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Iliococcygeus Fascia Suspension

Iliococcygeus fascia suspension (ICG fixation, "prespinous fixation") is a transvaginal native-tissue apical operation in which the vaginal vault is attached to the fascia overlying the iliococcygeus muscle, usually bilaterally, to restore apical support. The AUGS–IUGA terminology report places the suture target in the medial parietal iliococcygeus fascia, typically about 1 cm caudal to the ischial spine; this is distinct from engaging the sacrospinous ligament.[1][3][14] The site is chosen to reduce proximity to major neurovascular structures.[1][3][14]

For the more commonly performed sacrospinous variant, see Sacrospinous Ligament Fixation (SSLF). For the uterosacral alternative, see Uterosacral Ligament Suspension (USLS). For the broader prolapse decision framework, see Prolapse Repair.

History and Definition​

First described by Inmon (1963) and subsequently described by Shull et al. (1993) and Meeks et al. (1994). Peters and Christenson (1995) reported outcomes for a distinct, related coccygeus-fascial suspension.[2][3][14]

The procedure is less commonly performed than sacrospinous or uterosacral ligament suspension. A published single-case technique video describes it as technically straightforward.[1]

Relevant Anatomy​

The iliococcygeus is the most posterior and lateral component of the levator ani complex (alongside pubococcygeus and puborectalis):[5][6]

  • Origin: arcus tendineus levatoris ani (a fascial thickening on the obturator-internus fascia)
  • Insertion: coccyx and anococcygeal raphe
  • Geometry: forms a horizontal levator plate supporting the pelvic viscera
  • The medial parietal fascia overlying the iliococcygeus is the suture target, usually caudal to the ischial spine (about 1 cm in the AUGS–IUGA description).[7][14] Exposure identifies the levator fascia lateral to the rectum.[7][14]

Indications​

  • Posthysterectomy vaginal vault prolapse (POP-Q stage ≥ 2). Primary and best-studied indication.[8][9]
  • Mild uterine prolapse as a hysteropexy (outcomes acceptable; less favorable for advanced uterine prolapse).[10]
  • Consider a native-tissue vaginal option when established alternatives are unsuitable after shared decision-making; the 2026 German guideline limits consideration to cases without an adequate alternative.[1][15]
  • Both primary and recurrent prolapse.[3]

Selection cautions​

  • Markedly attenuated levator or fascial tissue may limit a reliable fixation bite and requires intraoperative judgment.[14]
  • Stage IV vault prolapse predicted recurrence in small five- and ten-year follow-up cohorts.[8][9]

Surgical Technique​

The operation is performed in dorsal lithotomy under regional or general anesthesia.[1][3]

  1. Vaginal incision. After prior hysterectomy, make a midline vertical posterior vaginal-wall incision. If hysterectomy is concurrent or the uterus remains in situ, place a posterior vertical incision near the apex without disrupting the cuff repair or cervix, respectively.[14] Identify and address any enterocele.
  2. Pararectal-space dissection. Enter the rectovaginal space and develop the pararectal space bilaterally by sharp and blunt dissection, sweeping the rectum medially. Carry dissection laterally and superiorly until the iliococcygeus muscle is exposed and palpable.[1]
  3. Fascia identification. Palpate each ischial spine and identify the medial iliococcygeus parietal fascia caudal to it, commonly about 1 cm inferior in the standardized description.[14]
  4. Bilateral suture placement. Place several interrupted sutures in the iliococcygeus fascia on each side, progressing caudally along the fascial line toward the perineum. Delayed-absorbable or nonabsorbable material, suture count (including two per side), and fascia-only or fascia-plus-muscle purchase vary by technique.[3][14]
  5. Vaginal-vault fixation. Attach the vaginal apex and lateral fornices to the fixation sutures and tie them to elevate the vault. The highest fixation is at the apex; subsequent sutures may be placed progressively more caudally.[14] Hysteropexy is a related variation.[14]
  6. Concomitant compartment repair. Perform anterior colporrhaphy, posterior colporrhaphy, or perineorrhaphy as needed. Meeks et al. emphasized adequate repair of all fascial defects and the perineal body in their retrospective series.[3]
  7. Vaginal closure and completion checks. Close the vaginal incision. At the end of vaginal apical repair, perform cystourethroscopy to inspect the bladder and urethra and verify ureteral efflux from both orifices; the 2018 AUGS consensus recommends routine cystoscopy for prolapse reconstruction except isolated posterior repair.[17] The 2026 AWMF S3 guideline states that cystourethroscopy may help detect bladder or urethral injury and assess ureteral function .[15] Perform a digital rectal examination after repair and document the findings.[14]

