Version May 2024
INTRODUCTION — Anterior vaginal wall prolapse describes support abnormalities of the anterior wall of the vagina. Prolapse of the anterior wall typically coexists with prolapse at other anatomic sites (vaginal apex, posterior vaginal wall) [1-3]. The prevailing view is that a common pathogenesis underlies support defects at different sites of the vaginal wall, replacing a previous focus on isolated anatomic compartments. Procedures for surgical repair of anterior vaginal wall defects should include repair of apical prolapse, if present [4].
Pelvic organ prolapse (POP) affects millions of women; approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States [5,6]. Eleven to 19 percent of women will undergo surgery for prolapse or urinary incontinence by age 80 to 85 years, and 30 percent of these women will require an additional prolapse or incontinence surgery [7].
Reconstructive procedures for prolapse of the anterior vaginal wall are reviewed here. Related topics regarding POP in women are discussed separately, including:
●Diagnosis and evaluation and conservative management (see "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management" and "Vaginal pessaries: Indications, devices, and approach to selection")
●Choosing a primary surgical procedure (see "Pelvic organ prolapse in women: Choosing a primary surgical procedure")
●Obliterative procedures (colpocleisis) (see "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)")
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.
TERMINOLOGY — The International Continence Society defines anterior vaginal wall defects as descent of the anterior vagina so that the urethrovesical junction or any other point on the anterior vaginal wall is less than 3 cm from the hymenal ring [8]. Clinically, any abnormal descent of the anterior vaginal wall or bladder base with or without straining may be considered an anterior vaginal wall defect [9]. However, clinically significant anterior vaginal wall prolapse is usually reflected by prolapse to or through the introitus.
The current designation reflects the actual site of vaginal wall prolapse (anterior vaginal wall), rather than the structures underlying it (bladder or urethra), and has replaced previously used terms, such as cystocele or urethrocele.
ANATOMY AND MECHANISMS OF INJURY
Normal anterior wall support — The upper two-thirds of the vagina is supported by the underlying levator ani muscles (pubococcygeus, puborectalis, and iliococcygeus) and a layer of dense fibrous musculoconnective tissue (the endopelvic fascia), which surrounds the cervix and vagina and extends laterally to the arcus tendineus fasciae pelvis (also called the "white line") on each side (figure 1) [10-12]. The arcus tendineus fasciae pelvis runs from the ischial spine to the inferior margin of the pubic symphysis. Despite common misconceptions, there is no vaginal fascia, only three distinct vaginal layers consisting of epithelium, muscularis, and adventitia [11].
The bladder has no true support structures of its own and simply overlies the upper one-third of the vagina [11]. The urethra is supported by the anterior vaginal wall and the surrounding urethrovaginal sphincter and compressor urethrae [13].
The anatomy of the female pelvic floor is discussed in detail separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Anatomy of pelvic support'.)
Pathogenesis of anterior wall defects — Traditionally, anterior vaginal wall defects were believed to be due to stretching or thinning of the anterior vaginal wall and its supports, thereby allowing herniation of the bladder and/or urethra into the vagina (figure 2). The approach to treatment based upon this assumption was surgical plication or tightening of the weak and redundant anterior vaginal wall (ie, anterior colporrhaphy) [11].
The current understanding of anterior vaginal wall prolapse is that the etiology is not an overall stretch defect, but is the result of a specific defect in the support structures of the vagina as a whole [14-17]. Lack of attention to the specific defect in vaginal support structures has been proposed as a major reason that anterior vaginal wall prolapse recurs in as many as 40 percent of patients after anterior colporrhaphy alone or because the apex has also not been addressed [14,18]. The concept of a site-specific defect has replaced prior theories on the pathogenesis of anterior vaginal wall defects and altered evaluation and management of anterior vaginal prolapse.
Site-specific defects — Four anatomic sites of anterior vaginal support abnormalities were originally described by Richardson in 1976. Clinical practice and research have focused on midline and paravaginal sites [19,20], although these "sites" are difficult to study in isolation. The ability to diagnose these defects has not been well studied or validated. Midline and paravaginal defects are defined as:
●Midline – Midline defects (also referred to as central) arise from vertical defects in the endopelvic fascia (musculoconnective tissue) extending anteriorly to posteriorly (figure 3). They often interrupt support of the urethrovesical junction, contributing to urethral hypermobility and stress urinary incontinence (SUI) [19].
