Apical prolapse is the descent of uterus, cervix, or vaginal vault. Pelvic organ prolapse (POP) affects millions of women; approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States [1,2]. Eleven to 19 percent of women will undergo surgery for POP or incontinence by age 80 to 85 years, and 30 percent of these women will require an additional POP or incontinence surgery [3,4]. Anterior vaginal wall prolapse without concomitant apical prolapse is uncommon , and apical prolapse repair should be included in the majority of pelvic reconstructive surgery procedures.
Reconstructive procedures for prolapse of the vaginal apex are reviewed here. Evaluation of women with POP, conservative management, and choosing a primary surgical procedure are discussed separately. Obliterative procedures for POP (colpocleisis) are also discussed separately. (See "An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapse in women" and "Vaginal pessary treatment of prolapse and incontinence" and "Pelvic organ prolapse in women: Choosing a primary surgical procedure" and "Pelvic organ prolapse in women: Obliterative procedures (colpocleisis)".)
The International Continence Society defines apical vaginal prolapse as any descent of the vaginal cuff scar or cervix, below a point which is 2 cm less than the total vaginal length about the plane of the hymen . The clinical significance of apical descent that is not beyond the hymen is unclear, as half of asymptomatic women presenting for routine gynecologic care have prolapse to the hymen . Similarly, studies suggest that prolapse becomes symptomatic when the leading edge protrudes beyond the vaginal opening . However, isolated anterior vaginal wall defects are uncommon. Therefore, if the anterior vaginal wall protrudes beyond the hymen, the apex likely has inadequate support, as well [5,9].
ANATOMY AND MECHANISMS OF INJURY
Apical prolapse refers to the downward displacement of the vaginal apex (figure 1). The vaginal apex is either the uterus and cervix or, in women who have undergone subtotal or total hysterectomy, the cervix or vaginal cuff.
Support of the vaginal apex is primarily derived from the integrity of the uterosacral and cardinal ligaments, the continuity of the endopelvic fascia, and a neuromuscularly intact levator ani muscle (figure 2). The etiology of apical prolapse is likely related to connective tissue, neural, and/or muscular defects in these normal supports.