Vaginal vault prolapse results from elongation or detachment of the sacrouterine-cardinal ligament complex. It commonly manifests with other vaginal defects, such as cystocele, enterocele, and rectocele. Patients typically present with symptoms similar to uterine prolapse: a mass protruding vaginally, dyspareunia, low back pain, or perineal pressure. Sometimes, patients present with symptoms of voiding dysfunction, such as incomplete emptying, retention, recurrent infections, or incontinence.

An enterocele is a hernia of the peritoneum, with its contents extending between the vagina and rectum at the level of the vaginal vault. The use of dynamic magnetic resonance imaging (MRI) has allowed routine identification of the contents: small bowel, sigmoid, fluid, or omentum. Most enteroceles are acquired as a result of prior surgery on the anterior vaginal wall altering the vaginal axis or poor closure of the cul-de-sac at the time of hysterectomy. The incidence of enterocele in patients who underwent gynecologic surgery is as high as 16%.1 For the purposes of this chapter, we divide enteroceles into simple and complex types. A simple enterocele exists when there is no concomitant vault prolapse. The only defect is between the perivesical and prerectal fascia, which allows the peritoneum to herniate through, creating an enterocele. In a complex enterocele, there is concomitant vault prolapse. Many techniques have been described for supporting the vaginal vault after enterocele repair and hysterectomy.


The most proximal portion of the vagina, called the vaginal cuff or vault, is supported by the cardinal ligaments and uterosacral ligament complex. The cardinal ligaments are thick, anteriorly based fascial condensations originating from the greater sciatic foramen and inserting into the lateral fascia of the cervix and adjacent vaginal wall. They provide critical uterine and apical vaginal support. The uterosacral ligaments originate from the sacral vertebrae and insert into the lateral vaginal fornices, fusing with the cardinal ligaments posteriorly and stabilizing the uterus, cervix, and apical vagina in a posterior direction toward the sacrum. The broad ligaments, located more superiorly, attach the lateral walls of the uterine body to the pelvic side wall, providing additional uterine support. They contain the fallopian tubes, the round and ovarian ligaments, and the uterine and ovarian blood supply.

Lateral walls of the rectum are supported to the lateral pelvic wall and sacrum by condensations of connective tissue to the levator muscle extending to the sacrum (i.e., pillars of the rectum). The rectovaginal septum is a fascial extension of the peritoneal cul-de-sac between the vaginal apex and the anterior rectal wall. The septum consists of two distinct fascial layers: posterior vaginal fascia and prerectal fascia. The layers fuse with the cardinal-uterosacral ligament complex proximally, stabilizing the posterior vaginal apex. The two layers fuse distally and insert into the perineal body. The perineal body is a tendinous structure located in the midline of the perineum between the vagina and anus, and it provides additional pelvic support to the posterior vaginal wall and rectum. It serves as a central insertion point for the superficial and deep transverse perineal, bulbospongiosus, and external sphincter muscles. The perineal membrane consists of the distal 3 to 4 cm of the vagina and serves as an attachment point for the levator musculature. This is a critical anatomic landmark in posterior repair.

The musculature of the pelvic floor provides the main support for the pelvic viscera. It is composed of the coccygeus and levator ani muscles. The horizontal levator plate allows maintenance of the normal vaginal axis. The levator hiatus refers to the midline openings of the levator ani that allow passage of the urethra, vagina, and rectum. The proximal vagina and rectum rest on the levator floor and remain well supported with increases in intra-abdominal pressure in patients with normal pelvic support.

Pelvic floor relaxation results in vaginal wall prolapse. Multiparity, obesity, hormonal changes, increasing age, and tissue and nerve damage can play important roles in vaginal prolapse. The resulting area of prolapse depends on the location of muscular and ligamentous damage.


Patients found to have small vault prolapse or enteroceles on physical examination are typically asymptomatic. As the vault prolapse increases, patients may report symptoms of vaginal and perineal fullness or lower back pain that improves with supine positioning. Other complaints include dyspareunia and symptoms of voiding dysfunction, such as incomplete emptying, retention, recurrent infections, or incontinence. Patient with voiding symptoms should be evaluated with video urodynamic studies. The physical examination is essential for diagnosis, and it usually reveals a bulging mass at the vaginal apex. An enterocele can be difficult to distinguish from a high rectocele or cystocele. Separate examination of the vaginal walls with a half-blade of a Graves speculum is routine with Pelvic Organ Prolapse Quantification measurements.

Simultaneous rectal and vaginal examination may aid in differentiating an enterocele from a high rectocele. Examination in the standing position and cystoscopic light in the bladder also may assist in making the proper diagnosis.2 Any concomitant defects should be documented.

Many radiologic modalities have been used in the diagnosis of enterocele, including defecography, fluoroscopy, dynamic cystocolpoproctography, and MRI. Dynamic MRI provides superior imaging of all three vaginal compartments and may help differentiate introital masses.3 In patients with severe prolapse of the anterior and apical vaginal wall, the upper urinary tract must be evaluated (e.g., renal ultrasound, pyelogram, computed tomography urography) because severe prolapse can cause severe angulation of the ureters resulting in ureteral obstruction.


Surgical Techniques

Numerous techniques have been described for vault prolapse and enterocele repair, including abdominal, vaginal, and laparoscopic repair. Because several of these procedures are discussed in detail in other chapters, they are mentioned briefly here as a reference only. Abdominal repair, with sacrocolpopexy or hysterectomy, closes the cul-de-sac using one of two popular techniques. The Moschcowitz repair obliterates the cul-de-sac using purse-string sutures from the bottom of the sac to the most cephalad aspect. The Halban repair obliterates the cul-de-sac by placing sutures in the sagittal plane between the anterior rectal wall and the posterior vaginal wall. Vaginal repair avoids the morbidity of a laparotomy and has the advantages of decreased hospital costs and quicker recovery time. In the following sections, we describe two techniques used for transvaginal sacrouterine fixation.

Transvaginal Sacrouterine Fixation for Vault Prolapse with Enterocele Repair

The patient is placed in the high lithotomy position after anesthesia is provided. The lower abdomen and vagina are prepared and draped in a sterile fashion. The labia minora are retracted, and a Foley catheter is placed. A ring retractor with hooks is positioned, and the enterocele is grasped with two Allis clamps. In patients undergoing concomitant hysterectomy, the peritoneal cavity is exposed. The vaginal apex is located by identifying the scar at the lateral apex. It is marked bilaterally with electrocautery. A vertical incision is made anteriorly from the base of the bladder extending posteriorly to the prerectal area. Sharp dissection is used to free the peritoneal sac from the vaginal wall. Special attention is necessary to avoid inadvertent bladder or rectal injury during the dissection. Cystoscopic illumination of the bladder can help define the bladder base.

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