Apical Prolapse
Apical pelvic organ prolapse is descent of the vaginal apex — the uterus/cervix in a patient with uterus in situ, or the vaginal cuff after hysterectomy.[1][2] It encompasses uterine prolapse, post-hysterectomy vault prolapse, and enterocele (peritoneal / small-bowel herniation into the upper vagina).[1][3]
The apex is the load-bearing center of vaginal support. Missed apical descent is the single most common reason anterior and posterior repairs recur — many apparent cystoceles and rectoceles are partly apex-driven. The operative question is rarely "which wall bulges?" and almost always "has Level I support failed, and what repair matches this patient's anatomy, sexual goals, uterine preferences, comorbidity, and recurrence risk?"
See also: POP Overview for the DeLancey framework, POP-Q, pessary management, and shared surgical principles. This page covers what is distinctive about the apical compartment.
Definition and Terminology
| Term | Meaning | Operative implication |
|---|---|---|
| Apical prolapse | Descent of the cervix, uterus, or vaginal cuff | Level I support repair required |
| Uterine prolapse | Descent of the uterus and cervix | Hysterectomy + apical suspension, or uterine-sparing hysteropexy |
| Vaginal vault / cuff prolapse | Descent of the apex after hysterectomy | Requires vault suspension; hysterectomy alone is not a prolapse repair |
| Enterocele | Small-bowel / peritoneal-sac herniation into the vaginal apex | Sac reduction or obliteration + apical support |
| Hysteropexy | Uterine-preserving apical suspension | When uterine preservation is desired and no uterine pathology |
| Colpocleisis | Obliterative closure of the vaginal canal | Most durable option when future vaginal intercourse is not desired |
POP-Q defines apical support via point C (cervix or vaginal cuff) and point D (posterior fornix, when the cervix is present). Total vaginal length (TVL) is measured with the prolapse reduced.[4] Definitions of apical-support loss vary across studies — point C below −1 cm, beyond +1 cm, or >50% of TVL have all been used — which is one reason literature comparisons are hard.[3]
Compartment-Specific Pathophysiology
Apical prolapse is the clinical failure of Level I support — the cardinal–uterosacral ligament complex suspending the cervix and upper vagina. (Level II and III frameworks are in the parent article.) What makes the apex distinctive:
- Apical descent amplifies anterior and posterior wall prolapse. Reducing the apex during exam is often the fastest way to determine how much of a visible compartment defect is actually apex-driven.
- Hysterectomy alone does not treat apical prolapse. A vaginal hysterectomy for uterine prolapse without a concurrent apical suspension leaves the cuff unsupported and sets up vault prolapse.[1]
- Enterocele is a distinctly apical phenomenon — the peritoneal sac descends into the pouch of Douglas / rectouterine space and can be occult until repair, especially after hysterectomy.
Generic POP risk factors apply (see parent). Apical-specific recurrence drivers include younger age at primary repair, preoperative Stage III–IV disease, uncorrected levator avulsion, and enlarged levator hiatus.[5][6]
Compartment-Specific Evaluation
The generic exam is in the parent article. The apex-specific maneuvers and points that matter:
| POP-Q point | What it measures |
|---|---|
| C | Most distal cervix or vaginal cuff |
| D | Posterior fornix (omit after hysterectomy) |
| TVL | Total vaginal length with prolapse reduced |
| GH / PB | Genital hiatus and perineal body — large hiatus predicts failure and recurrence |
Key examination step: manually reduce the apex with ring forceps, swab, or a speculum and re-measure Aa/Ba and Ap/Bp. If the anterior or posterior wall descent improves, the visible compartment prolapse is apex-driven and an isolated compartment repair will recur.
Apical-specific adjunctive considerations:
- Endometrial / cervical evaluation before uterine-preserving procedures, and before colpocleisis with uterus in situ, because post-operative surveillance access is limited
- Dynamic pelvic MRI / defecography when enterocele, sigmoidocele, or occult posterior pathology is suspected
- Occult SUI testing with reduction (as for any significant anterior or apical prolapse)
Surgical Management
Generic pessary, PFMT, and non-surgical options are in the parent. The following are the apical-specific procedures.
