Vaginal Vault Prolapse – Causes, Symptoms, Treatment

Vaginal Vault Prolapse/A vaginal vault prolapse is the name for a condition experienced in women when the top part of the vaginal wall loses its strength and begins to droop downwards. As the top of the vagina descends, it prolapses (bulges) into the vaginal canal and can even become visible from the outside of the vagina. A vaginal vault prolapse occurs as a result of weak pelvic floor muscles.

A vaginal vault prolapse can occur on its own. However, 72% of women suffer one or more other pelvic organ prolapses at the same time as a vaginal vault prolapse due to the loss of support that the vagina normally gives.

A vaginal vault prolapse is common in women who have undergone hysterectomy surgery to completely remove the uterus. The uterus usually sits above the vagina, linked by a piece of tissue called the cervix. If it is removed there is no longer anything there to anchor the top of the vagina in place, often allowing it to prolapse.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of the prolapse reoccurring. To avoid unnecessary delays and speak to your doctor if you have any concerns.

Stages of  Vaginal Vault Prolapse

There are four main stages of pelvic organ prolapse, as graded using the Pelvic Organ Prolapse Quantification System (POP-Q). Some women don’t experience any symptoms at all from a vaginal vault prolapse and are only diagnosed as a result of having a smear test or other routine pelvic examination. Others experience mild or moderate symptoms, and others experience debilitating and severe symptoms. As many as half of all women who have had children and/or are over the age of 60 will develop a degree of vaginal vault prolapse.

Doctors use the following system to grade the severity of a vaginal vault prolapse:

• Stage 1 – The vaginal wall prolapse and symptoms are very minor, and the pelvic organs are still generally well supported.
• Stage 2 – The vaginal wall has begun to droop, but it is not visible from the outside of the vagina. Symptoms are mild.
• Stage 3 – The top of the vagina has drooped to the degree that it is sometimes visible from the outside of the vagina when coughing, laughing, lifting or straining. Symptoms are moderate.
• Stage 4 – The vagina has prolapsed so much that it is completely and permanently visible on the outside of the vagina. Symptoms are now severe.

Studies suggest that a vaginal vault prolapse is always accompanied by a degree of both cystocele and rectocele prolapses due to the loss of support for these organs. These conditions have similar treatments to a vaginal vault prolapse, so can often be treated collectively.

Causes of Vaginal Vault Prolapse

As with all pelvic organ prolapses, the usual cause of a vaginal vault prolapse is weak pelvic floor muscles. This weakening causes the organs to begin to drop down and eventually prolapse. And as mentioned above, the most likely cause of this weakening is having a hysterectomy:

• Hysterectomy – Up to 40% of women who have had a hysterectomy (the complete removal of the womb and cervix) suffer a vaginal vault prolapse. The uterus provides support for the top of the vagina, if it is no longer there, then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken.
• Pregnancy – Around 50% of women who have carried a baby to full term will experience some kind of vaginal prolapse. This is in part due to the extra weight that the baby adds to the pelvic area, which can weaken the pelvic floor muscles. It is also thought to be caused by pregnancy hormones allowing vaginal tissues to stretch beyond their rebound limits. Multiple pregnancies will further increase your risk.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse. Mothers of four babies, all delivered vaginally, are at 12 times greater risk than women who have not given birth vaginally.
• Bodyweight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area.
• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
• Heavy lifting – Repetitive heavy lifting, and lifting incorrectly, increases the pressure put on the pelvic floor.
• Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Pelvic conditions – Heavy fibroids or a tumor somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.

A vaginal vault prolapse can also be caused by having another pelvic organ prolapse.

Symptoms of  Vaginal Vault Prolapse

You may experience some or all the following symptoms if you have a vaginal vault prolapse. Having some or all of them doesn’t guarantee that you have a vaginal vault prolapse, they are just risk factors.

• a heaviness, pressure or dragging sensation in the pelvic area
• pain in the lower back
• bleeding from the vagina that isn’t associated with your period
• urinary stress incontinence – a dribble of urine if you cough, laugh, sneeze, run or jump
• urinary incontinence – the inability to hold in urine at all
• the need to urinate more frequently
• the need to urinate more urgently
• difficulty urinating
• constipation
• a noticeable bulge inside the vagina
• a noticeably larger, or gaping vagina – so much so that a tampon cannot stay in place
• difficulty and pain when having sex
• tissue that protrudes from the vagina and is visible from the outside of the body
• symptoms and pain that is made worse by standing or walking

If you’re experiencing symptoms, make an appointment to see your doctor. Pelvic organ prolapses can be embarrassing, but it might be comforting to know that they are also very common.

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important and can help you decide on which course of treatment is best for you to meet your expectations of health and lifestyle.

