The upper third of the posterior vaginal wall is suspended by the cardinal-uterosacral ligament complex and the distal third fuses with the perineal body (Fig. 14.2). The middle half is supported by fascia attached laterally to the ATFP. There is controversy regarding the presence of a rectovaginal septum; however, histological studies and imaging studies have confirmed its presence [12, 13] (Fig. 14.3).

The levator ani muscle and rectovaginal septum work together, to provide the necessary support to the posterior vaginal wall. The perineal body is suspended by and attached to the puborectalis muscle. The puborectalis muscle forms a sling that creates an angle of 45° at the anorectal junction. Proximally, the vagina is supported by the pubococcygeus and iliococcygeus muscles on which it lies. In a woman with a healthy pelvic floor, the puborectalis muscle is in a resting tone which closes the vaginal canal and causes the anterior and posterior walls of the vagina to lie in apposition. There is little stress placed on the rectovaginal septum and connective tissue support of posterior vagina even during defecation, as the increased pressure placed on the posterior vaginal wall is equilibrated by the opposing anterior vaginal wall. However, with damage sustained during childbirth, the levator hiatus enlarges and the vaginal canal opens [14]. Defecation in such a situation leads to increased strain on the endopelvic fascial attachments and the rectovaginal septum which can lead to discrete tears resulting in rectocele and excessive perineal descent.

The two key questions that need to be asked before surgery are whether the symptoms of prolapse are bothersome enough and can they be attributed to the prolapse. Conservative therapy should be discussed prior to surgical intervention. It is important not to expose asymptomatic women or women with non-bothersome symptoms to the risks of surgery. It is also advisable to defer prolapse repair until the woman completes childbearing.

Anterior and posterior vaginal wall defects very rarely occur in isolation. Thorough pelvic floor examination, including POP-Q assessment is essential, to determine whether there is coexistent prolapse of other vaginal compartments. When prolapse is present at more than one anatomic site, a coordinated approach to the repair is required. The outcomes following both anterior and posterior wall repairs have been shown to be significantly improved, when performed concurrently with an apical support repair. In the presence of an apical prolapse, surgical support of apex, either abdominal or vaginal should be performed prior to an anterior colporrhaphy or posterior repair. In combined abdominovaginal procedures, it is always better to move from a clean field (abdominal) to a clean-contaminated field (vaginal) to decrease the risk of infection.

Important issues to address are, if prolapse coexists with urinary tract or bowel problems (urinary incontinence, urinary retention, constipation, or fecal incontinence). An urine analysis is usually done to rule out infection in symptomatic patients. Urodynamic testing should be considered in a patient with urinary incontinence and POP, as the combined condition falls in the category of complicated incontinence for which urodynamics has been recommended by the ICI guidelines [15]. Even if the patient does not complain of voiding dysfunction or incontinence, in the presence of an anterior wall prolapse of grade 3 or greater, it may be preferable to test urethral function with the prolapse reduced [15, 16]. A woman with severe anterior vaginal wall prolapse may be continent because of urethral kinking [17] and it is important to identify occult incontinence by prolapse reduction. Pessaries, large cotton swabs, or ring forceps-type instruments can be used to reduce anterior wall prolapse at the time of urodynamic testing, taking care that the urethra is not compressed. If concomitant stress urinary incontinence is proved to exist along with the prolapse, the choice of performing an appropriate anti-incontinence procedure along with the prolapse surgery can be offered with appropriate counseling.

Sexual dysfunction can be associated with POP and women may also experience dyspareunia or other sexual problems following repair. It is therefore important that whatever repair is chosen, attempt should be made to maintain adequate vaginal length.

The patient also needs to be assessed for pelvic floor dyssynergia (incoordinate contraction of the pelvic floor muscles) on pelvic examination or by ultrasound. In the presence of dyssynergia, the patient should be advised to undergo a course of physiotherapy, to re-learn proper pelvic floor contraction. A patient who pushes instead of squeeze while performing Kegel’s maneuver is most likely to be harmed rather than helped by the prescription of Kegel exercises.

In a patient with defecatory dysfunction along with posterior wall prolapse, defecogram or defecating proctogram may be useful to determine the presence of occult rectal prolapse, intussusception, or non-relaxation of the levator ani. If such defects are noted, it is essential to counsel the patient about possible management options. For example, in a patient with non-relaxing pelvic floor during defecation, physiotherapy and biofeedback to relearn appropriate relaxation of the levator ani muscles may be needed before surgery.

Lastly, it is important to determine the patient’s expectations from treatment to determine the best possible surgical treatment for her.

George White [7] said at the beginning of the twentieth century that “The only problem in plastic gynecology left unsolved by the gynecologist of the past century is that of permanent cure of cystocele.” Irony is that, this is true even now.

The principles in intraoperative care includes, use of prophylactic antibiotics and interventions for thromboprophylaxis. In the modified lithotomy position, the patient is examined under anesthesia, to determine the site-specific defects and the ease of approach to sacrospinous ligaments. The Lone Star vulvovaginal retractor is useful in the absence of trained assistants [16].