Technical points​

  • Bilateral fixation can preserve a more midline vaginal axis than unilateral sacrospinous fixation.[2][14]
  • Adequate pararectal-space exposure is the main technical step.[1]
  • The caudal-to-spine fascial target is intended to reduce neurovascular proximity.[14]

Outcomes — Long-Term Efficacy​

SeriesFollow-upnSubjective cure (PGI-I ≤2, no bulge)Objective cure (POP-Q stage <2 in all compartments)
Serati 2021 (10-year follow-up)[8]Median 120 mo39 evaluated32/39 (82%)29/39 (74.4%)
Serati 2015 (5-year follow-up; 36/44 had concomitant prolapse repair)[9]Median 68.8 mo44 evaluated39/44 (88.6%)37/44 (84.1%)

Both follow-up publications identified preoperative stage IV vault descensus as an independent predictor of recurrence in their analyzed cohorts (reported ORs 7.66 and 8.78).[8][9] A 2024 systematic review of heterogeneous iliococcygeus studies reported pooled overall cure of 84.9% (95% CI 73.3–96.4), reoperation of 3.3%, and complications of 10.4%.[16]

Meeks 1994 (early series)[3]​

  • Meeks's 110 retrospective cases included 37 women with uterine prolapse and enterocele and 73 with posthysterectomy enterocele; all had a cystocele or rectocele and at least three years of follow-up. Four of 110 had recurrent defects, all involving the anterior vaginal wall.[3]

Comparative Outcomes​

vs Sacrospinous Ligament Fixation (Maher 2001 matched case-control)[4]​

The source identified 50 iliococcygeus and 78 sacrospinous operations, then analyzed 36 matched pairs. Mean follow-up was 21 versus 19 months; the matched analysis had only 50% power to detect a 20% success difference.[4]

OutcomeICG fixationSacrospinous fixationp
Subjective success91%94%0.73 [4]
Objective success53%67%0.36 [4]
Patient satisfaction (VAS)78/10091/1000.01 [4]
Recovery time (days)54390.04
Postoperative cystocele——Difference not detected
Buttock pain——Difference not detected
Hemorrhage requiring transfusion——Difference not detected

Interpretation: this underpowered observational comparison detected no success or major-harm difference. Satisfaction and recovery favored sacrospinous fixation in the matched pairs; the authors cautioned against discarding it in favor of iliococcygeus fixation.[4]

vs Coccygeus Fascial Suspension vs Sacrospinous (Peters 1995)[2]​

In a retrospective, nonrandomized cohort of 121 records, 81 had coccygeus-fascial suspension and 30 sacrospinous fixation; 10 abdominal sacrocolpopexies were not comparable. Kaplan–Meier projected 2-year cure was 96% versus 80%, respectively.[2] The coccygeus-fascial target is related but not identical to iliococcygeus fascia fixation.[2]

vs Abdominal Sacrocolpopexy (Milani 2014, n = 36 vs 41)[11]​

  • Operative time: significantly shorter (78 versus 140 min, p < 0.001).
  • Relapse was 22% after ICG versus 15% after sacrocolpopexy (p = 0.36) in this small retrospective cohort. Median blood loss was higher with ICG (150 versus 100 mL). ICG remains a mesh-free vaginal option in appropriately selected patients.[11]

ICG with hysterectomy vs hysteropexy (Suh & Jeon 2018, total n = 144)[10]​

SubgroupEstimated 4-yr freedom from anatomic or symptomatic recurrence and prolapse retreatment
ICG with hysterectomy, mild prolapse (stage II or point C ≤ 0)100%
ICG with hysterectomy, advanced prolapse91.2%
ICG as hysteropexy, mild prolapse75.3%
ICG as hysteropexy, advanced prolapse48.0%