On examination, a central defect is visualized as an anterior vaginal wall defect, but the lateral vaginal fornices are intact bilaterally (ie, a large anterior wall bulge still firmly connected to the lateral pelvic sidewalls).
●Paravaginal – Paravaginal defects (also referred to as lateral) result from detachment of the lateral vaginal wall from the arcus tendineus fascia pelvis (figure 3). As a result, the lateral vaginal sulcus descends, often accompanied by a moderate anterior wall prolapse, loss of the urethrovesical angle, and significant SUI. This type of defect can occur unilaterally or bilaterally [19,21].
The presence of a paravaginal defect is assessed using a tongue depressor (or ring forceps). The tongue depressor (or ring forceps) is placed in the lateral anterior vaginal sulcus and then elevated. If the anterior wall defect resolves, then this suggests lateral separation of the vagina from the arcus tendineus fascia pelvis. Both vaginal sulci should be checked, as vaginal defects may occur unilaterally or bilaterally. By contrast, a persistent anterior wall defect despite supporting the lateral vaginal sulcus suggests a central or transverse defect.
Other site-specific defects that have been described include:
●Transverse – Transverse defects occur when the pubocervical fascia separates from its insertion into the ring of connective tissue around the cervix and uterosacral ligaments, creating a transverse support defect and loss of the anterior fornix of the cervix (figure 3). On examination, these defects often result in a large anterior vaginal wall defect, which appears to originate high on the anterior vaginal wall or near the cervix (also referred to as a high cystocele), although the urethra may remain well supported [19].
●Distal – Distal defects are the least common forms of anterior vaginal wall defects. They are due to a break in the fibromuscular support of the anterior vaginal wall, just before the insertion into the pubic symphysis [9]. These defects tend to be smaller and include the distal anterior vaginal wall (ie, near the introitus) and usually are associated with urethral hypermobility [4].
Vaginal wall abnormalities may be further divided into anterior or posterior. An anterior defect represents descent of the urethra and bladder neck with straining while a posterior defect represents descent of the bladder base [22].
CANDIDATES FOR ANTERIOR PROLAPSE REPAIR — Women with bothersome symptoms attributable to anterior vaginal wall prolapse that decline or fail conservative therapy are candidates for surgical repair. Surgical correction of asymptomatic pelvic organ prolapse (POP) or nonbothersome POP is of uncertain benefit and exposes patients to operative risk. Prolapse repair is typically deferred until after a woman completes childbearing.
Indications and contraindications for POP repair are discussed in detail separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Candidates for surgical treatment'.)
SURGICAL PLANNING — Issues specific to planning repair of apical prolapse are discussed in this section. General principles of surgical decision-making regarding pelvic organ prolapse (POP) (eg, obliterative versus reconstructive surgery, concomitant hysterectomy, concomitant anti-incontinence surgery) are discussed separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)
Site-specific repair — Anterior vaginal wall POP may be due to defects that are central, lateral, transverse, or distal, as described above. The procedure or combination of procedures used depends upon the specific site of the defect. To reduce failure risk, apical and lateral defects are identified and repaired when indicated. (See 'Site-specific defects' above.)
Concomitant repair of other sites of prolapse — Anterior vaginal wall defects rarely occur in isolation and are often accompanied by descent of the vaginal apex or posterior vaginal wall. The need for repair of other anatomic sites of prolapse is guided by the preoperative evaluation. Currently, most pelvic surgeons agree that apical support must be carefully evaluated preoperatively in all patients to determine whether an apical suspension is indicated. Studies have demonstrated significantly improved anterior and posterior prolapse repair outcomes when performed concurrently with an apical support repair, transvaginal or transabdominal [23]. This is discussed in detail separately.
