Vaginal prolapse repair
Vaginal prolapse repair is surgery that lifts pelvic organs back into place through the vagina, with no incision in the abdomen. I use it when a bladder, uterus, vaginal wall, or rectum has dropped far enough to cause symptoms that bother you.
The word “repair” covers several different operations. Which one I recommend depends on what has dropped, whether you still have your uterus, whether you want to keep the option of vaginal intercourse, and what you want out of treatment. This page walks through the choices.
When prolapse actually needs surgery
Prolapse is a support problem, not a dangerous one. It only needs treatment when it bothers you. If it doesn’t, watching it is a reasonable plan: in one series, 78% of women with symptomatic prolapse who chose no treatment had no change at 16 months.
Prolapse is also more common than most people realize, and easy to overcount. On a pelvic exam, some degree of prolapse shows up in 41 to 50% of women, but only about 3% actually notice a bulge. A woman’s lifetime chance of having prolapse surgery is roughly 12 to 13% by age 80. So the question is never whether an exam finds prolapse. It’s whether the prolapse is causing you trouble.
Common reasons women come in:
- A bulge or the feeling that something is falling out
- Pelvic pressure or heaviness that worsens through the day
- Trouble starting to urinate, or having to push the bulge up to empty
- Leaking urine, or new urgency
- Difficulty with bowel movements, including having to splint or press
- Discomfort with intercourse
What can be repaired
Prolapse is described by which wall or compartment has dropped, and one operation can address more than one at the same time:
- Front wall (cystocele): the bladder bulges into the front of the vagina
- Back wall (rectocele): the rectum bulges into the back of the vagina; a loop of small bowel can also bulge in as an enterocele
- Top, or apex: the uterus descends, or after a hysterectomy the top of the vagina drops as a vault prolapse
The apex matters more than it looks. When the top of the vagina isn’t well supported, the front and back walls tend to sag with it, so fixing the apex is often the key to a durable repair.
The vaginal operations I use
Apical suspension: the foundation
For a dropped uterus or vaginal vault, I reattach the top of the vagina to strong ligaments already in the pelvis. There are two well-studied ways to do this through the vagina:
- Uterosacral ligament suspension, which uses the uterosacral ligaments
- Sacrospinous ligament fixation, which uses the sacrospinous ligament
In a large randomized trial, these two worked equally well: about 64% of women met every success measure at two years. That number sounds modest, and it partly reflects a strict definition. Far fewer women ever need a second operation. At five years, repeat surgery for prolapse was needed in about 12% after uterosacral suspension and 8% after sacrospinous fixation.
Correcting the apex often takes care of the front and back walls on its own. In one study of women who had apical repair without a separate back-wall repair, 96% still had their posterior prolapse resolved five years later.
Anterior repair (for the front wall)
An anterior repair, or anterior colporrhaphy, tightens the weakened layer under the front vaginal wall to support the bladder, using your own tissue. It is effective, but honest numbers matter here: success runs 80 to 100% in surgeon case series and 40 to 60% in randomized trials. That gap is one reason I usually correct the apex at the same time rather than repairing the front wall alone.
Posterior repair (for the back wall)
A posterior repair, or posterior colporrhaphy, rebuilds the layer behind the back vaginal wall to support the rectum. The vaginal approach works better than repairing a rectocele through the rectum. I don’t add a posterior repair automatically, because a good apical suspension often handles the back wall too, and an unnecessary posterior repair can bring new bowel or intercourse symptoms.
Colpocleisis (closing the canal)
Colpocleisis narrows or closes the vaginal canal to hold everything in. It is fast, well tolerated, and highly durable: about 98% of women have their prolapse stay fixed. The trade-off is that it ends the ability to have vaginal intercourse, so I reserve it for women who are certain about that and who want the lowest-risk option, often because of other health conditions.
What about mesh?
For vaginal repairs, I use your own tissue, not mesh. The FDA removed all transvaginal mesh kits for prolapse from the US market in 2019 because their risks outweighed their benefits.
Mesh still has a legitimate place, but not in a vaginal repair. Abdominal sacrocolpopexy, done through the belly (usually through small laparoscopic incisions), uses mesh and has strong long-term anatomic results, with objective success around 73 to 78% at seven years. It carries its own trade-off: the mesh can wear through the vaginal wall over time. The FDA order does not apply to this operation, or to slings used for urinary leakage. When a mesh augmented repair is the better fit, I’ll tell you.