Independent failure predictors in this 144-woman retrospective cohort were advanced prolapse (stage > II and point C > 0) and a uterus-preserving technique.[10] The study authors considered hysteropexy an option for mild uterine prolapse.[10]

Complications​

Complications are incompletely characterized in small, heterogeneous series. Meeks reported postoperative complications in 41/110 patients.[3][4]

ComplicationRate / note
Any postoperative complication41/110 in the retrospective Meeks series; types and severity require the full report[3]
Hemorrhage3/110 (2.7%) had EBL > 750 mL in Meeks; 2 required transfusion[3]
Bladder injury1/110 in Meeks[3]
Bowel injury1/110 in Meeks[3]
Buttock / gluteal painNo statistically detected difference from sacrospinous fixation in the underpowered Maher comparison[4]
Postoperative catheterizationMean 6.1 days in Meeks[3]
Anterior compartment recurrenceAll 4 recurrent defects in Meeks involved the anterior wall[3]
Mesh-related complicationsNone (native tissue)

Risk Factors for Failure​

  • Preoperative stage IV vault prolapse. Independent predictor in the small Serati follow-up cohorts (reported ORs 7.66 and 8.78).[8][9]
  • Advanced primary uterine prolapse (POP-Q stage >II and point C >0) was associated with composite surgical failure (anatomic or symptomatic recurrence or prolapse retreatment) after ICG in Suh and Jeon's 144-woman retrospective cohort, which included hysterectomy with vault suspension and hysteropexy; median follow-up was 4 years.[10]
  • Uterus-preserving technique (hysteropexy), particularly for advanced prolapse.[10]

Advantages and Disadvantages​

AdvantageDisadvantage
A single-case technique video describes iliococcygeus-fascial suture placement; comparative technical simplicity versus SSLF is unproved[1]Less commonly performed; surgeon familiarity limited[1]
Bilateral fixation may preserve a midline axis; a clinical advantage is unproved[2][14]All four anterior-wall recurrences were in Meeks’s cohort[3]
Caudal-to-spine fascial placement is a theoretical way to reduce neurovascular proximity[14]Lower observed success as hysteropexy, particularly in advanced prolapse in one cohort[10]
Native tissue — no mesh[1]Limited high-quality comparative data — no large RCTs vs SSLF / USLS
Shorter operative time than abdominal sacrocolpopexy in one retrospective series[11]Attenuated fascia may complicate fixation[14]
No success difference detected against sacrospinous fixation in one matched-pair study[4]That study was underpowered; satisfaction and recovery favored SSLF[4]

Guideline Position​

The AUGS–IUGA 2020 terminology report classifies iliococcygeus fixation as a distinct native-tissue vaginal-apex operation and standardizes its fascial target and variations.[14] The current 2026 AWMF S3 prolapse guideline, recommendation 6.E54 , says iliococcygeus fixation may be considered when no adequate alternative is available and notes the absence of randomized trials or systematic long-term data for this procedure.[15] The 2019 ACOG/AUGS prolapse bulletin lists sacrocolpopexy, uterosacral ligament suspension and sacrospinous fixation as apical procedures.[12][13]

Key Principles​

  • ICG fixation is a transvaginal native-tissue apical operation; bilateral fixation is common, but unilateral variation exists. The usual suture target is medial iliococcygeus fascia caudal to the ischial spine, not a universal anterior-to-spine point.[14]
  • The fascial target is selected to reduce neurovascular proximity; actual injury reduction versus SSLF is unproved.[4][14]
  • Post-hysterectomy vault prolapse has five- and ten-year cohort follow-up: 88.6%/82% subjective and 84.1%/74.4% objective success among 44/39 evaluated women, respectively.[8][9]
  • Hysteropexy may be reasonable for selected mild uterine prolapse; one retrospective cohort estimated 48% four-year freedom from anatomic or symptomatic recurrence and prolapse retreatment for advanced prolapse with uterine preservation.[10]
  • Stage IV vault descensus predicted recurrence in the small Serati follow-up cohorts.[8][9]
  • The Maher matched-pair comparison with SSLF detected no success difference but was underpowered; satisfaction and recovery favored SSLF.[4]
  • All four recurrent defects in Meeks involved the anterior wall; evaluate other compartments.[3]
  • The procedure is relatively uncommon; the 2026 AWMF S3 recommendation limits consideration to situations without an adequate alternative because randomized comparative and systematic long-term evidence is lacking.[1][14][15]

