Vaginal vault prolapse happens when the top of the vagina (the vaginal cuff) sags down after a hysterectomy because its support from the pelvic ligaments has weakened. It often comes with prolapse of the bladder or rectum and can turn the vagina partly or fully inside out.
Key symptoms
- Bulge or pressure in the vagina, sometimes tissue felt outside
- Pelvic heaviness that gets worse with standing, lifting or straining
- Urine leakage, weak stream or incomplete emptying
- Constipation or needing to press on the vagina to pass stool
- Discomfort during sex, spotting or discharge from irritated tissue
What you find on exam
- History of hysterectomy; no cervix seen on speculum exam
- Vaginal apex moving down on straining; a split speculum shows each wall
- POP-Q staging of the apex and the front and back walls
- Erosion or ulcers on exposed vaginal skin; pelvic floor muscle strength
Tests
- Clinical diagnosis from the pelvic exam
- Urinalysis and post-void residual for urinary symptoms
- Urodynamic testing before surgery, including a check for hidden stress incontinence
- Imaging (ultrasound or dynamic MRI) only in complex or unclear cases
Treatment basics
- Pelvic floor muscle training and lifestyle changes for mild cases
- Vaginal pessary with vaginal estrogen to protect the tissue
- Sacrocolpopexy: abdominal, laparoscopic or robotic mesh repair
- Vaginal repair: sacrospinous or uterosacral ligament suspension; colpocleisis if no future intercourse is wanted
Red flags
- Unable to urinate or signs of blocked kidneys
- Prolapse that cannot be pushed back, with pain, vomiting or color change
- Bleeding ulcer on the exposed vaginal wall
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.