Vaginal Vault Prolapse
Vaginal vault prolapse is a form of apical pelvic organ prolapse in which the upper vagina descends from its normal position.
It most commonly occurs in women who have previously had a hysterectomy, when the top of the vagina is closed to form the vaginal cuff.
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The vaginal vault is supported by a complex network of connective tissue, fascia, ligaments and pelvic floor muscles. When these supporting structures become weakened, stretched or detached, the upper vagina can gradually descend into the vaginal canal and, in more advanced prolapse, may protrude through the vaginal opening.
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A hysterectomy does not automatically cause vaginal vault prolapse. However, removal of the uterus changes the anatomy and the way the upper vagina is suspended. If the apical support is inadequate or subsequently weakens, the vaginal cuff can descend. Vault prolapse may also develop as a recurrence of prolapse following previous pelvic surgery.
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What is vaginal vault prolapse?
The International Continence Society (ICS) defines vaginal vault (cuff scar) prolapse as clinically evident descent of the vaginal vault following hysterectomy.
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The vault is the uppermost part of the vagina. Following a total hysterectomy, the cervix and uterus are no longer present and the top of the vagina is closed, creating the vaginal cuff.
When the structures supporting this area no longer provide sufficient suspension, the vaginal apex moves downwards. The descent may occur predominantly at the apex or alongside prolapse of the anterior or posterior vaginal walls.
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Clinicians generally assess the degree of prolapse using the POP-Q (Pelvic Organ Prolapse Quantification) system, rather than relying solely on descriptive terms such as "mild", "moderate" or "severe".
In a woman who has had a hysterectomy, the leading edge of the vaginal cuff is recorded as POP-Q point C.
The anatomical stage of prolapse does not, by itself, determine how a woman feels or whether treatment is necessary. The physical findings should always be considered alongside symptoms and their effect on daily life.
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Why does vaginal vault prolapse happen?
There is no single cause of vaginal vault prolapse.
The upper vagina normally receives support from the apical suspension system, including the uterosacral and cardinal ligament complex, connective tissue and the surrounding pelvic floor structures. These structures work together to maintain the position of the vaginal apex.
Vault prolapse can occur when this support is weakened, stretched or disrupted.
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Factors that may contribute include:
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Previous hysterectomy or other pelvic surgery
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Pre-existing pelvic organ prolapse or weakness of apical support
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Recurrence of prolapse following previous prolapse surgery
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Changes in connective tissue and vaginal support with age
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Increased or repeated intra-abdominal pressure
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Chronic constipation and straining
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Persistent coughing or other conditions associated with repeated increases in abdominal pressure
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Factors affecting the strength and function of the pelvic floor and supporting connective tissues.
For some women, vault prolapse becomes apparent months or years after hysterectomy, rather than immediately following surgery.
It is therefore more accurate to regard hysterectomy as an important association with vault prolapse rather than suggesting that hysterectomy itself inevitably causes the condition.
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What does vaginal vault prolapse feel like?
Symptoms vary considerably between women and do not necessarily correspond directly to the measured stage of prolapse.
Possible symptoms include:
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A sensation of pressure, heaviness or dragging in the vagina
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A feeling that something is coming down
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Awareness of a bulge or tissue at the vaginal opening
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Discomfort that becomes more noticeable after prolonged standing or physical activity
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Difficulty emptying the bladder or changes in urinary symptoms
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Bowel symptoms, including difficulty with evacuation
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Discomfort or altered sensation during sexual activity
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Lower abdominal, pelvic or vaginal discomfort.
Some women have a visible prolapse but few or no symptoms. Treatment is generally guided by symptoms, individual circumstances and personal preference rather than by the anatomical finding alone.NICE states that treatment is rarely indicated when prolapse is asymptomatic.
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Can a pessary support a vaginal vault prolapse?
Yes. A vaginal pessary can provide mechanical support for a vaginal vault prolapse and is an established non-surgical treatment option.
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A pessary is placed inside the vagina to provide support to the prolapsed vaginal tissues. Different pessaries provide support in different ways, and the most appropriate device depends on the individual's anatomy, the degree and pattern of prolapse, vaginal length and width, symptoms, pelvic floor function and ability to manage the device.
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For vault prolapse, a ring pessary may be suitable for some women, while a space-occupying pessary such as an inflatable or Gellhorn shape or other supportive design may be considered when greater apical support is required. There is no single pessary that is right for every vault prolapse.
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A successful fitting should provide meaningful symptom relief without causing significant discomfort, pressure, bleeding or difficulty with bladder or bowel function. More than one fitting may sometimes be required to find a pessary that is comfortable and remains appropriately positioned.
NICE recommends considering a vaginal pessary for women with symptomatic pelvic organ prolapse, either alone or alongside supervised pelvic floor muscle training.
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A pessary supports the prolapse while it is in place; it does not repair or permanently reverse the underlying loss of apical support. Symptoms may therefore return when the pessary is removed.
Pessary care and vaginal tissue health
A pessary provides mechanical support for the prolapse but does not correct the underlying loss of vaginal support. Once fitted, it requires appropriate follow-up to ensure that it remains comfortable, effective and does not cause pressure-related injury to the vaginal tissues.