Vaginal native-tissue apical repair
| Procedure | Mechanism | Specific risks / tradeoffs |
|---|---|---|
| Uterosacral ligament suspension (USLS) | Bilateral suspension of the apex to the uterosacral ligaments near the ischial spine | Ureteral kinking/injury — intraoperative cystoscopy mandatory |
| Sacrospinous ligament fixation (SSLF) | Apex anchored to the sacrospinous ligament (usually right-sided) | Buttock pain; pudendal/sciatic neurovascular risk; posterior vaginal-axis shift can increase anterior recurrence |
| Iliococcygeus suspension | Apex to iliococcygeus fascia | Alternative when USLS/SSLF anatomy is unfavorable |
| McCall culdoplasty | At-hysterectomy obliteration of the cul-de-sac with uterosacral plication | Prevents enterocele / vault prolapse when done well at index hysterectomy |
OPTIMAL trial (multicenter RCT): at 2 years, USLS and SSLF had similar success (64.5% vs 63.1%).[7] At 5 years, many patients met strict composite-failure definitions, but patient-reported improvement persisted and re-treatment rates remained low (~10%). Counseling point: native-tissue apical surgery improves symptoms, but POP is a chronic support disorder and anatomic perfection is not guaranteed.
Sacrocolpopexy — the durable reconstructive repair
Sacrocolpopexy (SCP) suspends the vaginal apex to the anterior longitudinal ligament of the sacrum using Type I polypropylene mesh. Open, laparoscopic, or robotic approaches; outcomes broadly comparable in experienced hands.[1][8]
Compared with vaginal native-tissue apical repair, SCP shows lower awareness of prolapse, lower recurrence on exam, lower reoperation for prolapse, and lower postoperative SUI in Cochrane data.[8]
| Approach | Tradeoffs |
|---|---|
| Open abdominal | Longest durability data; most blood loss and longest recovery |
| Laparoscopic | Less blood loss / shorter stay than open; lower cost and shorter op time than robotic in many series |
| Robotic | Ergonomic suturing; longer op time and higher cost than straight laparoscopy without clear outcome superiority |
Candidates favoring SCP: younger patients, Stage III–IV, prior failed vaginal repair, shortened vagina, high-recurrence-risk anatomy, and patients already requiring abdominal surgery.
Mesh complications after sacrocolpopexy
The SCP-specific complication profile differs from historic transvaginal mesh. Mesh exposure is less common but is a real long-term risk; rates vary by follow-up duration, hysterectomy status, and mesh weight.[9][10][11]
| Finding | Pattern |
|---|---|
| Minimally-invasive SCP (pooled) | Mesh exposure ~3.5% |
| CARE 7-year follow-up | Mesh erosion probability ~10.5% by 7 years |
| Lightweight vs heavier mesh | Heavier mesh → higher graft-related complications long-term |
| Concomitant total hysterectomy | Higher exposure than supracervical hysterectomy or hysteropexy in most datasets |
Use macroporous monofilament Type I polypropylene when synthetic mesh is chosen. Biologic grafts in SCP have lower anatomic cure and are not a routine durability substitute.
Uterine preservation — hysteropexy
A genuine alternative to hysterectomy for uterine prolapse when the patient desires uterine preservation and has no cervical/endometrial pathology requiring removal.[1][12][13]
| Route | Examples |
|---|---|
| Vaginal native tissue | Sacrospinous hysteropexy, uterosacral hysteropexy, Manchester-Fothergill |
| Abdominal / laparoscopic / robotic | Sacral hysteropexy, mesh hysteropexy, uterosacral shortening |
Systematic reviews show similar short-term prolapse outcomes for preservation vs hysterectomy-based repair, with hysteropexy often showing shorter OR time, less blood loss, shorter LOS, and lower mesh exposure when mesh is used.[12][13] SAVE U 5-year follow-up: sacrospinous hysteropexy had lower apical failure than vaginal hysterectomy with uterosacral suspension (1% vs 7.8%) and higher composite success.[14]
Favor hysterectomy when: abnormal bleeding, cervical dysplasia, endometrial pathology, inability to ensure future surveillance, patient preference, or desire to eliminate future uterine procedures.
Favor hysteropexy when: uterine preservation preferred, preserved fertility potential, shorter operation desired, or hysterectomy-specific morbidity is being avoided.
