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Apical Prolapse

Apical prolapse is descent of the uterus/cervix or vaginal vault. Assess the apex together with the anterior and posterior walls: loss of upper vaginal support can contribute to a visible wall defect. Treatment depends on symptom bother, function, anatomy and patient goals; descent on examination alone does not require surgery.[1][2]

See POP Overview for general risk factors, staging, pelvic-floor therapy and pessary care, and Prolapse Repair Principles for the broader operative decision framework.

Terminology and Support​

TermMeaning and clinical implication
Uterine or cervical prolapseDescent of the uterus/cervix, including a retained cervical stump. Discuss uterine-preserving and hysterectomy-based options when surgery is chosen.
Vault prolapseDescent of the vaginal apex after total hysterectomy. Reconstructive repair restores apical support; an obliterative repair is another option for selected patients.
EnteroceleHerniation of a peritoneal sac, sometimes containing small bowel, into the upper posterior vaginal compartment. It may coexist with apical prolapse and is not synonymous with every rectocele.
HysteropexySuspension preserving the uterus. The specific route, material, cervical anatomy and future uterine evaluation matter.
ColpocleisisVaginal obliteration for a patient who accepts permanent loss of penetrative vaginal intercourse. It does not eliminate all sexual activity or every pelvic-floor symptom.

The cardinal–uterosacral complex provides Level I support to the cervix and upper vagina. When hysterectomy is performed to treat uterine prolapse, plan the associated support procedure: removal of the uterus is not itself apical suspension. The need for additional wall repair is individualized.[1][2]

Evaluation That Changes the Plan​

Record bulge symptoms, bladder emptying and leakage, bowel symptoms, sexual goals, prior operations/mesh, medical risk, and preferences concerning the uterus and vaginal intercourse.[1][2]

Examination elementInterpretation
POP-Q CMost distal cervix or vaginal cuff.
POP-Q DPosterior fornix when the cervix is present; omit when the cervix is absent. A supracervical hysterectomy does not automatically make D inapplicable.
TVLTotal vaginal length measured with prolapse reduced.
Genital hiatus / perineal bodyDescribe the outlet and support context. These measurements are not a stand-alone mandate for perineorrhaphy or a particular apical operation.
Apical reductionReassess anterior/posterior support while reducing the apex. Improvement demonstrates a contribution from apical support, but does not prove that a particular isolated repair will inevitably fail.

Stage with an empty bladder and adequate straining; consider an upright examination if the supine findings do not reproduce symptoms. Distinguish cervical elongation from generalized apical descent. Avoid using a single study's point-C threshold as a universal indication for surgery.[2]

Additional investigations should answer a specific question:

  • Bladder assessment: measure residual urine when emptying symptoms or other findings warrant it. Reduction stress testing can inform continence counseling; it does not predict postoperative leakage with certainty.
  • Urodynamics: use selectively. NICE recommends filling/voiding cystometry before planned SUI surgery with anterior/apical prolapse, voiding dysfunction, unclear incontinence type or urge-predominant mixed incontinence, or previous SUI surgery. This is not routine testing before every prolapse operation.
  • Imaging: dynamic imaging/defecography may help selected complex or discordant posterior/bowel presentations. It is not required simply because an enterocele is suspected clinically.
  • Retained uterus/cervix: investigate abnormal bleeding, lesions and relevant risk; confirm appropriate cervical screening. Uterine preservation or colpocleisis does not mandate ultrasound and endometrial biopsy in every asymptomatic low-risk patient, but closure makes subsequent access more difficult.[1][2][10]

Choosing Treatment​

Observation, pelvic-floor therapy and pessary treatment remain options according to symptoms and preference. Offer surgical discussion when symptoms remain unacceptable or nonsurgical treatment is declined. Consider recovery burden, recurrence, urinary/bowel and sexual outcomes, material-specific harm and the possibility of future treatment.[1]

Vaginal native-tissue suspension​

ProcedureMain considerations
Uterosacral ligament suspension (USLS)Usually bilateral support. Protect the ureters, assess the bladder and bilateral ureteral efflux cystoscopically, and investigate abnormalities. No fixed distance from the ischial spine guarantees safe sutures.
Sacrospinous ligament fixation (SSLF)Commonly unilateral, with bilateral variants. Discuss buttock/groin/leg pain and neural or vascular injury. Changing the vaginal axis does not establish inevitable anterior recurrence.
Iliococcygeus suspensionAlternative support site when anatomy and the operative plan favor it; less comparative trial evidence.
McCall culdoplastyCul-de-sac closure and uterosacral support, commonly associated with vaginal hysterectomy. The named procedure and extent should be documented rather than assuming any cuff closure provides the same support.