Patients should be carefully examined in the office prior to surgery in order to assess whether there are support defects of the vaginal apex (cervix or vaginal vault) or posterior vaginal wall, in addition to an anterior vaginal wall support defect. If significant apical prolapse is noted, an apical repair procedure should be performed at the time of surgery. When apical repair is performed via an abdominal route (eg, sacrocolpopexy or uterosacral ligament suspension), most surgeons will perform this portion of the procedure first and then proceed with an anterior colporrhaphy. This follows the principle of moving from a clean field (abdominal) to a clean contaminated field (vaginal) to decrease the risk of surgical site infection. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant repair of apical and anterior or posterior prolapse' and "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)".)
PREOPERATIVE EVALUATION — Preoperative evaluation for women planning surgical repair of anterior vaginal wall pelvic organ prolapse (POP) should address the following issues:
●Presence and severity of symptoms – The goal of POP repair is to correct anatomic defects that result in bothersome symptoms. A detailed discussion with the patient allows the surgeon to differentiate symptoms that affect the patient’s quality of life from those that are mild and not bothersome. Whenever possible, it is important to identify symptoms that are attributable to a specific anatomic compartment, since this aids surgical decision-making. As an example, women with advanced anterior and apical prolapse may experience urinary retention, but this is not associated with posterior vaginal wall prolapse. Prolapse is often present in more than one anatomic compartment (anterior, posterior, vaginal apex), however, and many symptoms are not specific to a single site [24].
●Anatomic site and degree of prolapse – POP is often present at more than one anatomic compartment and a coordinated approach to repair may be required. All potential defect areas must be assessed prior to surgery, especially the vaginal apex. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant repair of apical and anterior or posterior prolapse'.)
●Presence of associated conditions – POP often coexists with urinary tract or bowel dysfunction (eg, incontinence, urinary retention, constipation). Relevant symptoms should be elicited and further evaluation performed as appropriate. In addition, preoperative sexual function concerns should be discussed with the patient. Sexual dysfunction may be associated with POP. In addition, some women may experience dyspareunia or other alterations in sexual function following POP repair. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Urinary tract evaluation' and "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Bowel function evaluation'.)
Aspects of preoperative evaluation and preparation that are specific to anterior prolapse repair are discussed in this section. General principles of evaluation of women with POP are discussed in detail separately. (See "Pelvic organ prolapse in women: Diagnostic evaluation".)
Informed consent and patient goals — Surgeons should discuss the goals and expected outcomes of treatment with the patient. This helps to set realistic expectations and assess postoperative improvement. Patient satisfaction after surgery for POP and urinary incontinence correlates highly with achievement of self-described preoperative surgical goals, but poorly with objective outcome measures [25-27].
Informed consent should include a discussion of alternative treatments, the expected efficacy of the procedure, and the risk of surgical complications. If use of surgical mesh or a biograft is planned, the relative efficacy of this to native tissue repair and the risk of mesh-related complications should be reviewed. (See 'Use of reconstructive materials' below.)
History — Symptoms associated with prolapse and associated conditions (urinary, bowel, sexual function) should be elicited. The most common clinical manifestation of prolapse of the anterior vaginal wall is a bulge or protrusion from the vagina (picture 1). Protrusion of the vagina may result in vaginal discharge and/or bleeding from ulceration. Other symptoms frequently reported by women with anterior prolapse are urinary incontinence or voiding difficulty; some women need to reduce the prolapse using a finger in the vagina (ie, "splint") to urinate or defecate.
Women with urinary tract symptoms should undergo appropriate evaluation. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Urinary tract evaluation'.)
General symptoms of POP are discussed in detail separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)
Physical examination — Prolapse commonly involves two or more anatomic sites. A thorough speculum and bimanual pelvic examination should be performed. Many clinicians recommend examining the patient in standing and straining positions to truly appreciate the severity of prolapse (which is often less severe when supine). 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 (AUGS) is the POP quantitation (POP-Q) system (figure 4 and figure 5) [28].
Examination for site-specific defects is discussed above. (See 'Site-specific defects' above.)
The physical examination for assessment of POP is described in detail separately. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Speculum and bimanual examination'.)
