route; all "mesh" applications should not be evaluated under a single heading. IUGA patient information and NICE recommendations emphasize discussing options along with their methods and risks. There is no single best surgery for every patient.
Risks of prolapse surgery and the possibility of recurrence
Every surgical procedure carries risks such as bleeding, infection, anesthesia-related problems, and injury to adjacent organs. Depending on the chosen method, temporary pain, urinary incontinence, new incontinence, discomfort during sexual intercourse, or complications related to the material may also be discussed. The likelihood of these varies depending on individual characteristics and the procedure performed. Another patient's experience does not directly reflect one's own risk.
Prolapse may recur after surgery or become noticeable in another vaginal area. Defining success solely as "there will never be another prolapse" is unrealistic. Reduction in symptoms, daily function, and the need for additional treatment are all considered together. If a repeat operation is being considered, details of the previous surgery are particularly important. The patient should receive clear information about the materials used, the follow-up plan, and where to go in case of unexpected complications. Honest discussion of uncertainties during the decision-making process is part of reliable information sharing.
Post-operative recovery and sexual life.
The recovery process varies depending on the type of surgery and the individual's overall condition. Instructions from the surgical team should be followed regarding walking, returning to work, lifting heavy objects, and resuming sexual intercourse. It's not accurate to give everyone the same number of days. Preventing constipation and reducing excessive straining can support comfort in the early stages. It's important to follow the recommended exercise plan instead of remaining completely immobile for extended periods.
Sexual expectations should be discussed before surgery. Vaginal dryness, pain, or previous negative experiences can also be evaluated. Pain during intercourse is not always solely due to prolapse; therefore, it cannot be said that anatomical correction will definitively resolve all sexual complaints. Improvement and comfort are assessed at the follow-up examination. The patient's open sharing of concerns ensures that a safe return plan is tailored to their individual needs.
Which symptoms require immediate medical attention?
A planned gynecological evaluation should be performed for a newly noticed protrusion in the vagina. If there is inability to urinate, significant bleeding, fever, or rapidly increasing pain, treatment should not be delayed. Especially in individuals who have recently undergone uterine surgery, sudden severe pain, bleeding, or unexpected tissue discharge from the vagina should not be interpreted as chronic prolapse and should be evaluated urgently. Attempting to forcibly push the tissue back in or performing a home procedure is not appropriate.
For a personal examination and discussion of treatment options with Assoc. Prof. Dr. Nazlı Korkmaz, please use the contact information provided. This text is for general informational purposes only; treatment will be determined through examination and personal history. The RCOG guidelines and patient information on pelvic organ prolapse, as well as resources from NICE, IUGA, Gloucestershire Hospitals, and BSUG, have been used as a basis. The RCOG patient information document on pelvic organ prolapse can be reviewed as an additional resource.
Daily life and load management in vaginal prolapse
Women with vaginal prolapse sometimes avoid all exercise and social activities. However, how to maintain proper movement can be planned according to the individual. Recognizing which activities increase the feeling of pressure or bulging can help regulate the load. Taking breaks during jobs that require standing for long periods or reviewing heavy lifting technique can be helpful. The goal is not to unnecessarily restrict the person's life, but to create a routine that is compatible with the symptoms.
If constipation is present, the underlying causes should be assessed instead of simply trying to defecate by straining more. Diet, fluid intake, exercise, and medical treatment, if necessary, should be planned together. The cause of a persistent cough should also be investigated. Managing these issues will not resolve the existing advanced prolapse on its own, but it can support daily comfort and the overall treatment plan. If newly started exercise causes significant pain or bleeding, an evaluation should be sought instead of continuing. Not every symptom should be considered simply a natural consequence of the prolapse.
How to prepare for a consultation about vaginal prolapse treatment
Previous surgical reports, a list of medications used, and a brief record of complaints can facilitate the consultation. Notes can be made on when the bulge becomes more prominent during the day, whether there is discomfort during bowel movements or intercourse. The individual does not need to decide definitively whether they want surgery from the outset. The purpose of the initial consultation may be to understand the options and identify any missing information for a decision. If necessary, the choice can be reconsidered in a subsequent consultation.
If surgery is being considered, questions should be asked about which areas will be repaired, the materials used, expected healing, and long-term follow-up. If a pessary is chosen, who will provide care and the follow-up plan should be clarified. Not seeking any treatment can also be evaluated by discussing the symptoms and potential outcomes. However, if new drainage problems, bleeding, or pain develop, the follow-up plan should be reviewed. Informed decision-making is not just about choosing a method, but understanding its compatibility with daily life and the follow-up it requires.
Frequently Asked Questions
Can vaginal prolapse develop after the uterus has been removed?
Yes. Vaginal vault prolapse can develop when the tissues supporting the upper part of the vagina weaken. It doesn't occur in every woman.
Is vaginal vault prolapse cancer?
Prolapse is a support problem and is not the same as cancer. However, new bleeding or a different lesion should also be evaluated.
Is surgery necessary for mild vaginal prolapse?
It's not always necessary. Depending on the symptoms and examination findings, monitoring, exercise, or a pessary may be considered.
Can exercise completely correct advanced vaginal prolapse?
No such guarantee can be given. Exercise may help with muscle function and symptoms; it should not be expected to completely correct advanced anatomical sagging.
Can the pessary be used for a long time?
It can be used in suitable patients with regular care and check-ups. The model, check-up interval, and care plan are personalized.
Is mesh always used in vaginal vault prolapse surgery?
No. There are also methods that provide support to the patient's own tissues with sutures. The technique and materials to be used are discussed beforehand.
Will the sagging recur after surgery?
Repetition is possible. The probability and need for follow-up vary depending on the individual's characteristics and the method used.
Does prolapse explain all urinary complaints?
No. Incontinence, retention, and difficulty urinating can have other causes. These will also be evaluated and included in the treatment plan.