Colpocleisis — the most durable option
Obliterative closure of the vaginal canal. The most durable POP repair with the lowest perioperative morbidity; ACOG-endorsed first-line surgical option for appropriate candidates.[1][15][16]
| Procedure | Use |
|---|---|
| Le Fort partial colpocleisis | Uterus in situ; anterior + posterior walls approximated with lateral drainage channels |
| Total colpocleisis / colpectomy | Post-hysterectomy vault prolapse, or when the uterus is absent |
Short operative time, feasible under regional or local anesthesia in selected patients, low recurrence, high satisfaction. Counseling must explicitly document permanent loss of vaginal penetrative function; ~2–10% of patients later express regret, so selection must be careful. If the uterus is retained, ensure cervical and endometrial screening before closure.
Concomitant SUI at apical repair
Apical prolapse can mask SUI via urethral kinking, especially when anterior descent coexists. Evaluate occult SUI with prolapse reduction before apical surgery. The decision tree is the same as for the anterior compartment — see the POP Overview. Apical-specific note: at sacrocolpopexy, Burch colposuspension is a natural adjunctive option when abdominal access is already established, and is a reasonable sling alternative depending on SUI phenotype and mesh-preference shared decisions.[17]
Long-term Outcomes and Reoperation
Durability varies by procedure, by how failure is defined (anatomic, symptomatic, retreatment, satisfaction), and by selection.
| Procedure family | Long-term pattern |
|---|---|
| Colpocleisis | Lowest recurrence and reoperation in appropriately selected patients |
| Sacrocolpopexy | Most durable reconstructive repair; mesh exposure is the tradeoff |
| USLS | Effective native-tissue repair; ureteral-injury risk and recurrent support failure require counseling |
| SSLF | Effective native-tissue repair; posterior axis shift may contribute to anterior recurrence |
| Hysteropexy | Comparable short-term to hysterectomy-based repair in selected patients; long-term surveillance still evolving |
Large cohort data in older women show lower 7-year reoperation for recurrence after colpocleisis and sacrocolpopexy than after some vaginal native-tissue apical repairs, while patient-reported outcomes are often similar across procedures.[6][18][19]
Key Recommendations
- Treat the apex as the central load-bearing compartment in any POP operation.
- Always reduce the apex during exam. Visible anterior / posterior descent that improves with apical reduction is apex-driven.
- At hysterectomy for uterine prolapse, perform a concurrent apical suspension — hysterectomy alone is not a suspension.
- USLS and SSLF are equally effective native-tissue options in OPTIMAL; choose on anatomy, risk profile, and experience.
- Sacrocolpopexy is the most durable reconstructive apical repair; accept the mesh-exposure tradeoff in counseling.
- Hysteropexy is a valid option in appropriately selected patients preferring uterine preservation — particularly compelling per SAVE U data.
- Discuss colpocleisis early in advanced-prolapse patients with high comorbidity and no desire for future vaginal intercourse.
- Evaluate occult SUI with prolapse reduction before any apical surgery.
