Doctor Paul MacKoul: The Suspension – Vaginal Vault Prolapse

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The number of women that suffer from prolapse – or “drop down” – of the vagina is much higher than known.  Five hundred thousand women every year undergo surgery for this condition, and it is estimated that far more women have prolapse that is not diagnosed or reported. 

Anatomy

Prolapse encompasses several different organ systems, including the bladder, the vagina, the rectum, and the vaginal walls.   The suspension of the vagina is a fix of just one “level” with three levels of support to the vagina. 

Level 1 support is at the top of the vagina and is supported by the uterosacral ligaments and cardinal ligaments.   If this support is lost, the vagina will fall, or “prolapse” through the vaginal opening. 

Level 2 support is from ligaments that run the length of the vagina, with loss of their support causing drop down of the bladder.  This is also called a cystocele.

Level 3 support is from ligaments that support the urethra – the tube that empties urine from the bladder, and from ligaments supporting the rectum.  If these ligaments and muscles are weakened surrounding the rectum and pelvic floor, drop down of the rectum can occur, also known as a rectocele.  Further, loss of level 3 support can also cause urinary leakage when coughing, sneezing, or laughing, also known as stress urinary incontinence.

The Problem – Prolapse is Usually Not Just at One of the Three levels

Patients rarely have just one of three levels involved. Instead, Vaginal Vault Prolapse more often involves multiple or all levels, with many patients having drop down of the bladder, rectum, vagina, and in many cases stress urinary incontinence is also present.   Further, injury to the fascia of the vagina – the fascia is the supporting layer of tough tissue – can cause bowel to fall through as well.

The Cause

Delivery of babies through the vagina is the main cause of prolapse.  Damage to the pelvic “floor” and the three levels above can result in vaginal vault prolapse especially with larger baby weight and many deliveries.  There are other causes as well, including “collagen” disorders that results in weakened support, menopause, pelvic surgery, or anything that adds stress to the pelvic floor, thereby weakening the muscles and fascia.  Chronic coughing with lungs conditions, constipation that is severe and persistent, and heavy lifting can all increase the rates and frequency of prolapse.

The Symptoms

Women can be asymptomatic or can have severe symptoms including drop down of the vagina, bladder, and rectum through the vaginal opening.  Difficulty with urination and with bowel movements can occur at different stages of prolapse, with many women complaining of pressure, low back pain, a bulging sensation, pain, and difficulty with intercourse.

The Stage

Stage refers to the degree of prolapse, and most often is described as stage 0 – 4.  Stage 0 is no prolapse, whereas stage 4 refers to complete prolapse of the vaginal contents outside the vaginal opening.   For Stage 1, the prolapse is still within the vagina, and more than 1 cm above the vaginal opening.  Stage 2 is just above or at the opening, and Stage 3 is 1 – 2 cm below the opening.

Treatment

Surgery is usually the most common method of treatment, with results varying depending on the method used.   There are mesh and non-mesh treatment options.   Since the use of mesh is associated with controversy, non-mesh treatment methods are discussed below.

Non-Mesh Treatment Options

1. Uterosacral Ligament Suspension.  These ligaments are attached to the vagina and are cut during hysterectomy when the cervix is removed.  Reattachment of these ligaments to the vagina can occur at hysterectomy or can be done after.  For patients with multiple levels of prolapse, it can be difficult to identify these ligaments, and this procedure will not fix the problem associated with multi-level failure.

2. Sacrospinous Fixation (SSF).  SSF is a commonly used procedure in which the vaginal is attached to the ligaments between the ischial spine and the sacrum, or tail bone. This procedure is usually performed vaginally, and not all patients have identifiable ligaments.  Bilateral – both sides – can be performed to maintain a more normal vaginal angle for intercourse.  The problem with this procedure is the susceptibility of the vagina to increased pressure to the bladder fascia, resulting in a higher rate of cystocele formation.  For many of those patients undergoing SSF, a cystocele repair is usually performed.  Success rates can be higher than 90%, although many patients undergoing this procedure – as with other procedures – require additional surgery after 5 years either due to failure or the development of prolapse to other sites.

