History

A detailed history is required to evaluate the patient who presents with massive vaginal eversion. See Overview/Practice Essentials for a description of the symptoms with which a patient typically presents.

The duration of symptoms of the prolapse, with any information regarding functional problems that may be caused by the prolapse, should be ascertained. Ask patients about prior treatments they have attempted for the prolapse (conservative or surgical). Patients should be questioned about their urinary, bowel, and sexual function symptoms. This includes evaluation of urinary incontinence, storage and voiding dysfunction symptoms, accidental bowel leakage (previously known as fecal incontinence), and defecation dysfunction symptoms, as well as difficulties with sexual intercourse. The patient’s desire for future sexual activity should also be brought up, as this may guide future treatment or concomitant procedures. A detailed medical and surgical history should be obtained with a focus on prior pelvic surgeries and any significant gynecologic pathology.

Essential to the preoperative evaluation and surgical decision-making is the review of any prior pelvic surgery, including obtaining operative reports, especially if surgery was performed for prior pelvic floor dysfunction. It is imperative to evaluate and stabilize the patient’s general health to assess for and mitigate any increased surgical risks. The patient's general medical comorbidities may be important in the decision of how to proceed with treatment options.

Validated standardized questionnaires should be used to assess the degree of bother from the prolapse as well as urinary, bowel, and sexual function and symptoms. While an in-depth discussion of the questionnaires is beyond the scope of this article, they are a useful adjunct to a history obtained in the office and are helpful for gauging pre- and post-treatment success as well as for research purposes.

Physical Examination

A commitment to treat all associated and relevant pelvic floor defects requires a careful and comprehensive urogynecologic examination.

A diligent search for all pelvic support defects and repair of these defects increases the likelihood of overall surgical success and patient satisfaction. The apical, anterior, and posterior compartments are evaluated separately, with and without straining and/or coughing in the supine position and again in the erect position if needed.

It is our preference to examine patients with a full bladder upon arrival to test for stress urinary incontinence with and without the prolapse reduced. The patient is then asked to void and the postvoid residual urine volume is measured either by straight catheterization or ultrasound (bladder scan). An abdominal examination should be performed because intra-abdominal masses or ascites may be a risk factor for or exacerbate existing pelvic organ prolapse (POP).^[36]A comprehensive pelvic examination is then performed.

A standardized examination should be performed and documented. This examination begins on the outside of the vagina by examining the vulva, introitus, perineum, anal opening, urethral meatus, and any exteriorized prolapse. The prolapse should then be reduced and a careful speculum and bimanual examination performed. The authors prefer to use a half speculum to examine the anterior and posterior vaginal walls individually. The vaginal canal should be examined for evidence of prior surgical procedures such as scarring, suture or mesh exposure, and tenderness.

In cases of massive vaginal eversion, it may be difficult to reduce the prolapse. Use of lubricant or having the patient lie supine for a period of time before the examination may help with reduction. If it is not possible to reduce the prolapse in the office, an examination under anesthesia may be necessary.

The pelvic organ prolapse quantification system (POP-Q) examination is helpful for quantifying the extent of prolapse and accurate follow-up (see Overview/Problem for more detail). Carefully evaluate the rectovaginal and pubocervical fascia for integrity, strength, and thickness along its entire length. Look for any signs of enterocele, such as bowel peristalsis, along the posterior vagina or near the apex. In addition, look for any obvious pubocervical/rectovaginal detachments at the periphery of an apical bulge as well as localized loss of rugations. Evaluate the cul-de-sac in the supine and standing positions, with and without Valsalva maneuvers. The levator muscles should be palpated for any tenderness and Kegel strength measured. A rectal examination should be performed to evaluate for any rectal masses, sphincter tone, and the presence of rectovaginal fistula defects.

A neurologic examination to assess sacral dermatomes and reflexes is often performed.

