**4. Management**

#### **4.1 Conservative management**

Prevention of prolapse is important and measures should be taken to avoid conditions that increase intra-abdominal pressure. Constipation and chest conditions such as chronic obstructive pulmonary disease (COPD) should be treated adequately. Weight loss is key and hormone replacement therapy may help reduce the incidence. Antenatal exercises, proper intrapartum care and timely caesarean section are also important in reducing the incidence of prolapse.

Initial management should involve appropriate counselling and initiation of pelvic floor muscle training. The best outcomes have been seen when a trained physiotherapist is involved. A perineometer and biofeedback device can be used. Vaginal cones and electrical stimulation have been shown to be effective in incontinence management but no data is available regarding efficacy on urogenital prolapse.

There is a role for devices including vaginal pessaries. They are either silicone or polythene and come in different sizes. They are inserted into the upper vagina and support pelvic organs. They can be cleaned and replaced every 6 months which gives the practitioner a chance to check for any complications. Special attention and counselling should be done with regards to regular changing, sexual function and small possibility of side effects including vaginal discharge, infection and rarely fistula formation.

#### **4.2 Surgical management**

The definitive management of post hysterectomy vaginal prolapse is surgery. This should be done by an appropriately qualified surgeon following thorough assessment and counselling of a patient. Different routes of surgery should be considered and discussed with patient. The choice of surgery depends on type of prolapse, age of patient, previous surgery, comorbidities, surgeon's skills and level of sexual and physical activity.

The aim of surgery is to restore normal vaginal anatomy and restore sexual, bowel and bladder functions. In studies, restoration of apical vagina (Point C on POPQ ) to 0 or I is used as the measure of prolapse treatment [8].

The type of surgery chosen should be individualised to the patient. This would depend on concomitant prolapse in other compartments, previous prolapse surgery, previous abdominal surgery, sexual activity, presence/absence of bowel or urinary symptoms, total vaginal length, presence of comorbidities and patient's preference.

Abdominal sacrocolpopexy can be undertaken via open or laparoscopic route. Patient selection is vitally important. It is the route of choice for women with a short vaginal length, those who require concomitant abdominal surgery and those with history of dyspareunia. The vaginal vault is fixed to the longitudinal ligament on the anterior part of the sacrum using a permanent mesh. Abdominal sacrocolpopexy is associated with lower rates of recurrence, dyspareunia and post-operative stress urinary incontinence compared to sacrospinous ligament fixation [8]. Common complications include infection, bleeding from presacral veins and mesh erosion. Laparoscopy may not be available in all centres and the learning curve is long.

Robotic sacrocolpopexy is available in limited centres around the world owing to the huge cost associated with setting up.

Sacrospinous ligament fixation entails fixing the vaginal vault to the sacrospinous ligament on one side using absorbable or non-absorbable materials. For right handed surgeons this tends to be fixed to the right sacrospinous ligament. No benefit has been shown for bilateral compared to unilateral fixation. It is associated with low recurrence, high satisfaction and takes a short time to perform and a short recovery time. Common complications include buttock pain, pudendal nerve injury, high recurrence of 8–30% of anterior compartment and ureteral obstruction.

High uterosacral ligament suspension (HUSLS) is also an acceptable procedure for vault prolapse but should not be offered as a first choice and should be undertaken by a well-trained pelvic floor surgeon owing to the risk of complications. An RTC comparing high uterosacral ligament suspension and sacrospinous ligament fixation and found the two similar in terms of anatomical, functional and adverse effects [9]. Complications of high uterosacral ligament suspension include bladder injury, ureteric injury, urinary tract infection, blood transfusion and bowel injury.

Transvaginal mesh involves use of permanent mesh to support the vaginal vault to the uterosacral ligament bilaterally in order to restore level I supports. It has been withdrawn in most centres around the world owing to safety concerns and complications. An RTC compared transvaginal mesh and laparoscopic sacrocolpopexy and found that laparoscopic sacrocolpopexy had longer operating time but better success rate and patient satisfaction at 2 year follow up and women in the transvaginal mesh group had shorter vaginal length and risk of erosion [10].

Colpocleisis is the complete closure of the vagina when sexual activity is no longer desired. It can be used to treat vaginal vault prolapse after hysterectomy following careful assessment and counselling. It has the advantage of being minimally invasive, can be done under regional anaesthesia and the technique is easy to learn. Several techniques are known including purse string closure [11], vaginectomy [12], colpocleisis after performing standard anterior and posterior vaginal wall repair [13], purse-string closure of enterocele followed by approximation of perivesical and rectovaginal fascia and high levator plication [14] and le Forte's colpocleisis [15].

It is recommended that one inserts a mid-urethral tape for cure of stress urinary incontinence at the time of surgery if the vaginal route is chosen. Colposuspension has not been shown to be effective in these patients. In case of recurrent vault

prolapse post hysterectomy, the case should ideally be discussed at a multi-disciplinary team before an appropriate plan is made regarding the type of surgery and the person to undertake it.