See the linked technique pages below for operative anatomy and verification steps.

OPTIMAL: corrected two-year composite success was 100/155 (64.5%) after USLS versus 94/149 (63.1%) after SSLF; difference 1.4 percentage points (95% CI −9.4 to 12.2). This superiority trial did not demonstrate a difference and did not establish equivalence. Its 374 randomized women had prolapse and SUI with planned concomitant retropubic slings. The 2015 correction matters: the older PMC manuscript retains different outcome numbers.[3][4]

E-OPTIMAL: 285 women entered extended follow-up and 244 completed it. Estimated five-year first composite failure was 61.5% versus 70.3%, with substantial uncertainty around the difference. Symptoms generally remained improved. An earlier anatomic or symptom failure remained counted even if a later assessment improved; these percentages are not the proportion requiring repeat surgery or reporting persistent bothersome prolapse at five years.[5]

Sacrocolpopexy​

Sacrocolpopexy attaches the vagina to the anterior longitudinal ligament over the sacrum using mesh. Open, laparoscopic and robotic routes have different operative and recovery tradeoffs; robotic assistance does not guarantee better clinical outcomes. Symptoms, prior repair, anatomy, medical suitability, mesh preference and surgical expertise guide selection rather than a mandatory age or stage cutoff.[1][6]

Post-hysterectomy vault prolapse: the 2023 Cochrane review supports less recurrent prolapse and repeat prolapse surgery after sacral colpopexy than after several vaginal operations. Its 59 trials address many different comparisons and its search ended in March 2022; the vault findings cannot establish a universal ranking for uterine-preserving surgery.[6]

ASPIRe (2024) adds a major vault-specific randomized comparison: 376 women were randomized and 360 underwent surgery. Modeled three-year composite failure was 28% with sacrocolpopexy versus 43% with native-tissue repair; adjusted HR 0.57 (99% CI 0.33–0.98). The composite includes bulge, examination findings or retreatment; repeat operations were much less frequent. Its separate transvaginal-mesh arm studied a product no longer marketed in the US, and does not establish current availability of that procedure.[7]

Primary uterovaginal prolapse: September 2026 review​

The Huffman U-POP review included 24 studies (6,329 hysterectomy-plus-sacrocolpopexy patients; 681 vaginal hysterectomy-plus-native-tissue patients). It found lower pooled failure/retreatment proportions with sacrocolpopexy. Most evidence was observational and the analysis compared study-arm proportions, not 24 randomized head-to-head effects. This supports discussing durability when hysterectomy is chosen; it does not establish a personal absolute benefit, a universal high-risk cutoff or a reason to exclude hysteropexy.[8]

Mesh and hysterectomy counseling​

Abdominally placed sacrocolpopexy mesh differs from transvaginal mesh for prolapse. Discuss exposure, pain, infection, organ injury and possible further treatment. A single pooled exposure percentage cannot represent every mesh, hysterectomy type and follow-up interval.[6][7][9]

In e-PACT II, cumulative mesh exposure after minimally invasive total hysterectomy and sacrocolpopexy was 18/182 (9.9%), incorporating earlier events, at a mean 5.3 years. Only 82 of the original 200 participated in the later visit and 56 underwent examination. This is not a randomized comparison of total versus supracervical hysterectomy.[9]

Choose uterine/cervical removal based on pathology, screening needs, anatomy and preference; retaining the cervix does not eliminate exposure. See Supracervical Hysterectomy and Sacrocolpopexy for the procedure-specific evidence.