See Also
- POP Overview
- Anterior Compartment Prolapse
- Posterior Compartment Prolapse
- Female Pelvic Examination
- Uterosacral Ligament Suspension
- Sacrospinous Ligament Fixation
- Sacrocolpopexy
- Sacrospinous Hysteropexy
- Manchester-Fothergill Procedure
- Le Fort Colpocleisis
- Prolapse Repair
References
1. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519
2. Deprest JA, Cartwright R, Dietz HP, et al. "International Urogynecological Consultation (IUC): Pathophysiology of Pelvic Organ Prolapse (POP)." Int Urogynecol J. 2022;33(7):1699-1710. doi:10.1007/s00192-022-05081-0
3. Meister MR, Sutcliffe S, Lowder JL. "Definitions of Apical Vaginal Support Loss: A Systematic Review." Am J Obstet Gynecol. 2017;216(3):232.e1-232.e14. doi:10.1016/j.ajog.2016.09.078
4. Bump RC, Mattiasson A, Bo K, et al. "The Standardization of Terminology of Female Pelvic Organ Prolapse and Pelvic Floor Dysfunction." Am J Obstet Gynecol. 1996;175(1):10-17. PMID:8694033
5. Schulten SFM, Claas-Quax MJ, Weemhoff M, et al. "Risk Factors for Primary Pelvic Organ Prolapse and Prolapse Recurrence." Am J Obstet Gynecol. 2022;227(2):192-208. doi:10.1016/j.ajog.2022.04.046
6. Shah NM, Berger AA, Zhuang Z, Tan-Kim J, Menefee SA. "Long-Term Reoperation Risk After Apical Prolapse Repair in Female Pelvic Reconstructive Surgery." Am J Obstet Gynecol. 2022;227(2):306.e1-306.e16. doi:10.1016/j.ajog.2022.05.046
7. Jelovsek JE, Barber MD, Brubaker L, et al. "Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation … OPTIMAL Randomized Clinical Trial." JAMA. 2018;319(15):1554-1565. doi:10.1001/jama.2018.2827
8. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. "Surgery for Women With Apical Vaginal Prolapse." Cochrane Database Syst Rev. 2016;10(10):CD012376. doi:10.1002/14651858.CD012376
9. Deblaere S, Hauspy J, Hansen K. "Mesh Exposure Following Minimally Invasive Sacrocolpopexy: A Narrative Review." Int Urogynecol J. 2022;33(10):2713-2725. doi:10.1007/s00192-021-04998-2
10. Nygaard I, Brubaker L, Zyczynski HM, et al. "Long-Term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse." JAMA. 2013;309(19):2016-2024. doi:10.1001/jama.2013.4919
11. Page AS, Cattani L, Pacquee S, et al. "Long-Term Data on Graft-Related Complications After Sacrocolpopexy With Lightweight Compared With Heavier-Weight Mesh." Obstet Gynecol. 2023;141(1):189-198. doi:10.1097/AOG.0000000000005021
12. Meriwether KV, Antosh DD, Olivera CK, et al. "Uterine Preservation vs Hysterectomy in Pelvic Organ Prolapse Surgery: A Systematic Review With Meta-Analysis and Clinical Practice Guidelines." Am J Obstet Gynecol. 2018;219(2):129-146.e2. doi:10.1016/j.ajog.2018.01.018
13. Brennand EA, Scime NV, Huang B, et al. "Hysterectomy Versus Uterine Preservation for Pelvic Organ Prolapse Surgery: A Prospective Cohort Study." Am J Obstet Gynecol. 2025;232(5):461.e1-461.e20. doi:10.1016/j.ajog.2024.10.021
14. Schulten SFM, Detollenaere RJ, Stekelenburg J, et al. "Sacrospinous Hysteropexy Versus Vaginal Hysterectomy With Uterosacral Ligament Suspension in Women With Uterine Prolapse Stage 2 or Higher: Observational Follow-Up of a Multicentre Randomised Trial." BMJ. 2019;366:l5149. doi:10.1136/bmj.l5149
15. Welch EK, Dengler KL, Wheat JE, et al. "Colpocleisis Techniques: An Open-and-Shut Case for Advanced Pelvic Organ Prolapse." Urology. 2023;176:252. doi:10.1016/j.urology.2023.03.011
16. Lee D, Kim TH, Lee TS. "Effectiveness of Obliterative Surgery in Managing Advanced Apical Prolapse in Elderly Women: A 20-Year Single-Surgeon Experience." J Clin Med. 2025;14(9):3101. doi:10.3390/jcm14093101
17. Baessler K, Christmann-Schmid C, Maher C, Haya N, Crawford TJ, Brown J. "Surgery for Women With Pelvic Organ Prolapse With or Without Stress Urinary Incontinence." Cochrane Database Syst Rev. 2018;8(8):CD013108. doi:10.1002/14651858.CD013108
18. Berger AA, Bretschneider CE, Gregory WT, Sung V. "Longitudinal Reoperation Risk After Apical Prolapse Procedures in Women Aged 65 Years and Older." Obstet Gynecol. 2024;143(3):411-418. doi:10.1097/AOG.0000000000005511
19. Larouche M, Belzile E, Geoffrion R. "Surgical Management of Symptomatic Apical Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis." Obstet Gynecol. 2021;137(6):1061-1073. doi:10.1097/AOG.0000000000004393