**1. Introduction**

Pelvic organ prolapse is defined as the symptomatic downward displacement of pelvic organs usually through the vagina. The incidence is 3–6% based on symptoms but as high as 50% based on examination as a majority of the women are asymptomatic [1].

Risk factors for prolapse include previous vaginal deliveries, assisted/difficult vaginal deliveries, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and family history of pelvic organ prolapse.

There is no agreed definition of pelvic organ prolapse after hysterectomy. The International Continence Society (ICS) joint report defines it as "descent of the apex of the vagina after hysterectomy" [2]. The route of hysterectomy does not seem to be of consequence in developing prolapse later and subtotal hysterectomy does not prevent development of prolapse. Efforts should be made to support the top of the vagina at the time of hysterectomy. Techniques that have been employed include McCall's culdoplasty, attaching the posterior vaginal wall to the uterosacral ligaments and sacrospinous ligament fixation.

The incidence of post hysterectomy vaginal prolapse ranges from 0.2 to 43% [3, 4] according to older case series but more recently the incidence has been quoted at 11.6% if hysterectomy was done for prolapse and 0.2% for non-prolapse benign cases [5]. A large Austrian study revealed the incidence of post hysterectomy prolapse to be between 6 and 8% [6].

### **2. Relevant clinical anatomy**

The pelvic floor comprises skeletal muscle (levator ani and coccygeus), urogenital diaphragm, endopelvic fascia and perineal body. The levator ani comprises of pubococcygeus, ileococcygeus and puborectalis muscles. The striated muscles are under tonic contraction. The pelvic diaphragm provides a hammock which anteriorly has a defect or hiatus that allows passage of urethra, vagina and rectum.

The striated muscles of the pelvis contain both slow and fast twitch fibres. Fast twitch contract suddenly with increased abdominal pressures while slow twitch fibres maintain the muscle tone over a long time.

The perineal membrane or urogenital diaphragm is a dense fibrous tissue which spans the anterior part of the outlet and provides attachment for vagina, urethra and rectum. The perineal body lies between the vagina and anus and provides attachment for pelvic floor muscles.

Uterine support (De Lancey I) comprises of uterosacral and cardinal ligaments which are attached to the cervix and upper vagina. Uterosacral ligaments comprise of smooth muscles and form the medial border of the Pouch of Douglas while cardinal ligaments comprise of connective tissue and pelvic blood vessels. At hysterectomy providing support to these ligaments is key in avoiding vault prolapse regardless of the route of hysterectomy. The round ligament helps maintain anteflexion and version of the uterus whereas the broad ligament is just a fold of peritoneum and both have no role in supporting the uterus.

The middle third of the vagina is attached laterally to the arcus tendineus fascia pelvis, a condensation of obturator and levator fasciae (De Launcey II). Anteriorly this condensation is called pubocervical fascia and posteriolaterally it is attached to endopelvic fascia over pelvic diaphragm and sacrum by fascia of Denonvilliers (vaginal septum), and extends caudally into the into perineal body (De Launcey III) and cranially into peritoneum of the Pouch of Douglas.

#### **3. Assessment**

The general approach to patients presenting with prolapse symptoms entails a thorough and comprehensive obstetric and gynaecological history followed by a general, abdominal and pelvic examination. A review of risk factors which can be modified is essential as well as asking direct questions regarding bladder, bowel and sexual function. The impact on the quality of health should be assessed including time off work, relationships and coping mechanisms documented.

**Table 1** shows the International Continence Society's POPQ (pelvic organ quantification system) [7] which is used to assess pelvic organ prolapse. It has 6 points which are all measured at maximum Valsalva except total vaginal length. **Table 2** shows the criteria for staging.

*Management of Vaginal Vault Prolapse after Hysterectomy DOI: http://dx.doi.org/10.5772/intechopen.101385*


**Table 1.** *POPQ system.*


**Table 2.** *POPQ staging criteria.*
