Why prolapse can happen after a hysterectomy
The uterus is held up by ligaments that attach to the pelvic side walls and the sacrum, and the upper end of the vagina shares that support. When the uterus is removed, the surgeon closes the vagina at its upper end and attaches it to the remaining ligaments. That closed upper end is the vaginal vault.
Over time the ligaments that hold the vault can stretch. Pregnancy and childbirth before the hysterectomy, long-term constipation and straining, a persistent cough, heavy lifting, being overweight and menopause all add load. The NHS lists pelvic surgery such as hysterectomy among the factors that make prolapse more likely. The vault can then slide down the vagina.
Symptoms are the same as for other forms of prolapse. You may feel a lump or heaviness that is worse at the end of the day, notice tissue at the vaginal opening, have trouble emptying your bladder or bowel, or find intercourse uncomfortable.
Vault prolapse or bladder prolapse? Telling the bulges apart
After a hysterectomy there is no uterus to drop, so any bulge comes from one of three places. The vault itself can descend, which is apical prolapse. The front wall of the vagina can bulge with the bladder behind it, which is a cystocele. The back wall can bulge with the rectum behind it, which is a rectocele.
These often occur together. A woman who searches for bladder prolapse surgery after hysterectomy frequently has a cystocele and a dropped vault at the same time, because loss of support at the upper end lets the front wall fall too. Surgeons stage each compartment during an examination while you bear down, and plan the repair around every compartment that has dropped.
This matters for your decision. Repairing only the front wall when the vault is also down can be a reason a repair does not hold. If your diagnosis is a cystocele alone, see the cystocele repair page. If the vault is involved, the repair needs to restore apical support as well.
Options before surgery
Surgery is not the first step for everyone. NICE guideline NG123 recommends that women with prolapse are offered lifestyle advice, supervised pelvic floor muscle training for symptomatic stage 1 or 2 prolapse, and a vaginal pessary as an alternative to surgery. NICE recommends that the training programme runs for at least 16 weeks before its effect is judged. A pessary is a removable silicone device that holds the vaginal walls in place. It can be a long-term solution or a way to test whether relieving the bulge would relieve your symptoms.
If the bulge does not bother you, watchful waiting is reasonable. Surgery is usually considered when symptoms affect daily life, when a pessary is not tolerated, or when emptying the bladder or bowel becomes difficult.
How vault prolapse is repaired
ACOG describes three groups of reconstructive operations for vault prolapse. The first is suspension using your own tissue. In sacrospinous fixation the vault is stitched to the sacrospinous ligament on one or both sides. In uterosacral ligament suspension it is stitched to the remnants of the uterosacral ligaments. Both can be done through the vagina, without an abdominal incision.
The second is sacrocolpopexy. A strip of synthetic mesh is attached to the front and back of the vault and then to the sacrum, lifting the vagina back into the pelvis. It is done through an abdominal incision or laparoscopically, sometimes with robotic assistance. It is the mesh operation many American patients are asking to avoid when they search for repair without mesh.
The third is colpocleisis, an obliterative operation that closes most of the vaginal canal. It is a shorter procedure chosen by some women who no longer wish to have vaginal intercourse.
A 2023 Cochrane review of surgery for apical vaginal prolapse compared these approaches. It found that sacral colpopexy was associated with a lower risk of awareness of prolapse, recurrent prolapse on examination and repeat surgery for prolapse than a range of vaginal procedures. The authors rated the certainty of the evidence as very low to moderate. Your surgeon should explain how these trade-offs apply to your anatomy, age and plans.
Repair without mesh: what native-tissue vault support involves
A native-tissue vault repair re-attaches the vaginal vault to a strong structure in the pelvis using non-absorbable or delayed-absorbable sutures, with no synthetic implant left behind. The surgeon opens the vaginal wall at the vault, identifies the ligament to be used, places sutures through it and through the vault, and ties them so the vault sits back at its original level. Any cystocele or rectocele is repaired at the same time by tightening the supporting tissue under the front or back wall.
What you avoid is the set of complications specific to mesh: exposure of the material through the vaginal wall, erosion into the bladder or bowel, chronic pain and the possibility of a second operation to remove it. What you accept is that your own tissue is the material being relied on. Recurrence after any prolapse repair is possible, and the Cochrane evidence above suggests the risk of repeat surgery is somewhat higher after vaginal native-tissue suspension than after sacral colpopexy. The same review found that stress urinary incontinence after surgery was more common after vaginal procedures, while the effect on painful intercourse was uncertain. How you weigh a mesh-related complication against a possible second repair is a personal decision.
If you have already had a mesh sacrocolpopexy and the prolapse has come back, the situation is different again. Revision surgery with mesh in place is more involved, and not every surgeon or clinic takes it on. Tell any clinic you contact exactly what was done, and send the operative report.