Other studies — Laboratory evaluation and imaging are not typically necessary for evaluation of anterior vaginal wall prolapse. Preoperative testing should be performed as needed based upon patient age and medical comorbidities. (See "Preoperative medical evaluation of the healthy adult patient".)
PREOPERATIVE PREPARATION
Antibiotic prophylaxis — We recommend antibiotic prophylaxis for surgical site infection for procedures for the treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SUI) (table 1). Infectious complications of such procedures include urinary tract infection, wound infection, or infections associated with reconstructive materials (eg, abscess, cellulitis) [29-34].
The rationale of antibiotic prophylaxis in pelvic reconstructive procedures varies somewhat with the surgical route. The vaginal field is classified as clean-contaminated (wound class II). There are few direct data that address transvaginal pelvic floor surgery. The only randomized trial evaluated use of prophylactic antibiotics for midurethral sling placement and found no significant differences in rates of bacteriuria or wound infection in women treated with cefazolin compared with placebo, but the study was underpowered to detect these differences [35]. Indirect evidence derives from studies of vaginal hysterectomy, which involves the same surgical field. A meta-analysis of studies of vaginal hysterectomy found a decrease in pelvic infections with use of prophylactic antibiotics [36].
The risk of surgical site infection for procedures involving reconstructive materials (mesh, biografts) is discussed in detail separately.
Transabdominal pelvic reconstructive surgeries that do not involve a vaginal incision (eg, sacral colpopexy) are classified as clean procedures. There is no direct evidence about the use of prophylactic antibiotics for these procedures, but the risk of infection is likely similar to other transabdominal pelvic surgery. A meta-analysis of 25 randomized trials of abdominal hysterectomy found a significant decrease in serious postoperative infections with use of antibiotics (9 versus 21 percent) [37]
Our recommendation is consistent with professional society guidelines. American College of Obstetricians and Gynecologists (ACOG) guidelines advise antibiotic prophylaxis for surgical site infection for urogynecologic procedures involving colporrhaphy or hysterectomy [38]. American Urological Association (AUA) guidelines also advise use of antibiotic prophylaxis for all patients undergoing vaginal urologic surgery [39].
Procedures for the treatment of POP or SUI do not require antibiotic prophylaxis for bacterial endocarditis, in the absence of other indications.
Thromboprophylaxis — Isolated procedures for repair of anterior vaginal prolapse that are classified as minor surgery (defined as <30 minutes) and are performed in mobile patients with no additional thrombotic risk factors are classified as low risk for venous thromboembolism and do not require specific thromboprophylaxis. For procedures with a duration of 30 or more minutes, intermittent pneumatic compression or pharmacologic thromboprophylaxis is recommended by the American College of Chest Physicians (ACCP).
Additional discussions of preoperative prevention of thromboembolic events are presented separately.
●(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Vaginal estrogen — Many surgeons treat postmenopausal women with transvaginal estrogen preoperatively to maximize vaginal mucosal thickness at the time of surgery and postoperatively to facilitate tissue healing. In one trial comparing pre- and postoperative vaginal estrogen with placebo, 12-month surgical success rates were similar for both groups but patients receiving vaginal estrogen reported improved vaginal atrophy scores [40]. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Vaginal estrogen therapy'.)
MIDLINE DEFECT REPAIR (ANTERIOR COLPORRHAPHY) — Anterior colporrhaphy (also referred to as anterior repair) is the procedure of choice for repair of midline, or central, anterior vaginal wall defects and/or to reduce the volume of the anterior wall. This procedure may be combined with paravaginal or transverse defect repair, depending upon the sites of vaginal support defects in the individual patient. (See 'Site-specific defects' above.)
Procedure — Anterior colporrhaphy involves some degree of excision and/or plication of redundant anterior vaginal wall epithelium.
There are many variations in technique; the following is the approach we use in our practice:
●The patient is placed in the dorsal lithotomy position. A bladder catheter is placed. A weighted speculum or self-retaining retractor is placed within the vagina, allowing adequate visualization of the anterior vaginal wall.