Vaginal tissue health is particularly important when using a pessary.
After menopause, reduced oestrogen can contribute to genitourinary syndrome of menopause (GSM), in which the vaginal tissues may become thinner, drier and more susceptible to irritation or trauma.
Where GSM is present, vaginal oestrogen may be considered alongside pessary treatment to manage menopausal genitourinary symptoms and support vaginal tissue health.
It is not a treatment for the vault prolapse itself.
NICE guidelines specifically recommends considering vaginal oestrogen for women with pelvic organ prolapse who have genitourinary symptoms or signs associated with menopause.
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Pessary users should be advised about appropriate removal, cleaning and follow-up according to the type of pessary and their individual circumstances. Persistent vaginal discharge, bleeding, pain, pressure, difficulty passing urine or opening the bowels, or a pessary that becomes difficult to remove should prompt clinical review.
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The need for vaginal oestrogen should be assessed individually rather than assumed solely because a woman is using a pessary. Where vaginal oestrogen is appropriate, treatment should follow current menopause guidance and be reviewed according to the woman's symptoms and circumstances.
Pelvic floor physiotherapy
Pelvic floor muscle training can form part of conservative management for pelvic organ prolapse.
The purpose is not simply to "push the vault back up". A pelvic health physiotherapist can assess pelvic floor muscle strength, endurance, coordination and relaxation, together with breathing and pressure-management strategies and other factors that may be contributing to symptoms.
NICE recommends supervised pelvic floor muscle training for selected women with symptomatic prolapse, particularly where the prolapse does not extend more than 1 cm beyond the hymen during straining.
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For women with more advanced vault prolapse, pelvic floor rehabilitation may still have an important role in optimising muscle function and managing associated symptoms, although it should not be presented as a treatment that can anatomically restore a significantly descended vaginal apex.
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Other non-surgical measures
Management should be individualised. Depending on the woman's symptoms and circumstances, this may include:
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Pessary support
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Support garments
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Supervised pelvic floor rehabilitation
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Management of constipation and avoidance of persistent straining
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Addressing chronic cough or other factors that repeatedly increase intra-abdominal pressure
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Consideration of weight management where appropriate
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Vaginal oestrogen where indicated for menopausal genitourinary symptoms
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Observation where the prolapse is not causing troublesome symptoms.
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There is no single treatment that is right for every woman. Management should be individualised according to symptoms, quality of life, personal preferences, previous pelvic surgery and clinical circumstances. Depending on these factors, treatment may involve observation, non-surgical options such as pessary support and pelvic floor rehabilitation, or surgery.
When is surgery considered?
Surgery is generally considered when a vaginal vault prolapse is causing persistent, troublesome symptoms that have not improved with non-surgical treatment, or when a woman chooses not to continue with conservative management.
The decision should be based on the woman's symptoms, the effect of prolapse on her quality of life, the anatomical findings and her individual circumstances and preferences. **The presence or stage of prolapse alone does not automatically mean that surgery is required.
NICE recommends that women with pelvic organ prolapse are offered a discussion of no treatment, non-surgical management and surgical options as part of shared decision making. [NICE guideline NG123, recommendations 1.7.1 and 1.8.1–1.8.2]
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Surgical options for vaginal vault prolapse
For women considering surgery specifically for vaginal vault prolapse, NICE recommends discussing the benefits and risks of the available procedures alongside non-surgical alternatives. The current NICE guideline NG123, recommendations 1.8.14–1.8.16, recommends offering a choice of:
Vaginal sacrospinous fixation with sutures. The vaginal apex is attached to the sacrospinous ligament within the pelvis to restore apical support.
Sacrocolpopexy the vaginal apex is supported using mesh attached to the sacrum, usually performed through an abdominal or laparoscopic approach.
NICE's evidence review found no difference in cure or quality-of-life outcomes between sacrocolpopexy and sacrospinous fixation sufficient to recommend one procedure over the other, and therefore recommends offering women a choice between these two approaches.
Choosing the right operation
The most appropriate surgical approach is individual to the woman. Assessment should take into account the site and extent of prolapse, previous abdominal or pelvic floor surgery, vaginal anatomy, urinary and bowel symptoms, sexual function, general health, lifestyle and personal preferences, together with the potential benefits and risks of each procedure. NICE specifically recommends using its decision aid for surgery for vaginal vault prolapse to support informed and shared decision making.
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Surgery does not guarantee that prolapse will never recur. Women considering surgery should be counselled about the possibility of recurrent prolapse, potential changes in urinary, bowel or sexual function, recovery requirements and the known risks and uncertainties associated with the individual procedure.
NICE also highlights the particular considerations associated with procedures involving mesh.
For women considering sacrocolpopexy with mesh,NICE HealthTech guidance HTG444 (updated January 2026) states that the procedure can be used when appropriate arrangements for clinical governance, consent and audit are in place.
It also highlights recognised risks, including mesh erosion and recurrent vault prolapse, and recommends that the procedure is undertaken by clinicians specialising in pelvic organ prolapse and urinary incontinence.
Page reviewed and updated August 2026​​​