Workup

Haylen BT, Maher CF, Barber MD, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016 Feb. 27 (2):165-94. [QxMD MEDLINE Link].
Whitcomb EL, Rortveit G, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK. Racial differences in pelvic organ prolapse. Obstet Gynecol. 2009 Dec. 114(6):1271-7. [QxMD MEDLINE Link].
Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050. Obstet Gynecol. 2009 Dec. 114(6):1278-83. [QxMD MEDLINE Link].
Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010. 29(1):4-20. [QxMD MEDLINE Link].
Miedel A, Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M. Symptoms and pelvic support defects in specific compartments. Obstet Gynecol. 2008 Oct. 112(4):851-8. [QxMD MEDLINE Link].
Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976 Nov 1. 126(5):568-73.
Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013 Nov. 24 (11):1783-90. [QxMD MEDLINE Link].
Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol. 2000 Aug. 183(2):277-85. [QxMD MEDLINE Link].
Samuelsson EC, Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol. 1999 Feb. 180(2 Pt 1):299-305. [QxMD MEDLINE Link].
Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Sep. 20(9):1037-45. [QxMD MEDLINE Link]. [Full Text].
Lykke R, Løwenstein E, Blaakær J, Gimbel H. Hysterectomy technique and risk of pelvic organ prolapse repair: a Danish nationwide cohort study. Arch Gynecol Obstet. 2017 Sep. 296 (3):527-31. [QxMD MEDLINE Link].
Sze EH, Hobbs G. Relation between vaginal birth and pelvic organ prolapse. Acta Obstet Gynecol Scand. 2009. 88(2):200-3. [QxMD MEDLINE Link].
Spence-Jones C, Kamm MA, Henry MM, Hudson CN. Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence. Br J Obstet Gynaecol. 1994 Feb. 101 (2):147-52. [QxMD MEDLINE Link].
Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol. 2007 Apr. 109 (4):848-54. [QxMD MEDLINE Link].
Levin PJ, Visco AG, Shah SH, Fulton RG, Wu JM. Characterizing the phenotype of advanced pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2012 Sep-Oct. 18 (5):299-302. [QxMD MEDLINE Link].
Campeau L, Gorbachinsky I, Badlani GH, Andersson KE. Pelvic floor disorders: linking genetic risk factors to biochemical changes. BJU Int. 2011 Oct. 108 (8):1240-7. [QxMD MEDLINE Link].
Allen-Brady K, Cannon-Albright L, Farnham JM, et al. Identification of six loci associated with pelvic organ prolapse using genome-wide association analysis. Obstet Gynecol. 2011 Dec. 118 (6):1345-53. [QxMD MEDLINE Link].
Allen-Brady K, Norton PA, Farnham JM, Teerlink C, Cannon-Albright LA. Significant linkage evidence for a predisposition gene for pelvic floor disorders on chromosome 9q21. Am J Hum Genet. 2009 May. 84(5):678-82. [QxMD MEDLINE Link]. [Full Text].
Olafsdottir T, Thorleifsson G, Sulem P, et al. Genome-wide association identifies seven loci for pelvic organ prolapse in Iceland and the UK Biobank. Communications Biol. March 2020. 3:129:[QxMD MEDLINE Link].
Giri A, Wu JM, Ward RM, et al. Genetic determinants of pelvic organ prolapse among African American and Hispanic women in the Women's Health Initiative. PLoS One. 2015. 10 (11):e0141647. [QxMD MEDLINE Link].
Sun MJ, Cheng WL, Wei YH, Kuo CL, Sun S, Tsai HD. Low copy number and high 4977 deletion of mitochondrial DNA in uterosacral ligaments are associated with pelvic organ prolapse progression. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jul. 20(7):867-72. [QxMD MEDLINE Link].
Takacs P, Gualtieri M, Nassiri M, Candiotti K, Medina CA. Vaginal smooth muscle cell apoptosis is increased in women with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Nov. 19(11):1559-64. [QxMD MEDLINE Link].
Elneil S. Complex pelvic floor failure and associated problems. Best Pract Res Clin Gastroenterol. 2009. 23(4):555-73. [QxMD MEDLINE Link].
DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992 Jun. 166(6 Pt 1):1717-24; discussion 1724-8. [QxMD MEDLINE Link].
Richardson AC. The anatomic defects in rectocele and enterocele. J Pelvic Surg. 1995. 1(4):214-221.
Tulikangas PK, Walters MD, Brainard JA, Weber AM. Enterocele: is there a histologic defect?. Obstet Gynecol. 2001 Oct. 98(4):634-7. [QxMD MEDLINE Link].
Hsu Y, Chen L, Delancey JO, Ashton-Miller JA. Vaginal thickness, cross-sectional area, and perimeter in women with and those without prolapse. Obstet Gynecol. 2005 May. 105(5 Pt 1):1012-7. [QxMD MEDLINE Link].
Dancz CE, Walker D, Thomas D, Özel B. Prevalence of hydronephrosis in women With advanced pelvic organ prolapse. Urology. 2015 Aug. 86 (2):250-4. [QxMD MEDLINE Link].
Siddique M, Ingraham C, Kudish B, Iglesia CB, Polland A. Hydronephrosis associated with pelvic organ prolapse: a systematic review. Female Pelvic Med Reconstr Surg. 2020 Mar. 26 (3):212-18. [QxMD MEDLINE Link].
Hagen S, Glazener C, McClurg D, et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial. Lancet. 2017 Jan 28. 389 (10067):393-402. [QxMD MEDLINE Link].
Due U, Brostrøm S, Lose G. Lifestyle advice with or without pelvic floor muscle training for pelvic organ prolapse: a randomized controlled trial. Int Urogynecol J. 2016 Apr. 27 (4):555-63. [QxMD MEDLINE Link].
Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J. 2016 Jul. 27 (7):981-92. [QxMD MEDLINE Link].
Leffler KS, Thompson JR, Cundiff GW, et al. Attachment of the rectovaginal septum to the pelvic sidewall. Am J Obstet Gynecol. 2001 Jul. 185(1):41-3. [QxMD MEDLINE Link].
Bradley CS, Zimmerman MB, Wang Q, Nygaard IE, Women's Health Initiative. Vaginal descent and pelvic floor symptoms in postmenopausal women: a longitudinal study. Obstet Gynecol. 2008 May. 111 (5):1148-53. [QxMD MEDLINE Link].
Rana AM, Rana AA, Salama Y. Small bowel evisceration through the vaginal vault: a rare surgical emergency. Cureus. 2019 Oct 20. 11 (10):e5947. [QxMD MEDLINE Link].
Kato K, Suzuki S, Kawanishi H, et al. [Abdominal mass and ascites as risk factors of pelvic organ prolapse]. Nihon Hinyokika Gakkai Zasshi. 2018. 109 (2):96-101. [QxMD MEDLINE Link].
Majida M, Braekken IH, Umek W, Bo K, Saltyte Benth J, Ellstrom Engh M. Interobserver repeatability of three- and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function. Ultrasound Obstet Gynecol. 2009 May. 33(5):567-73. [QxMD MEDLINE Link].
Rodrigo N, Wong V, Shek KL, Martin A, Dietz HP. The use of 3-dimensional ultrasound of the pelvic floor to predict recurrence risk after pelvic reconstructive surgery. Aust N Z J Obstet Gynaecol. 2014 Jun. 54 (3):206-11. [QxMD MEDLINE Link].
Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012 May 24. 366 (21):1987-97. [QxMD MEDLINE Link].
Thomas AZ, Giri SK, Cox AM, Creagh T. Long-term quality-of-life outcome after mesh sacrocolpopexy for vaginal vault prolapse. BJU Int. 2009 Dec. 104(11):1676-9. [QxMD MEDLINE Link].
Freeman RM, Pantazis K, Thomson A, et al. A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J. 2013 Mar. 24 (3):377-84. [QxMD MEDLINE Link].
Food and Drug Administration. Urogynecologic surgical mesh: update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse. Silver Spring (MD): FDA. 2011. [Full Text].
U.S. Food and Drug Administration. FDA takes action to protect women’s health, orders manufacturers of surgical mesh intended for transvaginal repair of pelvic organ prolapse to stop selling all devices. Silver Spring (MD): FDA. 2019. [Full Text].
Tenfelde S, Tell D, Thomas TN, Kenton K. Quality of life in women who use pessaries for longer than 12 months. Female Pelvic Med Reconstr Surg. 2015 May-Jun. 21 (3):146-9. [QxMD MEDLINE Link].
Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use by members of the American urogynecologic society. Obstet Gynecol. 2000 Jun. 95(6 Pt 1):931-5. [QxMD MEDLINE Link].
