Vaginal Shortening and Vaginal Vault Prolapse

The uterus is continuous with the cervix, which is continuous with the vagina, much in the way that your head is continuous with your neck, which is continuous with your shoulders.

The vaginal canal is the area between the vulva, the opening into the vagina, and the vaginal tissue that surrounds and is continuous with the part of the cervix that protrudes into the top of the vagina from the uterus. In other words, the top of the vaginal tissue is continuous with the uterus at the cervical os, which is the opening to the cervix.

The vaginal canal is composed of soft tissue that can stretch and elongate.

A vaginal vault is not part of the normal female anatomy. The vaginal canal is made into a vaginal vault when a gynecologist surgically removes the uterus and cervix and sutures the top of the vagina closed. The surgical closing of the top of the vagina results in a loss of the vaginal tissue’s ability to stretch and elongate.

A partial hysterectomy is removal of the body of the uterus, leaving a cervical stump. With a partial hysterectomy the top of the cervical stump is sutured shut.

A total hysterectomy is surgical removal of both the body of the uterus and the cervix. During a total hysterectomy, a surgeon cuts into the top of the vagina around the cervix, creating a hole in the top of the vagina. The gynecologist then pulls the edges of the remaining tissue together, and sutures the top of the vagina shut, making the vagina into a shortened, closed pocket.

This is similar to the way that fabric is sewn together to make clothing. The more material that is included in sewing a seam, the smaller the garment.

The amount of vaginal tissue that is removed from around the cervix is at the discretion of the surgeon, and varies from doctor to doctor. As illustrated in medical journals, some doctors say a post-hysterectomy vaginal length of 5cm is long enough, some think the vagina should be 9cm, and others think 3-4cm is “adequate.”

After the vagina is sutured closed at the top, it is stitched to one or more of the severed ligaments. Because the sutures do not always hold, some women experience prolapse of the vagina. The vagina may prolapse through the opening of the vagina, much like a pocket that is turned inside out.

The profound physical changes women experience after hysterectomy are far reaching. The fallopian tubes, uterus, cervix, and vagina are interconnected with networks of muscles, broad bands of ligaments, bundles of nerves, arteries, and veins. When they are severed, as they are when the uterus is removed, the damage is extensive.

With the cervix and uterus as the anatomical anchor at the center of the female pelvis, the uterine ligaments provide structural integrity and support to the pelvic bones and pelvic organs. For example, the uterosacral ligament attaches to the uterus and to the sacrum in the lower back. So when the uterus is removed during hysterectomy, the severing of the structural support to the uterus affects all of the pelvic organs, the lower back, and the skeletal structure.

Whether a hysterectomy is “total” or “partial,” all of the ligaments, nerves, and blood supply attached to the uterus must be severed to remove the uterus. Structural support, blood flow, and sensation in the remaining tissue is compromised or lost entirely.

For more information about the different types of hysterectomy, click on the Hysterectomy link on the HERS Foundation’s website Home page.

The uterus, vagina, bladder, and rectum are attached to the pelvic walls by a network of connective tissue called the endopelvic fascia, and the upper portion of the vagina is suspended from the pelvic walls and sacrum. When the uterus is removed, all of the organs in the pelvis drift downward to take up the space that had been occupied by the uterus, until they are sitting on top of the vaginal vault at the apex (the top of the vagina) where it was sutured shut. If the vagina was not carefully sutured, the pressure of the remaining organs, such as the bowel, against the vaginal incision can break the sutures that were holding up the top of the vagina.

Eversion occurs when the top of the vagina where the vaginal tissue was sutured shut descends down to or below the opening of the vagina, much like a pocket that is turned inside out.

Prolapse of the vaginal vault after hysterectomy is not uncommon, but the precise frequency is unknown. It is estimated that about 20% of hysterectomized women experience vaginal vault prolapse.

Surgical repair of vaginal vault prolapse is one of the most challenging gynecological operations, with a small rate of success. Despite the fact that there are various operative techniques, no satisfactory method has been developed. There is a high incidence of repeat prolapse after surgical repair of vaginal vault prolapse. Each time the vaginal vault is surgically resuspended more vaginal tissue is pulled together to suture the vagina shut, which makes the length of the vagina even shorter.

Hysterectomy is recommended to many women as a treatment for uterine prolapse. But about 20% of the women who are hysterectomized for uterine prolapse develop vaginal vault prolapse after the surgery.

The uterus has many important lifelong functions. The most consistent problems women experience after hysterectomy, whether the cervix or ovaries are retained or not, include a 25-pound average weight gain in the first year following the surgery, a loss of sexual feeling, a loss of vitality, joint pain, back pain, profound fatigue, and personality change.

For more information, watch the short video “Female Anatomy: the Functions of the Female Organs.”