References​

1. Milani R, Frigerio M, Spelzini F, Manodoro S. Transvaginal iliococcygeus fixation for posthysterectomy vaginal vault prolapse repair. Int Urogynecol J. 2017;28(10):1599-1601. doi:10.1007/s00192-017-3315-6.

2. Peters WA, Christenson ML. Fixation of the vaginal apex to the coccygeus fascia during repair of vaginal vault eversion with enterocele. Am J Obstet Gynecol. 1995;172(6):1894-900; discussion 1900-2. doi:10.1016/0002-9378(95)91429-3.

3. Meeks GR, Washburne JF, McGehee RP, Wiser WL. Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Am J Obstet Gynecol. 1994;171(6):1444-52; discussion 1452-4. doi:10.1016/0002-9378(94)90386-7.

4. Maher CF, Murray CJ, Carey MP, Dwyer PL, Ugoni AM. Iliococcygeus or sacrospinous fixation for vaginal vault prolapse. Obstet Gynecol. 2001;98(1):40-4. doi:10.1016/s0029-7844(01)01378-3.

5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet. 2007;369(9566):1027-38. doi:10.1016/S0140-6736(07)60462-0.

6. DeLancey JO, Mastrovito S, Masteling M, et al. A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity. Am J Obstet Gynecol. 2024;230(5):476-484.e2. doi:10.1016/j.ajog.2023.11.1247.

7. Roshanravan SM, Wieslander CK, Schaffer JI, Corton MM. Neurovascular anatomy of the sacrospinous ligament region in female cadavers: implications in sacrospinous ligament fixation. Am J Obstet Gynecol. 2007;197(6):660.e1-6. doi:10.1016/j.ajog.2007.08.061.

8. Serati M, Salvatore S, Athanasiou S, et al. Ten years' follow-up after iliococcygeus fixation for the treatment of apical vaginal prolapse. Int Urogynecol J. 2021;32(6):1533-1538. doi:10.1007/s00192-020-04598-6.

9. Serati M, Braga A, Bogani G, et al. Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and safety at 5 years of follow-up. Int Urogynecol J. 2015;26(7):1007-12. doi:10.1007/s00192-015-2629-5.

10. Suh DH, Jeon MJ. Risk factors for the failure of iliococcygeus suspension for uterine prolapse. Eur J Obstet Gynecol Reprod Biol. 2018;225:210-213. doi:10.1016/j.ejogrb.2018.05.001.

11. Milani R, Cesana MC, Spelzini F, et al. Iliococcygeus fixation or abdominal sacral colpopexy for the treatment of vaginal vault prolapse: a retrospective cohort study. Int Urogynecol J. 2014;25(2):279-84. doi:10.1007/s00192-013-2216-6.

12. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic organ prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519.

13. American College of Obstetricians and Gynecologists and American Urogynecologic Society. Pelvic organ prolapse (joint publication of ACOG Practice Bulletin No. 214). Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794.

14. Meriwether KV, Gold KP, de Tayrac R, et al. Joint report on terminology for surgical procedures to treat pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2020;26(3):173-201. doi:10.1097/SPV.0000000000000846. AUGS–IUGA full report.

15. AWMF/DGGG et al. Diagnostik und Therapie des Descensus genitalis der Frau. S3 guideline 015-006, version 6.0, March 2026, recommendation 6.E54. Official full guideline.

16. Braga A, Amato G, Caccia G, et al. "Iliococcygeus fixation for the treatment of vaginal vault prolapse: a systematic review and meta-analysis." Minerva Urol Nephrol. 2024;76(6):683-690. doi:10.23736/S2724-6051.24.05818-X.

17. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Med Reconstr Surg. 2018;24(4):258-259. doi:10.1097/SPV.0000000000000529