Vault prolapse is often associated with defects of the apical fascia, represented here by dark lines, which must be addressed during vault reconstruction. Reprinted with permission of The Cleveland Clinic Foundation.
Specific technique, tools to help identify prolapse
Any patient with an advanced degree of vaginal prolapse should be assessed for vault prolapse using a careful, structured pelvic exam. In many cases, this can be difficult, even if the uterus is present.
Necessary tools include a bivalved speculum and a right-angle retractor, or the posterior blade of another gynecologic speculum.
When the uterus is present
An exteriorized cervix does not necessarily mean vault prolapse; this may occur with substantial cervical hypertrophy, while the apex remains well supported (FIGURE 3).
Exam technique. Place the right-angle speculum blade in the posterior fornix, inserting it to its full extent, and ask the patient to perform a Valsalva maneuver. If vault prolapse is present, the uterus will descend further as the speculum is slowly removed; reinsertion of the speculum will resuspend the uterus. If the vault is well supported, the cervix will remain in place despite Valsalva efforts.
Assess the degree of vault prolapse during this examination, to determine whether a McCall culdoplasty will restore vault support.
If uterine suspension is performed in a woman with substantial cervical hypertrophy, cervical prolapse may persist, necessitating partial amputation (Manchester procedure).
FIGURE 3 Exteriorized cervix does not necessarily mean vault prolapse
Cervical prolapse may be associated with vault prolapse (left) or simply represent cervical hypertrophy without vault prolapse (right). Reprinted with permission of The Cleveland Clinic Foundation.
In the hysterectomized patient
The goal of physical exam is to identify the apical scar tissue (cuff) resultant from the hysterectomy. In most women, the cuff is visible as a transverse band of tissue firmer than the adjacent vaginal walls. If the woman has extensive prolapse, the tissue is stretched and thus not as obvious.
Exam technique. Use a bivalved speculum to visualize the apex. In women with extensive prolapse, redundant vaginal tissue may impede visualization. Fortunately, the sites of previous attachment of the uterosacral-cardinal ligament complex can usually be identified as “dimples” on either side of the midline at the cuff (FIGURE 4).
Use both right-angle speculum blades, or 1 blade along the anterior vaginal wall and the index and middle fingers of your other hand along the posterior vaginal wall, to identify the dimples. Then place the tip of the speculum between the dimples, elevate the vault while the patient performs a Valsalva effort, and determine the degree of vault prolapse. This can be confirmed by digital exam by identifying the dimples by tact and elevating them to their ipsilateral ischial spines.
FIGURE 4 Identifying the vault in the hysterectomized patient
Posthysterectomy vault prolapse can be identified by looking for “dimples” at the apex, which represent sites of previous uterosacral-cardinal ligament complex attachment. Reprinted with permission of The Cleveland Clinic Foundation.
Which exam findings point to which technique?
The importance of accurate pelvic assessment is impossible to overemphasize. Besides determining the degree and type of prolapse present, the exam enhances surgical planning. Fascial tears or defects are usually identifiable during careful vaginal exam as areas of sudden change in the thickness of the vaginal wall.
By the end of the pelvic exam, we usually have developed a surgical plan for the prolapse repair, pending urodynamic assessment to determine the best anti-incontinence procedure, if necessary.
What are the surgical goals?
Objectives are to normalize support of all anatomic compartments; alleviate clinical symptoms; and optimize sexual, bowel, and bladder function—without precipitating new support or functional problems.
Abdominal versus vaginal approach
Most surgeons prefer a vaginal approach to pelvic reconstruction. However, this decision should be based on the patient’s individual variables.
If sexual function is critical to the patient, a sacrocolpopexy should be the primary option. Note that age does not always predict the importance of sexual function.
Vaginal length. If the vaginal apex (dimples) reaches the ischial spines with ease, a vaginal procedure should suffice. If it does not reach the spines, or extends far above, an abdominal sacrocolpopexy or obliterative procedure may more be appropriate.
Previous reconstructive procedures. Keep in mind that the area around the sacral promontory, or sacrospinous ligaments, may be difficult or risky to reach due to scarring and fibrosis. This is doubly important in this age of commonplace graft use.
Large paravaginal defects. Vaginal repairs can be technically difficult, and long-term outcomes have not been reported. An abdominal approach is probably better if substantial paravaginal defects are present.