Anterior colporrhaphy is the procedure of choice for repair of anterior wall prolapse. The technique described here takes care of any transverse defect, in which the pubocervical fascia is detached from the pericervical ring. The procedure starts with a vertical midline incision. The vaginal epithelium is then dissected off the underlying fibromuscular layer to the lateral vaginal sulci and up to the vaginal apex or cervix. This layer is then plicated in the midline using interrupted 2-0 polyglactin 910 suture (Vicryl) from the level of the bladder neck to vaginal apex. When placing the final most proximal suture, the endopelvic fascia is incorporated with the cardinal ligaments, thus reattaching the anterior vaginal wall to the vaginal apex (either the cervix or vaginal cuff) using permanent suture. When the uterus is still present, the proximal suture is placed through the cervical stoma. Since most cystoceles begin as superior transverse fascial tears from the cervix/apex, incorporation of the apical-most plication stitch to the supportive tissue of the apex is advocated (Fig. 14.4). Addressing this defect, with reattachment of the torn fascia at the time of anterior colporrhaphy, restores the continuity between anterior vaginal wall and apex, which can decrease the recurrences. A study comparing the use of permanent suture for the proximal apical stitch as opposed to absorbable has conclusively shown that the use of permanent suture is associated with improved anatomic correction, however, at the expense of increased suture exposures [18].

Paravaginal repair is the reattachment of the lateral sulcus of the anterior vaginal wall to the ATFP using permanent sutures, by careful dissection through the vesicovaginal space. The two points which mark the boundaries of the linear ATFP to which the vaginal wall will be reattached are, the ischial spine and the inferolateral pubic bone. Grade 0 permanent suture is passed perpendicular to the arcus 1.5 cm anterior to the ischial spine (first suture). Four to five sutures are then passed through the arcus with 1 cm distance between the sutures. Usually four to six sutures are placed on each side in a complete bilateral paravaginal defect. After the sutures are placed through the arcus, anterior fascial plication and other anterior compartment procedures are performed as indicated. The sutures are then sewn to the connective tissue layers of the bladder and the vagina at matching levels. For each of these landmarks, a point halfway between the ramus and the midline is chosen. Sewing the vagina and bladder at points too lateral, results in an inadequate lift, and choosing points too medial yields a very dramatic anterolateral elevation of the vagina that is difficult to close. In contrast, choosing the midpoints result in a tension-free skin closure. The vaginal wall is then closed with 2-0 Vicryl after trimming any excess vaginal epithelium [16].

In the abdominal paravaginal repair, low transverse or vertical midline incision may be used to enter the retropubic space. An intravaginal finger helps in demonstrating the location and extent of the paravaginal defect on either side. The first stitch is near the vaginal apex, the obturator internus muscle and fascia, with the arcus included, all within 1–2 cm of the ischial spine. The permanent sutures are then continued towardsthe pubis, reattaching the lateral vagina to pelvic side wall about 1–1.5 cm apart. After placing all the sutures, the knots are tied, from the spine up to the pubis. Any bleeding that may occur from the suture site, usually stops when the sutures are tied.

The laparoscopic approach achieves the same repair that would otherwise be done through the abdominal route. Utilizing an infraumbilical open laparoscopy technique and three ancillary ports, the peritoneal cavity is entered, and the superior bladder border is identified. Transperitoneal entry into the retropubic space is then achieved. The repair is then similar to that described for the abdominal approach [16].

Augmented repair of the anterior wall with either synthetic mesh kits or biological grafts came into vogue because of the poor long-term success rates reported with traditional anterior repairs. Although the connective tissue is reattached to strong supports in traditional repairs, the tissue itself is weak and the repair is less likely to be durable.

In the last decade, many surgeons moved from the earlier traditional paradigm of addressing single compartments with autologous tissue to newer multicompartment composite procedures utilizing synthetic mesh or biological grafts. Synthetic mesh-trocar-based kits such as Apogee™, Perigee™ and Prolift™ were developed to simplify the placement of mesh, and studies have shown cure rates in the range of 87–96 % [19, 20]. A second-generation mesh kit using type 1 macroporous polypropylene lightweight mesh (IntePro Lite™) for combined anterior/apical prolapse repair has been studied and found to have anatomic success rates in the range of 92 % with minimal mesh erosion [21]. A recent Cochrane review has confirmed that mesh use in the anterior compartment has a lower failure rate when compared to traditional repair [22, 23]. However, a systematic review of complications by the Review Group of the Society of Gynecologic Surgeons (SGS) found a high incidence of graft erosion, wound granulation and dyspareunia (10.3, 6.8, and 8.9 %, respectively) following the use of synthetic mesh [24]. In light of the recent FDA notifications cautioning the use of synthetic mesh [25], use of mesh-augmented repair has now become controversial and surgeons are going back to traditional native tissue repairs.

Various biological graft materials have also been used for anterior repair with variable success. Anatomical recurrence rates following the use of biological mesh (Pelvicol™) for anterior wall reinforcement vary from 6.9 to 50 % [26–28]. Gomelsky et al. [29] and Mahdy et al. [30] used porcine dermis absorbable graft (InteXen™) and reported failure rates of 12.9 % (mean follow-up 24 months) and 3.8 % (mean follow-up 8 months), respectively. Further studies are required before the efficacy of biological grafts in improving success rates of anterior repair can be validated. Studies assessing outcomes following different surgical techniques in anterior prolapse, has been tabulated in Table14.1.