What the 2019 FDA order covers
On April 16, 2019, the US Food and Drug Administration ordered the remaining manufacturers of surgical mesh intended for transvaginal repair of pelvic organ prolapse to stop selling and distributing those products in the United States. The FDA concluded that the manufacturers had not demonstrated reasonable assurance of safety and effectiveness for that use.
The order applies to mesh placed through the vagina to treat prolapse. It does not apply to mesh placed through the abdomen for sacrocolpopexy, and it does not apply to mesh slings for stress urinary incontinence. The FDA treats these as three separate device uses. In the UK, the NHS states that vaginal mesh surgery for prolapse is no longer done unless there is no alternative.
So if a US surgeon offers you sacrocolpopexy, that is a currently available operation. The question is whether you want a synthetic implant for apical support, or whether a native-tissue suspension would meet your goals.
Recovery and travel
Vaginal native-tissue repairs are generally done under general or regional anesthesia with a short hospital stay. Surgeons then restrict heavy lifting, straining and intercourse for a period they set while the tissue heals, commonly several weeks. Laparoscopic sacrocolpopexy has small abdominal incisions and a comparable restriction period. Open abdominal surgery takes longer to recover from.
If you are considering surgery abroad, the practical questions are the same as for any pelvic floor operation: how long you stay near the clinic before a check-up, when you can fly, and how follow-up works once you are home. Those are covered on the recovery and flying home page, including the week-by-week timeline the clinic gives its own patients. At Podo, plan for 5 to 10 days in Seoul after prolapse surgery. The final check is 5 to 10 days after surgery, before you fly home, and lifting is limited to 10 kilograms (about 22 pounds) for 8 weeks.
Questions to ask before vault prolapse surgery
Which compartments have dropped, and will each one be repaired in the same operation. Which ligament will hold the vault, and why that one. Will any mesh be used anywhere, including a sling for incontinence. How many vault repairs does the surgeon perform each year. What happens if the prolapse returns. If you have had prior prolapse surgery or a mesh implant, ask whether that changes the plan.
Bring the discharge summary from your hysterectomy if you have it. It tells the surgeon whether the cervix was removed and how the vault was closed.
A consultation at Podo
Consultations are available in English, and two of the clinic's three OB-GYN specialists are women. The clinic's pelvic ligament suspension technique uses the patient's own ligaments and sutures, without synthetic mesh, and is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse. After hysterectomy, the remaining pelvic ligaments are used to restore support around the vagina. If you have had a mesh sacrocolpopexy, whether further repair is possible is decided from the clinical examination.
Bring as many records of the earlier surgery as you can, including your hysterectomy discharge summary if you have it. The final decision rests on the in-person examination, and a revision is usually considered from 3 months after the original surgery, 2 months at the earliest.
For insurance, the clinic prepares the documents international insurers typically require: an itemized English receipt, a medical certificate, procedure codes and a completed claim form. Whether a procedure is reimbursed depends on your policy; the clinic provides documentation, not coverage decisions. Results and recovery vary from person to person. This page is general information and is not a diagnosis; a consultation is needed to decide whether a procedure suits you.
Questions
Can you get prolapse after a hysterectomy?
Yes. The upper end of the vagina, called the vault, depends on the same ligaments that held the uterus, and if they stretch the vault can drop. The front or back vaginal wall can bulge at the same time.
Is vault prolapse the same as bladder prolapse?
No. Bladder prolapse is a bulge of the front vaginal wall with the bladder behind it, while vault prolapse is descent of the upper end of the vagina. They often occur together after hysterectomy, and a repair plan should address both.
Can vault prolapse be repaired without mesh?
Yes. Sacrospinous fixation and uterosacral ligament suspension attach the vault to your own ligaments with sutures and leave no synthetic implant. Sacrocolpopexy uses mesh, and each approach has trade-offs that your surgeon should explain.
Did the FDA ban mesh for prolapse?
In April 2019 the FDA ordered manufacturers to stop selling mesh intended for transvaginal repair of pelvic organ prolapse. Abdominal mesh for sacrocolpopexy and mesh slings for incontinence were not included in that order.
Do I need surgery if I have a vault prolapse?
Not necessarily. Pelvic floor training and a vaginal pessary are recommended options before surgery, and watchful waiting is reasonable when the bulge does not bother you. Surgery is usually considered when symptoms affect daily life.
Does Podo treat vault prolapse after hysterectomy?
Yes. After hysterectomy, the remaining pelvic ligaments are used to restore support around the vagina. Whether that suits your anatomy is decided at an English-language consultation after examination.
Sources
About the reviewer
Dr. Mo Hyung-jin, MD, PhD, board-certified OB-GYN specialist, is the medical director of Podo Women's Clinic. He developed the pelvic ligament suspension technique used at the clinic for stress urinary incontinence and pelvic organ prolapse. Profile