Wu V, Farrell SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management. Obstet Gynecol. 1997 Dec. 90(6):990-4. [QxMD MEDLINE Link].
Friedman S, Sandhu KS, Wang C, Mikhail MS, Banks E. Factors influencing long-term pessary use. Int Urogynecol J. 2010 Jun. 21 (6):673-8. [QxMD MEDLINE Link].
Clemons JL, Aguilar VC, Sokol ER, Jackson ND, Myers DL. Patient characteristics that are associated with continued pessary use versus surgery after 1 year. Am J Obstet Gynecol. 2004 Jul. 191(1):159-64. [QxMD MEDLINE Link].
Alperin M, Khan A, Dubina E, et al. Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2013 May-Jun. 19 (3):142-7. [QxMD MEDLINE Link].
Wolff B, Williams K, Winkler A, Lind L, Shalom D. Pessary types and discontinuation rates in patients with advanced pelvic organ prolapse. Int Urogynecol J. 2017 Jul. 28 (7):993-7. [QxMD MEDLINE Link].
Chien CW, Lo TS, Tseng LH, Lin YH, Hsieh WC, Lee SJ. Long-term outcomes of self-management Gellhorn pessary for symptomatic pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2019 Aug 5. [QxMD MEDLINE Link].
Ballard AC, Parker-Autry CY, Markland AD, Varner RE, Huisingh C, Richter HE. Bowel preparation before vaginal prolapse surgery: a randomized controlled trial. Obstet Gynecol. 2014 Feb. 123 (2 Pt 1):232-8. [QxMD MEDLINE Link].
ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures. Obstet Gynecol. 2018 Jun. 131 (6):e172-e189. [QxMD MEDLINE Link].
Frick AC, Barber MD, Paraiso MF, Ridgeway B, Jelovsek JE, Walters MD. Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2013 Mar-Apr. 19(2):103-9. [QxMD MEDLINE Link].
Kearney R, DeLancey JO. Selecting suspension points and excising the vagina during Michigan four-wall sacrospinous suspension. Obstet Gynecol. 2003 Feb. 101 (2):325-30. [QxMD MEDLINE Link].
Nichols DH. Sacrospinous fixation for massive eversion of the vagina. Am J Obstet Gynecol. 1982 Apr 1. 142 (7):901-4. [QxMD MEDLINE Link].
Salman S, Babaoglu B, Kumbasar S, et al. Comparison of unilateral and bilateral sacrospinous ligament fixation using minimally invasive anchorage. Geburtshilfe Frauenheilkd. 2019 Sep. 79 (9):976-82. [QxMD MEDLINE Link].
Dwyer PL, Fatton B. Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Feb. 19 (2):283-92. [QxMD MEDLINE Link].
Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 2000 Dec. 183 (6):1365-73; discussion 1373-4. [QxMD MEDLINE Link].
Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. Individual contributors are noted in the acknowledgment section. Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg. 2020 Mar. 26 (3):173-201. [QxMD MEDLINE Link].
Serati M, Braga A, Bogani G, et al. Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and safety at 5 years of follow-up. Int Urogynecol J. 2015 Jul. 26 (7):1007-12. [QxMD MEDLINE Link].
Kandadai P, Flynn M, Zweizig S, Patterson D. Cost-utility of routine endometrial evaluation before le fort colpocleisis. Female Pelvic Med Reconstr Surg. 2014 May-Jun. 20 (3):168-73. [QxMD MEDLINE Link].
Culligan PJ, Blackwell L, Goldsmith LJ, Graham CA, Rogers A, Heit MH. A randomized controlled trial comparing fascia lata and synthetic mesh for sacral colpopexy. Obstet Gynecol. 2005 Jul. 106 (1):29-37. [QxMD MEDLINE Link].
Florian-Rodriguez ME, Hamner JJ, Corton MM. First sacral nerve and anterior longitudinal ligament anatomy: clinical applications during sacrocolpopexy. Am J Obstet Gynecol. 2017 Nov. 217 (5):607.e1-607.e4. [QxMD MEDLINE Link].
Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006 Apr 13. 354 (15):1557-66. [QxMD MEDLINE Link].
Chen CC, Falcone T. Robotic gynecologic surgery: past, present, and future. Clin Obstet Gynecol. 2009 Sep. 52(3):335-43. [QxMD MEDLINE Link].