3. Colpocleisis (LaForte) is a method that renders the vagina unable to have intercourse, and essentially obliterates the vagina completely.  This is vaginal procedure that should only be done for women who do not require sexual function and has a high success rate.

Doctor Paul MacKoul: Mesh Treatment Options To Treat Sacrospinous Suspension

1. Vaginal Mesh Kits.  These “kits” are essentially a box which includes a device, called a “trocar” that is used to place mesh through the vagina.  These procedures rely on the mesh interacting with supporting vaginal tissues to correct prolapse. In effect, the mesh “scars” into these tissues and forms a dense, thick supporting platform for the bladder, rectum, and vaginal.   In 2019, the U.S. Food & Drug Administration (USFDA) ordered the manufacturers of ALL surgical mesh products indicated for the repair of prolapse through the transvaginal route to stop selling and distributing their products.  The reason for this has to do with the effects of the mesh on the surrounding tissues of the bladder and rectum.  Mesh actually “grows” into tissues it comes in contact with, creating a “fibrotic” reaction that results in extensive scar tissue formation between the mesh and the tissues.  The mesh also contracts down – or becomes smaller – with time, and can also erode through the tissues into the vaginal or even the bladder or rectum.  Severe pelvic pain can result, as well as difficulty with intercourse or not being able to have intercourse at all.  Bleeding can occur with erosion of the mesh.  Over time, mesh can cause problems with normal bowel function or urination. Although success rates with the placement of mesh through the vaginal route can be high, the risks far outweigh the benefits for their use.

2. Sacrocolpopexy.  This is the attachment of the apex – or top of the vagina – to the sacrum, or spine.  The exposure of the mesh to the bladder or rectum is minimized, although the mesh can be exposed to the abdominal contents resulting in adherence, scarring, and pain.  These procedures can be performed either abdominally through a larger incision, or laparoscopically through standard or robotic approaches.   The mesh is sewn to the top of the vaginal or the cervical stump after hysterectomy, and then attached to the sacrum.  The mesh can also be used to extend and attach to the back wall of the vagina, as well as to the front wall.  Extensive scarring of the mesh to the bladder and rectum can still occur, and erosion and scar tissue formation is possible.

The Suspension – Complications According to Doctor Paul MacKoul

In general, complications are low and success rates are high if a skilled specialist is performing the procedure. 

SSF: Sacrospinous suspension can result in bleeding and nerve injury, since the pudendal nerve lies directly behind the ligament.   SSF has a higher risk of recurrent prolapse.

Vagina Mesh Kits:  The use of vaginal mesh placement has essentially been abandoned

Sacrocolpopexy:  Sacrocolpopexy is now considered the standard treatment for vaginal vault prolapse.  Mesh is still required, with mesh placement between the vagina and the sacrum needed to suspend and support the vagina.   Mesh related complications still can occur as noted above – erosion, scarring and pain, bleeding, pain with intercourse and vaginal dysfunction. 

What Procedure is Best When Dealing With the Suspension of The Vaginal Vault According to Doctor Paul MacKoul?

The suspension of the vaginal vault with mesh or not depends on personal requirements and expectations for success. 

For those who are not interested in sexual function, a simple procedure such as a Laforte colpocleisis will provide elimination of prolapse without mesh at a high success rate. 

For those who wish to preserve sexual function, and do not want exposure to mesh, SacroSpinous Fixation is most likely the best option, however success rates are not as high as mesh.  The reason for this is that many women just do not have supporting ligaments that are intact or strong enough to allow for long term attachment of the vagina for suspension.  Daily factors that increase stress to the pelvic floor can eventually result in failure.

For those willing to accept a mesh related procedure, such as sacrocolpopexy, seek out a skilled urogynecologist to perform the procedure.  The use of a specialist will decrease complications and increase success rates.  Understand that the use of any mesh-based procedure still exposes the patient to complications outlined in the above discussion.  Discuss these risks and the incidence of these risks with your urogynecologist for more specific information.