Version May 2024
INTRODUCTION — 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]. One in five women will undergo surgery for prolapse or incontinence by age 80 years, and up to 30 percent of these women will require an additional pelvic floor surgery [3,4].
Reconstructive surgery corrects the prolapsed vagina and aims to restore normal anatomy, while obliterative surgery corrects prolapse by removing and/or closing off all or a portion of the vaginal canal (colpocleisis) to reduce the viscera back into the pelvis. Most women with symptomatic POP are treated with a reconstructive procedure. However, obliterative procedures are an effective option for patients who do not want, or cannot tolerate, more extensive surgery and/or who accept loss of vaginal function (ie, ability to have vaginal intercourse). In addition, obliterative procedures are consistently associated with high rates of satisfaction [5].
Obliterative procedures for POP are reviewed here. Evaluation of patients with POP and choosing a primary surgical procedure are discussed separately.
●(See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
CANDIDATES FOR SURGERY — Indications for obliterative prolapse repair are generally the same as for other POP repair procedures (ie, symptomatic prolapse in patients who decline or have inadequate response to conservative therapy). However, obliterative procedures are less invasive and better tolerated by patients with frailty and/or significant medical comorbidities. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Candidates for surgical treatment'.)
Obliterative procedures are reserved for patients who decline or are not candidates for more extensive surgery and accept loss of vaginal function (ie, ability for vaginal intercourse). A study that surveyed older adults on their sexuality reported that the prevalence of sexual activity decreased with aging [6]. Sexual activity amongst women ages 57 to 64 was 62 percent and decreased to 17 percent in women ages 75 to 85.
In the appropriate population, the advantages of obliterative procedures compared with other types of POP surgery are that such procedures typically have a shorter operative duration, decreased perioperative morbidity, and an extremely low risk of prolapse recurrence [7-14]. A retrospective cohort study of older women (median age 80) reported similar rates of patient satisfaction after obliterative versus reconstructive surgery [15].
The main disadvantages include:
●Loss of vaginal function, including the potential for vaginal intercourse
●Inability to evaluate the cervix or uterus via a vaginal route (eg, for cervical cytology or endometrial biopsy)
PREOPERATIVE EVALUATION AND PREPARATION — POP often coexists with other pelvic floor symptoms. Similar to other reconstructive procedures, prior to recommending an obliterative procedure, surgeons should obtain a thorough pelvic floor history, including assessment of bothersome urinary symptoms (incontinence and voiding difficulties) and/or defecatory problems. In addition, the symptoms specific to prolapse (eg, sensation of a vaginal bulge, irritation from ulceration of prolapse vaginal tissue) should be elicited. During the history and physical examination, the presence and severity of each of these disorders should be assessed, as this information may alter surgical decision making.
Aspects of preoperative evaluation and preparation that are specific to obliterative POP surgery are discussed in this section. General principles of evaluation of women undergoing POP repair are discussed in detail separately.
Informed consent and patient goals — It is important to discuss with the patient each symptom that is present and the effect on her quality of life. This helps to set goals for reconstructive surgery and assess postoperative improvement. Studies have demonstrated that patient satisfaction after POP surgery correlates highly with achievement of self-described preoperative surgical goals, but poorly with objective outcome measures [16-18].
Informed consent for obliterative POP surgery should include a discussion of the risks of surgery and loss of vaginal function, including the ability to have future vaginal intercourse, potential changes in body image, and potential for regret. Since many women develop stress urinary incontinence (SUI) following correction of apical prolapse, it is particularly important to discuss this risk and whether preventive surgery should be performed. (See 'Concomitant stress urinary incontinence surgery' below and "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Occult SUI'.)
History — Symptoms should be reviewed that are related to POP and to associated urinary or anal incontinence. Women with POP may experience a bulge or protrusion from the vagina. Protrusion of the vagina may result in vaginal discharge and/or bleeding from ulceration. Other symptoms may include pelvic pressure, urinary retention, or constipation; some women have the need to reduce the prolapse using a finger in the vagina (ie, splint) to urinate or defecate.