Elliott DS, Frank I, Dimarco DS, Chow GK. Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg. 2004 Oct. 188(4A Suppl):52S-56S. [QxMD MEDLINE Link].
Geller EJ, Siddiqui NY, Wu JM, Visco AG. Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Obstet Gynecol. 2008 Dec. 112(6):1201-6. [QxMD MEDLINE Link].
Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynaecol Obstet. 2016 Mar. 132 (3):284-91. [QxMD MEDLINE Link].
Romanova AL, Carter-Brooks C, Ruppert KM, Zyczynski HM. 30-Day unanticipated healthcare encounters after prolapse surgery: impact of same day discharge. Am J Obstet Gynecol. 2020 May. 222 (5):482.e1-482.e8. [QxMD MEDLINE Link].
Carter-Brooks CM, Du AL, Ruppert KM, Romanova AL, Zyczynski HM. Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway. Am J Obstet Gynecol. 2018 Nov. 219 (5):495.e1-495.e10. [QxMD MEDLINE Link].
Grimes CL, Balk EM, Crisp CC, et al. A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence. Int Urogynecol J. 2020 Jun. 31 (6):1063-89. [QxMD MEDLINE Link].
Thompson JC, Cichowski SB, Rogers RG, et al. Outpatient visits versus telephone interviews for postoperative care: a randomized controlled trial. Int Urogynecol J. 2019 Oct. 30 (10):1639-46. [QxMD MEDLINE Link].
Muffly TM, Paraiso MF, Gill AS, Barber MD, Rainey MC, Walters MD. Interventional radiologic treatment of pelvic hemorrhage after placement of mesh for reconstructive pelvic surgery. Obstet Gynecol. 2012 Feb. 119 (2 Pt 2):459-62. [QxMD MEDLINE Link].
Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014 Mar 12. 311 (10):1023-34. [QxMD MEDLINE Link].
Hill AJ, Walters MD, Unger CA. Perioperative adverse events associated with colpocleisis for uterovaginal and posthysterectomy vaginal vault prolapse. Am J Obstet Gynecol. 2016 Apr. 214 (4):501.e1-501.e6. [QxMD MEDLINE Link].
von Pechmann WS, Mutone M, Fyffe J, Hale DS. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol. 2003 Jul. 189 (1):121-6. [QxMD MEDLINE Link].
DeLancey JO, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynecol. 1997 Jun. 176(6):1228-32; discussion 1232-5. [QxMD MEDLINE Link].
Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstet Gynecol. 2017 Apr. 129 (4):e102-e108. [QxMD MEDLINE Link].
Papalambros E, Sigala F, Felekouras E, et al. Management of massive presacral bleeding during low pelvic surgery -- an alternative technique. Zentralbl Chir. 2005 Jun. 130 (3):267-9. [QxMD MEDLINE Link].
Brubaker L for the Pelvic Floor Disorders Network. Burch colposuspension at the time of sacrocolpopex in stress continent women reduces bothersome stress urinary symptoms: The CARE randomized trial. J of Pelvic Med and Surg. 2005. 11(S1):S5.
Culligan PJ, Lewis C, Priestley J, Mushonga N. Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy using lightweight Y-mesh. Female Pelvic Med Reconstr Surg. 2020 Mar. 26 (3):202-6. [QxMD MEDLINE Link].
Propst K, Tunitsky-Bitton E, Schimpf MO, Ridgeway B. Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J. 2014 Jan. 25 (1):21-31. [QxMD MEDLINE Link].
Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997 Mar. 89(3):466-75. [QxMD MEDLINE Link].
Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013 May 15. 309 (19):2016-24. [QxMD MEDLINE Link].
Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol. 1996 Dec. 175(6):1418-21; discussion 1421-2. [QxMD MEDLINE Link].
Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol. 2004 Jan. 190(1):20-6. [QxMD MEDLINE Link].
Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30. 4:CD004014. [QxMD MEDLINE Link].
Hudson CO, Northington GM, Lyles RH, Karp DR. Outcomes of robotic sacrocolpopexy: a systematic review and meta-analysis. Female Pelvic Med Reconstr Surg. 2014 Sep-Oct. 20 (5):252-60. [QxMD MEDLINE Link].
Morgan DM, Pulliam S, Adam RA, et al. Analysis of high-, intermediate-, and low-volume surgeons when performing hysterectomy for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2016 Jan-Feb. 22 (1):43-50. [QxMD MEDLINE Link].