Keeping or removing the uterus
If your uterus has dropped, you don’t automatically have to lose it. A hysteropexy suspends the uterus in place instead of removing it. In a five-year randomized trial, keeping the uterus (sacrospinous hysteropexy) actually failed less often than removing it with a suspension (37% vs 54%). Professional guidelines now recommend offering uterine preservation to everyone with a uterus and no reason it must come out, such as abnormal bleeding or a suspicious finding. I’m glad to talk through both paths.
Prolapse and bladder leakage
Fixing prolapse can uncover a leakage problem the prolapse was masking. About 40% of women who test negative for stress incontinence before surgery start leaking afterward if nothing is done about it. Because of that, I check for hidden leakage before your operation, with the prolapse held up, so we can decide together whether to add a continence procedure. Adding one at an abdominal repair, for instance, cuts the chance of new leakage, and the vaginal repairs differ too: new stress incontinence showed up in about 6% after native-tissue vaginal repair versus 18% after abdominal sacrocolpopexy in one registry.
What recovery is like
Most vaginal prolapse repairs are outpatient or a single overnight stay, with no abdominal incision to heal. You may go home with a catheter for a day or two if your bladder is slow to wake up, which is common and temporary.
Expect a few weeks of taking it easy, avoiding heavy lifting and intercourse while the repair heals. Most women are back to their usual activities within about six weeks. I’ll give you specific limits based on which repair you had.
Risks are uncommon but real: bleeding, infection, injury to the bladder, ureter, or rectum, temporary trouble emptying the bladder, and new discomfort with intercourse. Prolapse can also come back over time, which is why the choice of operation and getting the apex right matter so much.
Alternatives to surgery
Surgery is one option among several, and it’s rarely urgent. Before or instead of an operation, we can try:
- A pessary, a removable support you wear in the vagina. I offer one to anyone with symptomatic prolapse. Among women who stick with a pessary, most feel much or very much better, and it avoids surgery entirely.
- Pelvic floor physical therapy, which can ease symptoms and is worth trying, especially for milder prolapse.
- Addressing things that strain the pelvic floor, like constipation and extra weight.
There’s no rule that you must fail conservative treatment before surgery. It’s your body and your decision.
How I think about this
I don’t push anyone toward the operating room. The right choice depends on how much the prolapse bothers you, whether you want to keep your uterus, whether vaginal intercourse matters to you, and your overall health, not on how the prolapse looks on an exam.
When surgery does make sense, I focus on supporting the apex well, adding a front- or back-wall repair only when it’s needed, and being straight with you about the numbers. A repair that lasts five to ten years and lets you get back to your life is the goal, and for most women that’s exactly what it delivers.
References
- Meriwether KV, Gold KP, de Tayrac R, et al. Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse. Female Pelvic Medicine & Reconstructive Surgery. 2020. doi:10.1097/SPV.0000000000000846
- 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
- 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
- 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
- Nager CW, Visco AG, Richter HE, et al. Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5 year results of a randomized clinical trial. American Journal of Obstetrics and Gynecology. 2021. doi:10.1016/j.ajog.2021.03.012
- Chang OH, Carter Ramirez A, Edwards A, et al. The Role of Uterine Preservation at the Time of Pelvic Organ Prolapse Surgery. Urogynecology. 2025. doi:10.1097/SPV.0000000000001667
- Committee on Practice Bulletins—Gynecology, American Urogynecologic Society. Pelvic Organ Prolapse (ACOG Practice Bulletin No. 214). Obstetrics & Gynecology. 2019.
- Barber MD. Pelvic organ prolapse. BMJ. 2016. doi:10.1136/bmj.i3853
- Grimes C, Lukacz ES, Gantz MG, et al. What happens to the posterior compartment and bowel symptoms after sacrocolpopexy? Evaluation of 5-year outcomes from E-Care. Female Pelvic Medicine & Reconstructive Surgery. 2014. doi:10.1097/SPV.0000000000000085
- Hooper GL, Moynihan L, Leegant A, et al. Vaginal Pessary Use and Management for Pelvic Organ Prolapse. Urogynecology. 2023. doi:10.1097/SPV.0000000000001293
- 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
- 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