●An Allis clamp is placed 1 cm proximal to the urethra along the midline of the anterior vagina and another Allis clamp 2 to 3 cm proximal to the other clamp on the anterior vaginal wall. Alternatively, two more Allis clamps can be placed on either side of the vaginal cuff or distal to the cervix. The anterior vaginal wall may be injected with saline or a solution of diluted vasopressin (eg, 20 units of vasopressin in 100 mL of saline), if desired to assist in identifying planes of dissection. Safe practices for use of vasopressin are described separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Vasopressin and other vasoconstrictors'.)
●A vertical incision is made between the Allis clamps on the vaginal cuff/cervix. Metzenbaum scissors are then used to dissect the vaginal epithelium off the underlying tissues bilaterally (figure 6).
●Once adequate mobility of the vaginal epithelium is achieved, the scissors are then carefully placed beneath the most superficial layer possible in the anterior vaginal wall epithelium and advanced with gentle pressure for 2 to 3 centimeters. The scissors are spread slightly as they are withdrawn, thereby assisting in dissection of the vaginal epithelium from the underlying tissue. The path of the scissors is incised, extending the vertical incision.
●This process is repeated until the just past the defect or to the level of the cervix or vaginal cuff. Additional Allis clamps are placed on the epithelial edges to assist in retraction. Once completed, further dissection of the epithelium from the underlying tissues is performed bilaterally until the epithelium has been dissected off the entirety of the bladder. Care should be taken to limit the dissection to the extent needed to correct the defect. Excessive dissection may increase the risk of denervation injury to the bladder.
●Plication of the vaginal muscularis and adventitia is then performed using figure-of-eight sutures; some people run the suture placed as laterally as possible in the field of dissection, but deep enough to include only vaginal adventitia and muscularis and not bladder subepithelium or epithelium. Delayed absorbable sutures (eg, 0-0 Vicryl, PDS) are most often used and are tied in the midline. Multiple layers of closure may be used for larger defects. Care should be taken to avoid excessive tissue plication around the urethra, to avoid obstruction.
●Once plication of the defect has been performed, redundant vaginal epithelium may be trimmed. Excessive reduction in vaginal diameter should be avoided, as it may result in significant dyspareunia. At procedure completion, the surgeon should be able to easily insert two fingers in the vagina. The vaginal incision is closed with a fine delayed absorbable suture (eg, 3-0 Monocryl).
For patients with stress urinary incontinence (SUI), a midurethral sling or other incontinence procedure is typically performed with the vaginal repair. Historically, a Kelly bladder neck plication was advised, but randomized trial data show that anterior colporrhaphy alone or with a Kelly (or Kelly-Kennedy) plication is not an effective anti-incontinence procedure. Additional discussions of incontinence procedures are available separately.
●(See "Female stress urinary incontinence: Choosing a primary surgical procedure".)
Anterior colporrhaphy is typically performed transvaginally, with few exceptions. Use of a transabdominal approach at the time of concurrent abdominal surgery (hysterectomy, Burch urethropexy) has been reported. In this approach, the surgeon excises a triangle-shaped wedge of the anterior vaginal cuff (wide base at the level of the cuff and narrowing distally). The transabdominal approach has been evaluated in few studies, which found high recurrence rates at five years after surgery (61 percent) [41,42].
Complications — Data are lacking regarding the incidence of perioperative complications of anterior colporrhaphy. Potential complications include [43,44]:
●Hemorrhage
●Bladder, urethral, or ureteral injury
●Hematoma
●Wound infection or dehiscence
●Vaginal pain or dyspareunia
●Urinary tract infection
●De novo or worsening detrusor overactivity
●Urinary retention
●Urogenital fistula
●Urethral diverticulum
If reconstructive materials are used, the risk of complications increases and may include mesh erosion, mesh contracture, and mesh-related infection [45]. (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Complications by procedure'.)
Hemorrhage or hematoma — Intraoperative complications are rare for anterior colporrhaphy, but hemorrhage requiring transfusion may occur. The vaginal plexus and inferior vesical vessels can easily bleed if care is not taken while dissecting this delicate plane. If a hematoma develops and is stable in size, it can be left in place. Bleeding must be controlled for any hematoma that is expanding; severe bleeding may require hypogastric artery ligation on the ipsilateral side. Opening and draining a significant and expanding hematoma will rarely reveal the source of active bleeding.