Pulliam SJ, Morgan DM, Guaderrama N, Guire K, Adam RA. Differences in patterns of preoperative assessment between high, intermediate, and low volume surgeons when performing hysterectomy for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2016 Jan-Feb. 22 (1):7-10. [QxMD MEDLINE Link].
Rahmanou P, Price N, Jackson SR. Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study. Int Urogynecol J. 2015 Nov. 26 (11):1687-94. [QxMD MEDLINE Link].
Dietz HP. Prolapse worsens with age, doesn't it?. Aust N Z J Obstet Gynaecol. 2008 Dec. 48(6):587-91. [QxMD MEDLINE Link].
Wee WW, Wong HF, Lee LC, Han HC. Incidence of hydronephrosis in severe uterovaginal or vault prolapse. Singapore Med J. 2013 Mar. 54(3):160-2. [QxMD MEDLINE Link].
Beverly CM, Walters MD, Weber AM, Piedmonte MR, Ballard LA. Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 1997 Jul. 90(1):37-41. [QxMD MEDLINE Link].
Jones K, Yang L, Lowder JL, Meyn L, Ellison R, Zyczynski HM. Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse. Obstet Gynecol. 2008 Sep. 112(3):630-6. [QxMD MEDLINE Link].
Rock J, Jones III H. The nonsurgical management of pelvic organ prolapse: The use of vaginal pessaries. Te Linde's Operative Gynecology. 10th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008. 937.
Goldberg RP, Tomezsko JE, Winkler HA, Koduri S, Culligan PJ, Sand PK. Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation. Obstet Gynecol. 2001 Aug. 98(2):199-204. [QxMD MEDLINE Link].
Khandwala S. Transvaginal mesh surgery for pelvic organ prolapse: one-year outcome analysis. Female Pelvic Med Reconstr Surg. 2013 Mar-Apr. 19(2):84-9. [QxMD MEDLINE Link].
Finamore PS, Echols KT, Hunter K, Goldstein HB, Holzberg AS, Vakili B. Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Mar. 21(3):285-91. [QxMD MEDLINE Link].
Feiner B, Gietelink L, Maher C. Anterior vaginal mesh sacrospinous hysteropexy and posterior fascial plication for anterior compartment dominated uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Feb. 21(2):203-8. [QxMD MEDLINE Link].
De Ridder D. Should we use meshes in the management of vaginal prolapse?. Curr Opin Urol. 2008/07. 18(4):377-82.
Kramer BA, Whelan CM, Powell TM, Schwartz BF. Robot-assisted laparoscopic sacrocolpopexy as management for pelvic organ prolapse. J Endourol. 2009 Apr. 23(4):655-8. [QxMD MEDLINE Link].
Jordaan DJ, Prollius A, Cronje HS, Nel M. Posterior intravaginal slingplasty for vaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. June/2006. 17(4):326-9. [QxMD MEDLINE Link].
Mattox TF, Moore S, Stanford EJ, Mills BB. Posterior vaginal sling experience in elderly patients yields poor results. Am J Obset Gynecol. May/2006. 194(5):1462-6. [QxMD MEDLINE Link].
Feiner B, Jelovsek JE, Maher C. Efficacy and safety of transvaginal mesh kits in the treatment of prolapse of the vaginal apex: a systematic review. BJOG. 2009 Jan. 116(1):15-24. [QxMD MEDLINE Link].
Fatton B, Amblard J, Jacquetin B. [Is hysterectomy indicated during prolapsus treatment?]. Ann Urol (Paris). 2007 Jun. 41(3):91-109. [QxMD MEDLINE Link].
Addison WA, Livengood CH, Sutton GP, Parker RT. Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele. Am J Obstet Gynecol. 1985 Sep 15. 153(2):140-6. [QxMD MEDLINE Link].
Barksdale PA, Elkins TE, Sanders CK, et al. An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault. Obstet Gynecol. 1998 May. 91(5 Pt 1):715-8. [QxMD MEDLINE Link].
Borstad E, Rud T. The risk of developing urinary stress-incontinence after vaginal repair in continent women. A clinical and urodynamic follow-up study. Acta Obstet Gynecol Scand. 1989. 68(6):545-9. [QxMD MEDLINE Link].
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996 Jul. 175(1):10-7. [QxMD MEDLINE Link].