Diagnosis of Vaginal Vault Prolapse

• Plain Films – Plain films are usually not appropriate for the evaluation of pelvic prolapse.[rx] Barium defecography is in use at some places as a part of the assessment of pelvic floor dysfunctions, however, with the advent of newer and non-ionizing radiation imaging techniques like MR defecography, barium defecography has become largely obsolete.
• Computed Tomography – Due to concern for radiation exposure and availability of MRI, which provides a better soft-tissue resolution, computed tomography (CT) is usually not appropriate for the evaluation of pelvic prolapse; however, one should look on the sagittal abdomen and pelvis images for a hint of pelvic floor prolapse by drawing a pubococcygeal line and see for overt prolapse and then recommend a dynamic MRI pelvis (MR Defecogram) for further evaluation.[rx]
• Magnetic Resonance – Dynamic magnetic resonance imaging (MRI) provides an accurate assessment of pelvic prolapse. MRI provides a better anatomic detail compared to the transtibial ultrasound and is also useful as a preoperative tool. Furthermore, the MRI examination does not require bowel preparation and does not involve sensitive pelvic exposure. Despite its benefits, the MRI is not widely available, expensive, and contraindicated in patients with MRI incompatible devices or hardware.
• Ultrasonography – Translabial ultrasound is a relatively inexpensive way of evaluating pelvic prolapse and is widely available. Besides, the ultrasound does not produce ionizing radiation and allows dynamic evaluation of the pelvic floor. However, the diagnostic quality of the ultrasound exam depends on the sonographer’s skill level and the interpreting radiologist’s familiarity with the examination.
• Nuclear Medicine – Nuclear medicine studies are usually not appropriate for the evaluation of pelvic prolapse.[rx]
• Angiography – Angiography is usually not appropriate for the evaluation of pelvic prolapse.[rx]

Treatments of Vaginal Vault Prolapse

• Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Heath and Care Excellence (NICE) recommends keeping your BMI under 30.
• Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
• Avoid straining on the toilet – Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
• Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about a prolapse, then gentler, lower impact exercise like swimming may be better for you.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week or so.
• Kegel exercises – Performing daily pelvic floor exercises could be all you need to keep your vaginal vault prolapse under control. Using an electronic pelvic toner such as the Kegel8 Ultra 20 Pelvic Toner will make the exercises more beneficial. In the circumstance of non-surgical treatments not fully relieving your symptoms and they remain severe, you may be advised to have a surgical intervention for your vaginal vault prolapse. There are several surgeries available. The surgery your surgeon will select will be based on you age, health, lifestyle, sexual activity, and their skill set. The procedure may be completed in conjunction with others, to repair all prolapses you are experiencing at once:
• Vaginal vault prolapse repair surgeries – The two most common vaginal vault prolapse repair surgeries are abdominal sacrocolpopexy surgery (success rate of close to 90%) and sacrospinous fixation surgery. During these procedures, the top part of the vagina is moved and surgically attached to the lower abdominal wall, the lower back or the ligaments of the pelvis. Your surgeon will do this via deep surgical stitches. For those with a strong pelvic floor, the surgery can be completed under general anesthetic through the vagina. However, surgeries undertaken through the vagina are associated with loss of sensation and a high rate of additional complications following the surgery due to the tissue damage. Therefore it is most often performed through the abdomen, either during open or laparoscopy (keyhole) surgery. Using a synthetic mesh lining as additional support is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient.
• Other surgeries – Other surgeries include a uterosacral ligament suspension and iliococcygeal fixation. These are less common due to their higher risk of damage to the other pelvic organs and the higher skill set needed by your surgeon. However, they are associated with less risk to normal vaginal function so may be favored, where possible, for women who are sexually active.

How Long Does it Take to Recover from a Vaginal Vault Prolapse Surgery?

For the surgery you will have a catheter fitted, which will stay in place for a further 8 – 24 hours following the surgery. You may go home with the catheter and get it removed by a nurse at the follow-up appointment the next day. After the catheter is removed, you may notice some difference in your urine flow as a result of swelling.

20% of patients experience bright red bleeding from the vagina following a prolapse surgery involving mesh, this suggests the mesh is coming through into the vagina as you move. If this happens you need to treat it as an emergency and the exposed mesh will be removed during a second operation.

The usual recovery period for a vaginal vault prolapse surgery is around six weeks. During the first fortnight, you will likely feel discomfort and some pain in your buttocks, depending on the surgery undergone. You may also be prescribed medication and recommended activity to avoid developing deep vein thrombosis. Throughout the six week recovery, you will also likely experience bleeding and a creamy white discharge, which you can use pads (not tampons) to manage. You may be recommended to avoid driving, and some insurance companies may not even cover you during the first-fortnight post operation.

After the six weeks, most women can go about their daily business, and comfortably resume having sex. If, during the surgery, another prolapse was located or damage was done to the surrounding organs, the procedure may have been extended to incorporate these further repairs. This could result in a slightly longer recovery time.

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