The vaginal wall consists of an inner epithelial lining surrounded by endopelvic fascia, which is composed of smooth muscle, elastin, and collagen and is attached to deeper pelvic supports. The cervix and upper third of the vagina are supported by the uterosacral and cardinal ligaments (part of the paracolpium). The middle third is attached by the pubocervical fascia to the arcus tendineus fasciae pelvis (the so called white line), which runs along the pelvic floor between the pubic symphysis and the ischial spine. The lower third is fused with the urogenital diaphragm, comprising the levator ani fascia, perineal membrane, and perineal body

Causes of genitourinary prolapse

Childbirth:
Large babies
Long labours
Assisted delivery
Poor postnatal exercise regimens Congenital:
Connective tissue disease Iatrogenic:
Hysterectomy
Increased intra-abdominal pressure:
Obesity
Chronic respiratory disease
Pelvic masses

Symptoms of genitourinary prolapse

Cystourethrocele:
Urinary stress incontinence
Urinary retention
Recurrent urinary tract infections
Uterine prolapse:
Backache
Difficulty keeping tampons in
Ulceration if procedentia
Rectocele:
Dyschezia
Constipation
Any prolapse:
Lump coming down

　　Coital difficulties–dyspareunia, loss of vaginal sensation, vaginal flatus
The levator ani muscles do not normally meet between the rectum and vagina, and suturing them together at the time of posterior repair will lead to coital pain. Prolapse of the anterior vaginal wall may be due to detachment of the lateral vaginal support to the arcus tendineus fascia pelvis. In this case paravaginal repair, either by the transvaginal or abdominal route, is gaining popularity

　It has been asserted that surgical cure of some forms of cystourethrocele is associated with subsequent stress incontinence, perhaps secondary to an intrinsic problem with the sphincter that is revealed when the urethra becomes straight again. However, a preoperative and postoperative prospective clinical and urodynamic study has shown no evidence that bladder or urethral function is compromised by colporrhaphy or vaginal hysterectomy, although excessive and unnecessary dissection of the bladder neck should be avoided in women who are continent.
If there is concurrent urinary stress incontinence a Burch colposuspension will correct cystocele, as well as giving excellent long term urinary continence. When uterine prolapse is present vaginal hysterectomy is the procedure of choice. This can be combined with anterior or posterior repair when, as is commonly the case, concurrent cystocele and rectocele are present. Although uncommonly performed today, cervical amputation with a Manchester or Fothergill repair can be performed for mild uterine descent, especially when the cervix has become enlarged and conservation of the uterus is desired. A retrospective comparison of Manchester repair with vaginal hysterectomy for uterine prolapse found that both procedures had a similar outcome

Recurrence of problems

　　 The incidence of recurrent prolapse is reported to be 16%. This may be due to a failure to correct the precise initial anatomical defect or it may arise as a complication of the original surgery. Such examples include enterocele after Burch colposuspension, cystocele after sacrospinous fixation, and rectocele or enterocele after sacrocolpopexy. Vaginal vault prolapse will occur if the vault is not secured to the uterosacral ligaments at hysterectomy. Repair can be effected vaginally or suprapubically, and the patient's medical condition and wishes about sexual activity need to be considered when planning surgery.
　　The simplest procedure is colpocleisis, or occlusion of the vaginal lumen, which can be performed under local anaesthesia. This is appropriate only for sexually inactive women, but it has low morbidity and a low rate of recurrence and is a useful technique in frail elderly women. Sacrospinous fixation, with stitching of the vaginal cuff to the sacrospinous ligament, does not alter vaginal capacity, and recovery time is quick as it is a vaginal repair. Although infrequent, complications are serious as damage can occur to the pudendal artery, pudendal nerve, or sciatic nerve. Injuries may be minimised by avoiding the lateral third of the sacrospinous ligament and placing the stitch superficially. One year cure rates of 90% have been reported with this technique.
　　Sacrocolpopexy uses the abdominal approach, the vaginal vault being attached by non-absorbable mesh to the sacral promontory. Vaginal anatomy is not distorted, but this procedure also carries the risk of haemorrhage from the sacral venous plexus. Cure rates of 88%-97% have been reported between one and 10 years later. Alternatively, the Zacharin procedure corrects the anatomical defect by closing the levator hiatus and suturing the vagina to the levator plate. It entails more extensive dissection than colposacropexy, and a retrospective comparison of the two procedures, both performed by the same surgeon, has shown colposacropexy to have superior results. Laparoscopic sacrocolpopexy has also been described, but no long term follow up data are available.