Postoperatively, if the patient has a vaginal hematoma or vaginal bleeding beyond minimal staining, a vaginal pack may be placed. A bladder catheter should also be placed to prevent associated urinary retention. Vaginal packing should be removed within 24 hours. If brisk vaginal bleeding persists, the patient should be returned to the operating room to identify the source and control the bleeding. If there is only a small volume of ongoing bleeding, the patient may be observed with assessment of vital signs, pad counts, and serial hemoglobin levels.
A stable hematoma will eventually resolve and may be managed expectantly. Drainage of a hematoma should be avoided, if possible, since this can introduce infection. For patients with severe pain, or who form an abscess within the hematoma, drainage is indicated.
Wound breakdown or infection — Patients with wound breakdown or infection after anterior colporrhaphy will often complain of pain, bleeding, persistent serosanguineous or purulent discharge, and, in some cases, dyspareunia. For suture-only procedures, cases of wound breakdown can be allowed to heal by secondary intention. Wound infection is diagnosed based upon a finding of surrounding erythema and tenderness. Induration or a purulent discharge may also be present. Fever will develop in some, but not most patients. In cases of infection, the wound should be irrigated and the patient treated with an antibiotic with skin flora coverage (eg, a cephalosporin). Debridement may sometimes be required to remove excessive necrotic tissue.
Urinary tract issues
●Detection of surgical injury – Cystotomy may occur and is usually recognized intraoperatively. Cystoscopy is recommended at completion of the anterior colporrhaphy [46]. Urethral injury and ureteral injury are rare. Management of urinary tract injury during gynecologic surgery is discussed separately. (See "Urinary tract injury in gynecologic surgery: Identification and management".)
●Urinary tract infection – Urinary tract infection that requires treatment occurs in nearly 5 percent of patients after anterior colporrhaphy [47]. (See "Acute simple cystitis in adult and adolescent females".)
●Postoperative urinary retention – Some women develop urinary retention postoperatively. This will typically resolve within several days and is managed by replacing the bladder catheter and then doing voiding trials to assess bladder function. Management of this issue is discussed separately. (See "Postoperative urinary retention in females".)
●Detrusor overactivity – Many women have transient voiding dysfunction immediately after surgery, including de novo or worsening detrusor overactivity. Management of this condition is discussed separately. (See "Female urinary incontinence: Treatment".)
Mesh-related complications — Women who have undergone anterior prolapse repair with synthetic mesh remain at risk of complications. Issues that can arise include mesh exposure and/or contraction and resultant pain. Discussions of complications related to transvaginal synthetic mesh and their management are presented separately.
●(See "Transvaginal synthetic mesh: Complications and risk factors".)
●(See "Transvaginal synthetic mesh: Management of exposure and pain following pelvic surgery".)
Vaginal pain or dyspareunia — Vaginal incisional pain typically resolves four to six weeks after the procedure. In some women, vaginal discomfort continues, particularly dyspareunia [48,49]. As an example, in a meta-analysis of native-tissue POP repair, 4 percent of women had new onset dyspareunia [49]. In some cases, postoperative vaginal narrowing may cause insertional dyspareunia; vaginal dilation or release of any restrictive bands can be performed to facilitate intercourse and pelvic examination. Ideally vaginal dilation and intercourse are the best therapies.
Outcome — Prospective studies regarding isolated traditional colporrhaphy have reported a range of success rates at one- to two-year follow-up of 37 to 83 percent [50-55]. The range of anterior colporrhaphy success or failure rates vary based on the outcomes measured. Postoperative outcome metrics include the POP-Q assessment of anatomic support, standardized quality of life and satisfaction questionnaires, reoperation rates, and assessment of functional status. As an example, a systematic review and meta-analysis of 10 trials comparing traditional anterior colporrhaphy with permanent mesh colporrhaphy reported that traditional anterior repair was associated with more postoperative prolapse on physical examination and patient awareness of prolapse than permanent mesh repair [56]. By contrast, the two procedures had similar reoperation rates (3 versus 1.3 percent), de novo dyspareunia rates, and quality of life data. Definition of treatment failure is an important distinction to make when examining the outcomes of any surgical trial, especially regarding pelvic reconstructive surgery. Although prolapse recurrence, thereby failure rates, may seem high when using strict guidelines, it must be noted that only a minority of patients with anatomic failure by strict criteria are symptomatic enough to desire a second surgical repair, as illustrated by overall low reoperation rates.