Medical comorbidities should be reviewed and preoperative medical consultation obtained if appropriate. (See "Overview of the principles of medical consultation and perioperative medicine".)
Physical examination — A thorough speculum and bimanual pelvic examination are performed. The findings of the examination should be recorded using a quantitative and reproducible method for recording POP. The system currently recommended by the International Continence Society and the American Urogynecologic Society is the pelvic organ prolapse quantitation (POP-Q) system (figure 1 and figure 2) [19] (see "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Speculum and bimanual examination'). Prolapse assessment should be done with the prolapse maximally everted and all vaginal compartments assessed.
Evaluation of urinary dysfunction — POP frequently coexists with urinary incontinence or urinary retention, and women planning apical prolapse repair should be evaluated for these conditions.
Urinary incontinence — Many women with stage II or greater apical prolapse remain continent despite loss of anterior vaginal and bladder/urethral support. However, 13 to 65 percent of continent women develop symptoms of SUI after surgical correction of the prolapse [20-23]. A retrospective study of women who underwent colpocleisis reported that 8 of 30 developed de novo SUI postoperatively [11]. This likely occurs because the prolapse kinks and obstructs the urethra; this obstruction is alleviated when the prolapse is repaired. This is referred to as "occult" or "potential" stress incontinence. The decision to perform a prophylactic continence procedure at the time of colpocleisis remains unclear; however, several small case series suggest that concomitant midurethral sling at the time of colpocleisis is safe and does not result in high rates of urinary retention [24,25]. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment".)
Continent women undergoing colpocleisis should be counseled regarding the risks and benefits of prophylactic continence procedures versus staged procedures. Consideration should be given to evaluating these women preoperatively with reduced cough stress testing, although reduction testing does not accurately predict postoperative SUI (approximately 40 percent of women with negative testing will develop postoperative stress incontinence) [26]. In a study of stress-continent women undergoing vaginal surgery for prolapse (7 percent had colpocleisis), 72 percent of women with a preoperative positive reduced cough stress test who did not get a midurethral sling developed urinary incontinence three months after surgery compared with 30 percent of women who underwent concomitant midurethral sling procedure [27]. This testing may impact surgical decision making, particularly for women undergoing transvaginal apical prolapse repair. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Occult SUI'.)
Women with bothersome SUI should be counseled regarding a concomitant procedure for SUI, regardless of preoperative urinary retention. In a case series of 38 women with POP and SUI undergoing colpocleisis and midurethral sling, 11 women had preoperative urinary retention [24]. Ten of 11 women with preoperative retention had resolution of retention and no women experienced prolonged retention requiring sling release after surgery, suggesting it is reasonable to offer women with POP and bothersome SUI midurethral sling at the time of colpocleisis. In contrast, rectus fascial sling is associated with a threefold increase in reoperation for postoperative retention when performed at the time of colpocleisis [11].
Urinary retention — A postvoid residual (PVR) urine volume should be determined within 10 minutes of voiding. In general, a PVR of less than 50 to 100 mL is considered adequate emptying, and a PVR of greater than 200 mL is considered inadequate. Older women with advanced POP are at increased risk for urinary retention, which, in rare cases, may result in hydronephrosis [28].
SURGICAL PLANNING
Choosing a type of obliterative procedure — All colpocleisis procedures remove vaginal epithelium and then appose the anterior and posterior vaginal muscularis. Apposing the anterior and posterior vaginal walls inverts the prolapsed apex and the sutured tissue forms a column of pelvic support [8]. The two most common techniques for obliterative surgery for POP are [9]:
●Partial colpocleisis (Le Fort colpocleisis) – Partial (Le Fort) colpocleisis is done in patients in whom the uterus is left in situ and includes removal of strips of anterior and posterior vaginal epithelium, leaving a small strip of lateral epithelium on each side. The primary purpose for leaving the lateral strips of epithelium is to provide an outlet for cervical or uterine bleeding or drainage in patients where the uterus is left in situ. However, some surgeons leave the lateral epithelium in patients without a uterus to help orient junior surgeons when learning the procedure.
●Total colpocleisis – Total colpocleisis is generally reserved for vaginal vault prolapse and refers to removal of the majority of the vaginal epithelium. This procedure is also referred to as complete colpocleisis, colpectomy, or vaginectomy.
