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The aging of our population has resulted in a greater number of women presenting with symptomatic vaginal vault prolapse. Recent population surveys have demonstrated that 11.1- 29.2 % of adult woman may require surgery and re-operation for vaginal prolapse (3). Typically, women with vaginal vault prolapse will present with an exteriorized vaginal mass (Fig.1). It is crucial for the treating clinician to carefully evaluate the patient’s anatomy to determine which segment(s) is prolapsed. Care should be taken to evaluate the degree of support weakness of the vaginal apex. In a patient who has undergone a hysterectomy, the vaginal "dimples" are typically seen on either side of the midline at the vaginal apex. These dimples represent utero-sacral ligament attachments to the vaginal apex. In planning reconstructive surgery, accurate localization of the vaginal apex is crucial in achieving satisfactory restoration of normal anatomy.
Care must be taken to not confuse vaginal vault prolapse with an anterior vaginal prolapse (cystocele) or posterior support weakness (rectocele). Vaginal vault prolapse typically occurs concomitantly with a posterior vaginal enterocele. It is important to resuspended the vaginal apex when it is present along with the enterocele being repaired, and vice-versa.

Anatomic Correlates.

Vaginal vault prolapse typically occurs as a result of tearing of the utero-sacral ligaments off of the vaginal cuff in a woman who has previously undergone a hysterectomy. In non-hysterectomized women, stretching of the utero-sacral ligaments due to inherent connective tissue weakness can result in vaginal vault prolapse. A transverse or longitudinal fascial tear at the vaginal apex and resultant disruption of fascial integrity can lead to development of vaginal vault prolapse. In repairing the prolapse, it is important to identify the individual fascial tears and repair them.

Bladder function.

Women with vaginal prolapse may present with various forms of voiding dysfunction. These include urinary retention, urgency and urinary frequency and stress incontinence. When evaluating bladder function in a woman with vault prolapse it is key to evaluate her bladder function with a prolapse reduced. A woman who leaks during her pelvic examination with a vault suspended should be strongly suspected of having intrinsic sphincter deficiency which needs to be addressed individually at the time of her prolapse correction surgery. Urodynamic testing to evaluate urethral sphincter function is an important requirement in the pre-operative care of a woman with exteriorized vaginal prolapse who will be undergoing surgical therapy.