Use of reconstructive materials — We recommend native tissue repair rather than use of transvaginal synthetic mesh for women undergoing primary anterior colporrhaphy because long-term efficacy and patient satisfaction with use of reconstructive materials have not been proven superior and complication rates are higher following mesh insertion [57-64]. Most experts agree that anterior vaginal prolapse repair should utilize grafts only under limited circumstances [65-67]. In 2019, the US Food and Drug Administration banned the sale and distribution of transvaginal synthetic mesh (ie, transvaginal mesh kits) because of safety concerns after having reclassified the products as class III (ie, high risk) devices in 2016 [66]. Vaginally placed mesh slings and mesh for abdominally placed sacrocolpopexy are not included in this ban. (See "Transvaginal synthetic mesh: Use in pelvic organ prolapse", section on 'Issues surrounding synthetic mesh for POP'.)
In cases of recurrent anterior wall defects, the utilization of graft augmentation may be considered based on potential improved objective outcomes, despite associated increased potential complication risks and costs [56,68-71]. In one meta-analysis of randomized trials, native tissue anterior repair resulted in significantly higher rates of recurrent anterior compartment prolapse than repair augmented with a polyglactin absorbable mesh (52 versus 33 percent, risk ratio [RR] 1.39, 95% CI 1.02-1.90) or porcine dermis mesh (21 versus 10 percent, RR 2.08, 95% CI 1.08-4.01) [56]. However, there was no difference in postoperative awareness of prolapse after either absorbable mesh or a biological graft. By contrast, a subsequent randomized trial reported no difference in improvement in quality of life between patients undergoing combined anterior and posterior repair with mesh kit augmentation and significant mesh exposure rates of 15.6 percent with associated higher reoperation rates in the mesh group [72].
Complications related to use of reconstructive materials are discussed in detail separately. (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Complications by procedure'.)
PROCEDURES NO LONGER ROUTINELY PERFORMED
Paravaginal defect repair — Paravaginal repair involves reattaching the lateral vagina to the pelvic sidewall. This procedure is rarely performed in current practice, since it has not been found to improve the outcomes for which it was originally intended, anterior vaginal wall prolapse and stress urinary incontinence (SUI).
Most women with anterior vaginal wall prolapse also have prolapse of the vaginal apex. Both anatomic issues may be repaired at the same time through vaginal or abdominal approaches. Apical repair procedures (eg, sacral colpopexy) alone have been found to correct anterior prolapse as effectively as apical repair combined with paravaginal repair, based upon observational data [73,74]; no randomized trials have addressed this issue. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Abdominal route'.)
Paravaginal repair was originally thought to also be a treatment for SUI, but it does not appear to be an effective procedure for this indication. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Procedures no longer recommended'.)
Repair of other site-specific defects — Transverse vaginal wall defects are typically corrected with procedures that are usually considered operations for prolapse of the vaginal apex, including sacral colpopexy or uterosacral ligament fixation. Apical and anterior vaginal prolapse often coexist and likely share a common pathogenesis, as noted above. (See 'Concomitant repair of other sites of prolapse' above and "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Abdominal sacrocolpopexy' and "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Uterosacral ligament suspension'.)
Support procedures performed for a significant anterior vaginal wall and apical defect are generally performed in the routine fashion, although a slightly lower dissection on the anterior vaginal wall from the apex may be performed to insure adequate anterior wall support.