Whether performing a partial or total colpocleisis, 3 to 4 cm of distal vaginal epithelium should be left in place to avoid placing traction on the posterior urethra when suturing the anterior and posterior vaginal muscularis. This distal traction on the posterior urethra and bladder neck may increase stress urinary incontinence (SUI) postoperatively.
Concomitant hysterectomy — Concomitant hysterectomy is often performed at the time of POP surgery, despite case series data that suggest that hysterectomy performed at the time of colpocleisis increases operative duration and morbidity [13,29,30]. In a retrospective study of 92 women who underwent total colpocleisis, concomitant hysterectomy was associated with significant increases in operative duration (an average of 52 minutes longer) and transfusion rate (35 versus 13 percent) compared with no hysterectomy [29]. A study from the American College of Surgeons National Quality Improvement Program (NSQIP) database of over 1000 women undergoing colpocleisis reported an overall serious complication rate of 1.2 percent [30]. However, the rate was notably higher for women who underwent concomitant hysterectomy compared with those who underwent colpocleisis only (3.7 versus 0.7 percent). Obliterative surgery is highly effective, regardless of whether hysterectomy is performed.
Some surgeons routinely recommend concomitant hysterectomy because obliterative procedures preclude future evaluation of the cervix or uterus (eg, cervical cytology or endometrial biopsy). Hysterectomy also prevents future pyometra, but this complication is rare [31-35]. However, the increased morbidity associated with concomitant hysterectomy does not offset rare uterine/cervical complications. Patients with a uterus and/or cervix should undergo preoperative evaluation of the cervix and endometrium (cervical cytology and endometrial sampling and/or transvaginal ultrasound) when indicated prior to obliterative procedures without concomitant hysterectomy. Preoperative evaluation is particularly important for patients with vaginal bleeding from any source; endometrial evaluation is indicated even if there is a visible source for the patient's bleeding, such as ulcerations of the prolapsed tissue.
Hysterectomy may be advisable in women with risk factors for cervical cancer (eg, current or recent high risk human papillomavirus infection or cervical intraepithelial neoplasia) or endometrial cancer (eg, obesity, tamoxifen use, Lynch syndrome), although there are no studies evaluating obliterative procedures in these groups. (See "Overview of the evaluation of the endometrium for malignant or premalignant disease", section on 'Transvaginal ultrasound' and "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Epidemiology' and "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Risk factors'.)
For women who are undergoing colpocleisis and are at an average risk of cervical and/or endometrial cancer, we suggest not performing concomitant hysterectomy. This strategy is also supported by a published decision analysis that concluded it was preferable to perform colpocleisis alone rather than colpocleisis with vaginal hysterectomy in women older than 40 years evening when accounting for endometrial cancer [36].
A detailed discussion of hysterectomy at the time of surgery for POP can be found separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy'.)
Concomitant stress urinary incontinence surgery — Women undergoing obliterative POP surgery often have symptomatic or occult SUI. Concomitant continence surgery is appropriate in some women, depending upon their symptoms and goals for treatment. (See 'Evaluation of urinary dysfunction' above.)
Historically, a Kelly suburethral plication was done at the time of colpocleisis to treat or prevent SUI; however, this procedure is often unsuccessful. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Procedures no longer recommended'.)
The outcomes of combined surgical treatment of POP and SUI were best illustrated in the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial, which evaluated the addition of a concomitant prophylactic midurethral sling procedure in continent women at the time of vaginal prolapse surgery, including women who underwent colpocleisis (24 women; 8 percent of participants) [27]. Women who had a concomitant sling had lower rates of incontinence or treatment for incontinence one year after surgery, but had an increased risk of complications (eg, voiding dysfunction). A detailed discussion of the OPUS trial can be found separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)
In addition, several small case series suggest that concomitant midurethral sling at the time of colpocleisis is safe and does not result in high rates of urinary retention [24,25]. A retrospective study of 30 women who underwent colpocleisis and midurethral sling placement reported one perioperative complication (a myocardial infarction); only two women (6.6 percent) had mild postoperative SUI (not requiring a pad) [25]. Review of the National Surgical Quality Improvement Program database from 2005 to 2011 found similar rates of complications, urinary tract infection, and reoperation in women who had colpocleisis with and without concomitant sling procedures [37]. Another study of 231 women reported similarly low (approximately 10 to 11 percent) postoperative retention rates in patients undergoing colpocleisis with or without midurethral sling [38].