Emge LA, Durfee RB. Pelvic organ prolapse: four thousand years of treatment. Clin Obstet Gynecol. 1966 Dec. 9(4):997-1032. [QxMD MEDLINE Link].
Farnsworth BN. Posterior intravaginal slingplasty (infracoccygeal sacropexy) for severe posthysterectomy vaginal vault prolapse--a preliminary report on efficacy and safety. Urogynecol J Pelvic Floor Dysfunct. 2002. 13(1):4-8. [QxMD MEDLINE Link].
Goh V, Halligan S, Kaplan G, et al. Dynamic MR imaging of the pelvic floor in asymptomatic subjects. AJR Am J Roentgenol. 2000 Mar. 174(3):661-6. [QxMD MEDLINE Link].
Halligan S, Bartram C, Hall C, Wingate J. Enterocele revealed by simultaneous evacuation proctography and peritoneography: does "defecation block" exist?. AJR Am J Roentgenol. 1996 Aug. 167(2):461-6. [QxMD MEDLINE Link].
Hanson GE, Keettel WC. The Neugebauer-Le Fort operation. A review of 288 colpocleises. Obstet Gynecol. 1969 Sep. 34(3):352-7. [QxMD MEDLINE Link].
Iglesia CB, Fenner DE, Brubaker L. The use of mesh in gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1997. 8(2):105-15. [QxMD MEDLINE Link].
Jenkins VR. Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse. Am J Obstet Gynecol. 1997 Dec. 177(6):1337-43; discussion 1343-4. [QxMD MEDLINE Link].
Miklos JR, Kohli N, Lucente V, Saye WB. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol. 1998 Dec. 179(6 Pt 1):1418-22; discussion 1822-3. [QxMD MEDLINE Link].
Nguyen JK, Hall CD, Bhatia NN. Transvaginal bladder neck suspension to Cooper's ligament: a review of the literature. Int Urogynecol J Pelvic Floor Dysfunct. 2000. 11(5):320-4. [QxMD MEDLINE Link].
Petros PE. Vault prolapse II: Restoration of dynamic vaginal supports by infracoccygeal sacropexy, an axial day-case vaginal procedure. Int Urogynecol J Pelvic Floor Dysfunct. 2001. 12(5):296-303. [QxMD MEDLINE Link].
Pohl JF, Frattarelli JL. Bilateral transvaginal sacrospinous colpopexy: preliminary experience. Am J Obstet Gynecol. 1997 Dec. 177(6):1356-61; discussion 1361-2. [QxMD MEDLINE Link].
Randall CL, Nichols DH. Surgical treatment of vaginal inversion. Obstet Gynecol. 1971 Sep. 38(3):327-32. [QxMD MEDLINE Link].
Shull B. Clinical evaluation and physical examination of the incontinent woman. J Pelvic Surg. 2000. 6(6):334-43.
Timmons MC, Addison WA, Addison SB, Cavenar MG. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele. Evolution of operative techniques. J Reprod Med. 1992 Apr. 37(4):323-7. [QxMD MEDLINE Link].
Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JO. Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol. 2004 Mar. 103(3):447-51. [QxMD MEDLINE Link].
Welgoss JA, Vogt VY, McClellan EJ, Benson JT. Relationship between surgically induced neuropathy and outcome of pelvic organ prolapse surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1999. 10(1):11-4. [QxMD MEDLINE Link].
Minagawa T, Ogawa T, Ishizuka O, Nishizawa O. Impact of dynamic transrectal ultrasonography on pelvic organ prolapse. J Urol. 2015 Feb. 193(2):670-6. [QxMD MEDLINE Link].
Cosma S, Menato G, Preti M, et al. Advanced utero-vaginal prolapse and vaginal vault suspension: synthetic mesh vs native tissue repair. Arch Gynecol Obstet. 2014 May. 289(5):1053-60. [QxMD MEDLINE Link].
Attenberger UI, Morelli JN, Budjan J, et al. The value of dynamic magnetic resonance imaging in interdisciplinary treatment of pelvic floor dysfunction. Abdom Imaging. 2015 Oct. 40(7):2242-7. [QxMD MEDLINE Link].
Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstet Gynecol. 2017 Apr. 129 (4):e102-e108. [QxMD MEDLINE Link].
Geoffrion R, Hyakutake MT, Koenig NA, Lee T, Cundiff GW. Bilateral sacrospinous vault fixation with tailored synthetic mesh arms: clinical outcomes at one year. J Obstet Gynaecol Can. 2015 Feb. 37 (2):129-37. [QxMD MEDLINE Link].