POSTOPERATIVE CARE
Bladder function — Postoperative urinary retention rates of approximately 2 to 8 percent have been reported after anterior colporrhaphy [75]. Options for management include use of an indwelling bladder catheter or active voiding trial. Patients with an unsuccessful voiding trial at any time are managed with an indwelling bladder catheter; the voiding trial is repeated in 24 to 48 hours. (See "Urogynecologic surgery: Perioperative care issues", section on 'Catheter removal and voiding trial'.)
Discharge medications — Some data suggest that postoperative vaginal estrogen therapy expedites healing of vaginal incisions and prevents the occurrence of urinary tract infection in postmenopausal women but vaginal estrogen does not appear to improve surgical success rates [40,76-78]. Postoperatively, we prescribe 1 gram of conjugated estrogens cream at bedtime nightly for six weeks. Use of 1 gram of estrogen cream at bedtime two nights per week can then be used for maintenance therapy. (See "Urogynecologic surgery: Perioperative care issues", section on 'Vaginal estrogen therapy'.)
Activity restrictions — Data to support specific postoperative activity restrictions are lacking. One trial including 95 women undergoing prolapse surgery reported similar patient satisfaction scores and anatomic outcomes with either liberal or restrictive postoperative activity recommendations [79]. A different trial comparing expedited with standard postoperative activity in 107 patients undergoing vaginal or laparoscopic surgery for apical prolapse reported similar three-month anatomic and symptomatic prolapse scores between the groups [80]. A limitation of both trials was the short (three month) follow-up period for assessing anatomic outcomes.
Historically, surgeons have advised avoiding sexual activity and putting anything (other than physician ordered medication) in the vagina for six to eight weeks. Many physicians also suggest that patients avoid weight lifting greater than 5 lbs, straining with bowel movements, and activities associated with sudden or repetitive increases in intra-abdominal pressure (ie, jogging, heavy weight lifting) for at least six weeks after surgery. Additional discussion of postoperative activity following urogynecology procedures is available separately. (See "Urogynecologic surgery: Perioperative care issues", section on 'Activity restrictions'.)
Return to work — Patients generally feel able to return to work three to four weeks after an isolated anterior vaginal wall defect repair, although we ask them to continue the activity restrictions described above for a total of six weeks. Based on the extent of concomitant procedures and type of employment, patients may need to be on medical leave for six weeks, however, most surgeons agree that vaginal surgery may require allowing a faster return to work after surgery [81].
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
●Terminology – Anterior vaginal wall prolapse describes support abnormalities of the anterior wall of the vagina. Prolapse of the anterior wall typically coexists with prolapse at other anatomic sites, especially the apex (vaginal apex, posterior vaginal wall). (See 'Introduction' above and 'Terminology' above.)
●Pathogenesis – The pathogenesis of anterior vaginal wall prolapse is thought to be defects at specific sites of the support structures, rather than an overall stretch of the anterior wall. (See 'Pathogenesis of anterior wall defects' above.)
●Preoperative evaluation – Preoperative evaluation of women with anterior vaginal defects included identification of the specific site(s) of anterior defects as well as prolapse at other anatomic sites. (See 'Candidates for anterior prolapse repair' above.)
●Antibiotic prophylaxis – For women undergoing surgical repair on anterior vaginal wall prolapse, we recommend antibiotic prophylaxis for surgical site infection (Grade 1B). (See 'Antibiotic prophylaxis' above.)
●Efficacy of surgical repair – Anterior colporrhaphy is performed to correct midline defects and is typically performed transvaginally. Anterior colporrhaphy is only moderately effective for repair of anterior vaginal wall prolapse. Success rates of anterior colporrhaphy range from 37 to 83 percent. (See 'Midline defect repair (anterior colporrhaphy)' above.)
●Use of native tissue – For women undergoing primary anterior colporrhaphy, we recommend native tissue repair rather than use of reconstructive materials (Grade 1B). Use of reconstructive materials by surgeons experienced with the specific procedure may be considered only after appropriate patient counseling in women with factors that increase the risk of prolapse recurrence (eg, recurrent prolapse, obesity, large anterior wall defects). Such use should be carefully individualized and surgeons should counsel patients about the lack of efficacy and safety data and about alternative treatments. (See 'Use of reconstructive materials' above.)
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