Combined treatment for POP and SUI is discussed in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment".)
ANESTHESIA — Colpocleisis can be performed under general or regional anesthesia. We advise using enhanced recovery after surgery (ERAS) protocols that include oral fluid intake with a carbohydrate and electrolyte clear beverage (such as Gatorade) within two hours of surgery; narcotic-sparing anesthesia and postoperative pain control; and early ambulation and resumption of normal activities. Most patients are able to be discharged from the hospital on the day of surgery. (See "Enhanced recovery after gynecologic surgery: Components and implementation".)
PROCEDURE — Using sharp and blunt dissection, the vaginal epithelium is dissected off the underlying muscularis (figure 3). A total colpocleisis removes all of the vaginal epithelium, while a partial colpocleisis leaves a small portion of vaginal epithelium on each side to provide drainage tracts in women with a uterus, as noted above. (See 'Choosing a type of obliterative procedure' above.)
The leading edge of the prolapse is identified and successive interrupted delayed absorbable sutures are used to reduce the prolapse until it lies above the levator plate, effectively obliterating the vaginal canal. Approximately 3 to 4 cm of epithelium on the distal anterior vaginal wall should be left in place to avoid pulling the posterior urethra down when suturing the anterior and posterior vagina. The urethrovaginal junction can be easily identified by placing gentle traction on the Foley catheter and palpating the balloon. The urethrovesical junction can then be marked with a sterile skin marker to prevent over dissection of the epithelium in this area.
Finally, a wide perineorrhaphy is created by removing a large diamond shaped area of perineal skin and distal vaginal epithelium. The levator muscles (specifically edge of the puborectalis) are then approximated with nonabsorbable sutures. Typically, the genital hiatus is reduced to allow passage of one finger.
FOLLOW-UP
Routine postoperative care — Most women will experience a small amount of vaginal bleeding as well as perineal incisional pain following obliterative POP surgery. These symptoms typically resolve within one week postoperatively and can be treated with nonsteroidal anti-inflammatory medications. Narcotics are usually unnecessary. Patients should be advised to call their surgeon in case of severe or persistent bleeding or abdominal pain or the development of increasing incisional pain, vaginal discharge, dysuria, or fever. Routine postoperative clinical evaluation should occur within the first two to four weeks.
A detailed discussion of postoperative care after gynecologic surgery can be found separately.
●(See "Enhanced recovery after gynecologic surgery: Components and implementation" and "Enhanced recovery after gynecologic surgery: Components and implementation", section on 'Postoperative'.)
●(See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)
Sexual function — Vaginal intercourse is precluded following colpocleisis, but other sexual activities are possible. There are few data regarding sexual function following colpocleisis. In one prospective study, women reported differing impacts on sexual function, including worse (3 percent), unchanged (87 percent), and improved (10 percent) [5]. A case series that followed 33 patients for a median of six years after colpocleisis reported no patients experienced regret due to lack of sexual function [39].
COMPLICATIONS — Overall, complications of colpocleisis are low. As an example, a retrospective study of 4776 colpocleisis procedures performed in the United States reported low rates of complications, intensive care unit admissions, and mortality (7, 3, and 0.15 percent, respectively) [40]. Similarly, a review of published reports of colpocleisis since 1980 calculated a surgical mortality rate of 1 in 400 cases [9], while a review of the National Surgical Quality Improvement Program database found a 0.4 percent mortality rate [37]. Complication rates and ICU admissions were lower when women had their colpocleisis in a high-volume center (one that did more than 11 colpocleisis procedures per year) by a urogynecologist [40].