Media Gallery

Enterocele and massive vaginal eversion. Posthysterectomy vaginal vault prolapse.
Enterocele and massive vaginal eversion. Large apical endopelvic fascial defect representing an enterocele demonstrated by the transabdominal route. Note the proximal cervicovaginal and rectovaginal fascia separate from the peritoneum.
Enterocele and massive vaginal eversion. Levels of support as described by DeLancey (1992). Note that level I refers to apical (or uterovaginal) support.
Enterocele and massive vaginal eversion. Normal posthysterectomy vaginal vault. Note the presence of continuity of the endopelvic fascia at the vaginal apex, resulting from the fusion of cervicovaginal and rectovaginal fascia, and their fusion with the uterosacral ligament portion of endopelvic fascia.
Enterocele and massive vaginal eversion. Early enterocele with no vault prolapse. Note contact of peritoneal contents with vaginal epithelium, with no intervening endopelvic fascia.
Enterocele and massive vaginal eversion. Progressive enterocele now demonstrating true vaginal vault prolapse.
Enterocele and massive vaginal eversion. Massive enterocele with total vaginal vault prolapse.
Enterocele and massive vaginal eversion. Posterior enterocele in a patient with a uterus. Note that peritoneal contents have dissected between the vaginal skin and rectovaginal fascia through a proximal defect.
Enterocele and massive vaginal eversion. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier.
Enterocele and massive vaginal eversion. The anatomy surrounding the right ischial spine.
Enterocele and massive vaginal eversion. Note the pudendal neurovascular bundle at the lateral aspect of the sacrospinous ligament. Also note the proper penetration of the suture into the body of the coccygeus muscle.
Enterocele and massive vaginal eversion. Following penetration of the sacrospinous ligament, the permanent suture (on the left) is attached to the posterior vagina by a figure-eight stitch, incorporating rectovaginal fascia but not penetrating the epithelium. Once this stitch is tied, a pulley has been created whereby the vagina can be drawn up to the ligament by pulling on the free suture and then tied down. The delayed absorbable suture is driven through-and-through and is tied on the vagina.
Enterocele and massive vaginal eversion. Depiction of completed fascial reconstruction with uterosacral reattachment in the sagittal view. Note that the vaginal apex has been restored to its normal anatomic location and is directed to the hollow of the sacrum.
Enterocele and massive vaginal eversion. LeFort colpocleisis begins with dissection and excision of a rectangular patch of epithelium on both the anterior and posterior vagina. Gradual inversion of the vaginal tube is accomplished by interrupted sutures that approximate anterior to posterior. Reapproximation of the lateral vaginal edges serves to maintain the tunnels on either side of the repair. From Thompson JD. Surgical correction of defects in pelvic support. In: Rock JR, Thompson JD, eds. TeLinde's Operative Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997.
Enterocele and massive vaginal eversion. Transabdominal repair of the large enterocele noted in Image 2. Note interrupted permanent sutures used for repair.
Enterocele and massive vaginal eversion. Mesh configuration for abdominal sacral colpopexy. Mesh may come preformed or made in the operating room from two pieces of polypropylene mesh. If so, the crux of the Y is formed by permanent sutures with the knots tied down on the side that faces the sacrum, not the vagina.
Enterocele and massive vaginal eversion. Note the anatomy of the lower presacral space. Take care to adequately mobilize the sigmoid colon and ensure the safety of the right ureter. Identification of the middle sacral vessels is important to avoid hemorrhage.
Enterocele and massive vaginal eversion. Note adequate bites taken into the anterior sacral fascia at sacral level 2 (S2). Take care not to attach the mesh too high (towards the sacral promontory) so that the normal vaginal axis is maintained. Also, take care to avoid excess tension on the vagina.
Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum at sacral level 3 (S3).
Enterocele and massive vaginal eversion. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus.
Enterocele and massive vaginal eversion. Massive vaginal eversion in a patient with post hysterectomy vaginal vault prolapse.
Enterocele and massive vaginal eversion. A variety of pessaries that are available for the treatment of pelvic organ prolapse.
Enterocele and massive vaginal eversion. Uterosacral ligament suspension.
Enterocele and massive vaginal eversion. Iliococcygeus fixation.
Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum.

of 25

Author

Rony A Adam, MD Professor of Clinical Obstetrics and Gynecology, Vanderbilt University School of Medicine

Rony A Adam, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Panza, MD, FACOG Assistant Professor of Clinical Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Rochester Medical Center

Joseph Panza, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urogynecologic Society, Society of Gynecologic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Chief Editor

Kris Strohbehn, MD Professor and Vice Chair of Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center

Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, Society of Gynecologic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Robert K Zurawin, MD Associate Professor, Chief, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society of Laparoendoscopic Surgeons, Texas Medical Association, AAGL, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Received consulting fee from Ethicon for consulting; Received consulting fee from Bayer for consulting; Received consulting fee from Hologic for consulting.

Raisa O Platte, MD, PhD Urogynecology Associate, Department of Obstetrics and Gynecology, Geisinger Health System

Raisa O Platte, MD, PhD is a member of the following medical societies: American Medical Association, AAGL, American Urogynecologic Society, International Continence Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Thinh H Duong, MD, FACOG to the development and writing of this article.

Sections Enterocele and Massive Vaginal Eversion
Overview
Presentation
Workup
Treatment
Media Gallery
References

Enterocele and Massive Vaginal Eversion Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?