Pelvic organ prolapse after hysterectomy
Have you had a hysterectomy and now feel pelvic pressure, a vaginal bulge, or a sense that something is falling out? You may have vaginal vault prolapse. This is when the top of the vagina drops down because it has lost its support.
The medical name for the top of the vagina is the vaginal vault, or vaginal apex.
Why this happens
When you have a hysterectomy, the surgeon removes the uterus but leaves the vagina in place. The ligaments that used to hold the uterus are the same ones that support the top of the vagina. If those ligaments weaken over time, the top of the vagina can slip down.
After a hysterectomy, the back wall at the top of the vagina has no ligaments attached to it. That makes it the most common spot for prolapse to start. As the top drops, it can pull the bladder or rectum down with it. A drop near the bladder is called a cystocele; near the rectum, a rectocele. Many bulges that look like a simple cystocele or rectocele are partly a dropped vault, and a repair that misses the top of the vagina is more likely to fail.
This does not mean your hysterectomy was done wrong. Vault prolapse is a known long-term possibility. It reflects the everyday effects of gravity, aging, and changes in your tissue.
Signs you should get checked
- Pressure or fullness in the pelvis
- A low, period-like backache that gets worse the longer you stand
- A bulge you can see or feel at the vaginal opening
- Trouble with bowel movements, or a feeling that you do not empty fully
- Bladder symptoms like leaking, urgency, or trouble starting your stream
- Changes in sex, such as discomfort or a sense that something is “in the way”
Treatment options
There is no single right answer here. We talk through your symptoms, your goals, and what matters most to you, then choose a plan together. You do not have to try one treatment before you can choose another. Some women start with a pessary or physical therapy. Others go straight to surgery. You can also combine approaches.
A pessary is a removable silicone device that sits in the vagina and holds the top of the vagina up. Many women use one for years and skip surgery altogether. Fitting can take a few tries after a hysterectomy or prior prolapse surgery, but that history is not a reason to skip a trial. Every woman with bothersome prolapse should be offered one.
Pelvic floor physical therapy can ease pressure and bulge symptoms, even though it does not usually change how far the prolapse drops on exam. It is often part of the plan before or after surgery. We have pelvic floor physical therapists in our office, along with a wider network across northeast Wisconsin and the Upper Peninsula of Michigan.
If you choose surgery, the goal is to re-support the top of the vagina. There are three main routes:
- Sacrocolpopexy. A strip of lightweight mesh connects the top of the vagina to a ligament over your tailbone. We usually do this through small incisions with the help of a robot. It is one of the most studied prolapse repairs.
- Native tissue repair through the vagina. We use your own ligaments and stitches, with no mesh. The two common versions attach the top of the vagina to your uterosacral ligaments (uterosacral ligament suspension) or to a nearby sacrospinous ligament (sacrospinous ligament fixation). In a large randomized trial, the two worked equally well.
- Colpocleisis. This closes or narrows the vaginal canal. It is a shorter, lower-risk surgery, and prolapse rarely comes back after it, but it is only for women who are sure they will not want vaginal intercourse again.
In the first year, native tissue and mesh repairs work about equally well. A large registry found similar recurrence rates at one year for both, and very few women in that registry needed another operation over three years. Over the longer term, pooled trial data show prolapse comes back less often after sacrocolpopexy. The trade-off is that the mesh can wear through the vaginal wall, called mesh exposure. In a long-term trial of open sacrocolpopexy, about 1 in 10 women had a mesh exposure by seven years.
Native tissue repair avoids mesh, so there is no risk of mesh exposure. It works well for many women, though prolapse is more likely to come back over time. In that same randomized trial, about 1 in 10 women had another treatment for prolapse within five years. Having had a hysterectomy raises the chance of recurrence after any type of repair.
Before any prolapse surgery, I check whether you leak urine when the prolapse is held up. Putting the vault back in place can uncover stress leakage that the bulge was hiding, and we can plan for it.
Your next steps
If you have had a hysterectomy and notice new pelvic symptoms, get checked. Prolapse is very treatable, and an exam tells us which part of the vagina has dropped and which options fit you.
Learn more about pelvic organ prolapse
References
- American College of Obstetricians and Gynecologists, American Urogynecologic Society. Pelvic Organ Prolapse. ACOG Practice Bulletin No. 214 (Interim Update). Obstet Gynecol. 2019.
- Barber MD. Pelvic organ prolapse. BMJ. 2016. doi:10.1136/bmj.i3853
- Barber MD, Brubaker L, Burgio KL, et al. Factorial comparison of two transvaginal surgical approaches and of perioperative behavioral therapy for women with apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014. doi:10.1001/jama.2014.1719
- Jelovsek JE, Barber MD, Brubaker L, et al. Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the OPTIMAL randomized clinical trial. JAMA. 2018. doi:10.1001/jama.2018.2827
- Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013. doi:10.1001/jama.2013.4919
- Ferrando CA, Bradley CS, Meyn LA, et al. Twelve month outcomes of pelvic organ prolapse surgery in patients with uterovaginal or posthysterectomy vaginal prolapse enrolled in the multicenter Pelvic Floor Disorders Registry. Urogynecology. 2023. doi:10.1097/SPV.0000000000001410
- Andy UU, Meyn L, Brown HW, et al. Outcomes at 12, 24, and 36 months in women treated for pelvic organ prolapse with pessary or surgery: results from the multicenter Pelvic Floor Disorders Registry. Urogynecology. 2025. doi:10.1097/SPV.0000000000001669
- Haylen BT, Vu D. Surgical anatomy of the vaginal vault. Neurourol Urodyn. 2022. doi:10.1002/nau.24963
- Hooper GL, Moynihan L, Leegant A, et al. Vaginal pessary use and management for pelvic organ prolapse. Urogynecology. 2023. doi:10.1097/SPV.0000000000001293
- Carberry CL, Tulikangas PK, Ridgeway BM, et al. American Urogynecologic Society Best Practice Statement: evaluation and counseling of patients with pelvic organ prolapse. Urogynecology. 2025. doi:10.1097/SPV.0000000000001641
- Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet. 2014. doi:10.1016/S0140-6736(13)61977-7