Significant postoperative complications are often related to comorbidities in an older adult population; postoperative cardiac, thromboembolic, pulmonary, or cerebrovascular events occur in approximately two percent of patients [9,41]. Four percent of patients experience complications related to the procedure itself (eg, transfusion or pyelonephritis); these events occur mostly when concomitant hysterectomy is performed [9,29]. Less frequently, complications include ongoing vaginal bleeding, fever and intraoperative ureteral injury. In a retrospective review of 245 women undergoing colpocleisis, the most common adverse event was urinary tract infection, which occurred in 35 percent of women [42]. Patient frailty is a better predictor than age of serious complications in patients undergoing colpocleisis [43].
OUTCOME — Colpocleisis is highly effective for treating prolapse; success rates range from 90 to 100 percent [5,10-14,44]. As an example, a large retrospective study (n = 310) found that 93 percent of women who underwent colpocleisis reported their symptoms were cured or greatly improved. The complication rate was 15 percent; most complications were minor, but four deaths occurred (two cases of postoperative pulmonary embolisms, one myocardial infarction 42 days after surgery, one case of sepsis related to a bowel injury during a concomitant procedure) [45]. In over 90 percent of women with urinary retention undergoing colpocleisis, urinary retention resolves after surgery [46]. In a case series of 33 patients who had undergone colpocleisis and were contacted a median of six years from surgery, the overall satisfaction and strong regret rates were 78 and 13 percent, respectively [39]. Strong feelings of regret were associated with postoperative bladder and bowel symptoms.
Colpocleisis does not appear to alter body image and regret after the procedure is uncommon (ranging from than 0 to 13 percent) and not related to patient age [7,13,29,47-50].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse" and "Society guideline links: Gynecologic surgery".)
SUMMARY AND RECOMMENDATIONS
●Description and indications – Obliterative surgery treats pelvic organ prolapse (POP) by removing and/or closing off all or a portion of the vaginal canal (colpocleisis) to reduce the vagina and viscera back into the pelvis. While most patients with symptomatic POP are treated with a reconstructive procedure, obliterative procedures are an effective option for patients who do not want, or cannot tolerate, more extensive surgery and who are not planning future vaginal intercourse. (See 'Candidates for surgery' above.)
●Types of colpocleisis – All colpocleisis procedures remove vaginal epithelium and then appose the anterior and posterior vaginal muscularis. Apposing the anterior and posterior vaginal walls inverts the prolapsed apex and the sutured tissue forms a column of pelvic support.
•Partial (Le Fort) colpocleisis – In this procedure, strips of anterior and posterior vaginal epithelium are removed (figure 3). The remaining lateral portions of epithelium are left in place, providing drainage tracts for uterine bleeding or discharge. Partial colpocleisis is the preferred procedure for patients with a uterus and a reasonable option for patients with vaginal vault prolapse. (See 'Choosing a type of obliterative procedure' above.)
•Total colpocleisis (colpectomy) – This procedure is typically done for vaginal vault prolapse (ie, cervix and uterus are absent) and involves removal of the majority of the vaginal epithelium. (See 'Choosing a type of obliterative procedure' above.)
●Role of hysterectomy – For patients who are undergoing colpocleisis and are at an average risk of cervical and/or endometrial cancer, we suggest NOT performing concomitant hysterectomy (Grade 2C). Concomitant hysterectomy at the time of colpocleisis increases operative duration, morbidity, and complications. (See 'Concomitant hysterectomy' above.)
●Concomitant SUI surgery – Patients undergoing obliterative POP surgery often have symptomatic or occult stress urinary incontinence. Concomitant midurethral sling is appropriate in some women and does not seem to increase postoperative rates of urinary retention. (See 'Concomitant stress urinary incontinence surgery' above and "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)
●Complications – Significant postoperative complications of colpocleisis are often related to comorbidities and frailty more than chronological age. The most common complications related to the procedure itself are transfusion and pyelonephritis. (See 'Complications' above.)
●Efficacy – Colpocleisis is highly effective for treating prolapse; success rates range from 90 to 100 percent, with long-term success rates of 78 percent. Colpocleisis does not appear to alter body image, and regret after the procedure is uncommon (ranging from 0 to 13 percent). (See 'Outcome' above.)
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