Uterine preservation​

Offer an appropriate uterine-preserving option when the patient prefers it and evaluation does not identify a reason for removal. Options include native-tissue sacrospinous hysteropexy and abdominal sacrohysteropexy; Manchester repair includes cervical amputation and is a distinct operation. No single outcome estimate applies to all routes and materials.[1][6]

Ten-year SAVE-U (2026): the original trial randomized 208 women. The extended primary endpoint was available for 93 (44 hysteropexy; 49 vaginal hysterectomy/USLS), with 89 examinations. Apical failure with bothersome bulge or repeat apical surgery occurred in 3/44 versus 7/49; reported risk difference −6.6 percentage points (95% CI −19.9 to 6.7). Attrition and the inclusion of earlier failures limit the estimate. It supports native-tissue hysteropexy as an option, without proving long-term superiority or equivalence.[11]

This trial is distinct from SUPeR, which evaluated transvaginal mesh hysteropexy. See the POP overview for that distinction. Future pregnancy requires specific counseling; preservation of the uterus does not establish reproductive safety, and NICE excludes Manchester repair when future childbearing is planned.[1]

Colpocleisis​

Consider colpocleisis when the patient accepts permanent loss of penetrative vaginal intercourse, especially when comorbidity increases the burden of reconstructive surgery. Discuss retained organs, future access, urinary symptoms and the possibility of regret. Hysterectomy and concomitant continence surgery are separate decisions.[1][10]

Le Fort partial repair retains lateral epithelial channels and can also be used for a posthysterectomy vault; total colpocleisis is usually performed after hysterectomy. The variants should not be treated as interchangeable in every patient. In a multicenter prospective cohort, 125/132 respondents were satisfied with their decision at one year, while only 103/152 had an examination. Satisfaction, anatomic recurrence and reoperation are different endpoints.[10][12]

See Colpocleisis for the operative sequence and more detailed outcome/screening evidence.

Continence Planning and Follow-up​

Separate bothersome SUI, occult leakage on reduction, urgency and no incontinence. Discuss combined versus staged continence treatment and the tradeoff between postoperative leakage, catheterization, procedure-specific harm and a possible later operation. Neither a positive reduction test nor existing abdominal access automatically mandates a sling or Burch procedure. The 2026 Cochrane review distinguishes these populations and finds uncertainty in prophylactic Burch evidence for stress-continent women.[1][13]

Follow symptoms, examination findings, bladder/bowel and sexual function, repeat treatment and material-related complications separately. Arrange an early recovery/emptying plan; NICE recommends a six-month postoperative review with vaginal examination and access to reassessment for recurrent symptoms or complications. New bleeding, persistent discharge, pain, recurrent bulge or emptying difficulty warrants assessment.[1][9][10]

See Also​

Videos​

High Uterosacral Ligament Suspension
Dr Deeksha Pandey (2021)

References​

1. NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). Recommendations 1.3.15–1.3.16, 1.8 and 1.9. Recommendations.

2. Barbier H, Carberry CL, Karjalainen PK, et al. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction. Int Urogynecol J. 2023;34:2657–2688. doi:10.1007/s00192-023-05629-8.

3. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311:1023–1034. doi:10.1001/jama.2014.1719. Corrected publisher main and supplement reviewed.

4. Incorrect Outcomes Data. JAMA. 2015;313(22):2287. doi:10.1001/jama.2015.4817. OPTIMAL correction.

5. Jelovsek JE, Barber MD, Brubaker L, et al. Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy on outcomes at 5 years in the OPTIMAL randomized clinical trial. JAMA. 2018;319:1554–1565. doi:10.1001/jama.2018.2827.

6. Maher C, Yeung E, Haya N, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2.

7. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159:845–855. doi:10.1001/jamasurg.2024.1206.

8. Huffman JA, Ashmore S, Kim S, et al. Hysterectomy with minimally invasive sacrocolpopexy versus native tissue repair for primary uterovaginal prolapse: a systematic review and meta-analysis. Int Urogynecol J. Published September 3, 2026. doi:10.1007/s00192-026-06863-6.

9. Bretschneider CE, Myers ER, Geller EJ, et al. Long-term mesh exposure 5 years following minimally invasive total hysterectomy and sacrocolpopexy. Int Urogynecol J. 2024;35:901–907. doi:10.1007/s00192-024-05769-5.

10. Grzybowska ME, Futyma K, Kusiak A, Wydra DG. Colpocleisis as an obliterative surgery for pelvic organ prolapse: is it still a viable option in the twenty-first century? Narrative review. Int Urogynecol J. 2022;33:31–46. doi:10.1007/s00192-021-04907-7.

11. Oegema K, et al. Sacrospinous hysteropexy versus vaginal hysterectomy in women with uterine prolapse: 10-year follow-up of a randomised controlled trial. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06822-1.

12. FitzGerald MP, Richter HE, Bradley CS, et al. Pelvic support, pelvic symptoms, and patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:1603–1609. doi:10.1007/s00192-008-0696-6.

13. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.