International Journal of Gynecology and Obstetrics 110 (2010) 27–30

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Risk factors for vaginal prolapse after hysterectomy

Adolf Lukanovič a,⁎, Katarina Dražič b
a
Department of Obstetrics and Gynecology, University Medical Center Ljubljana, Ljubljana, Slovenia
b
Department of Obstetrics and Gynecology, General Hospital Jesenice, Slovenia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To identify risk factors for pelvic organ prolapse (POP) and their influence on the occurrence of
Received 30 November 2009 vaginal prolapse after hysterectomy. Methods: Medical records from 2 groups of women who had undergone
Received in revised form 26 January 2010 hysterectomy were reviewed retrospectively. The study group was 82 women who had undergone surgery
Accepted 1 March 2010 for vaginal prolapse after hysterectomy; the control group was 124 women who had undergone
hysterectomy with no diagnosis of vaginal prolapse by the time of the study. All hysterectomy procedures
Keywords:
had been performed for benign gynecological disease, including POP. Both groups of women completed a
Hysterectomy
Pelvic organ prolapse
self-administered questionnaire to obtain additional information on the occurrence of POP. Results: The
Risk factors incidence of vaginal prolapse after hysterectomy was significantly higher in women with a higher number of
vaginal deliveries, more difficult deliveries, fewer cesareans, complications after hysterectomy, heavy
physical work, neurological disease, hysterectomy for pelvic organ prolapse, and/or a family history of pelvic
organ prolapse. Premenopausal women had vaginal prolapse corrected an average of 16 years after
hysterectomy, and postmenopausal women 7 years post hysterectomy. Conclusion: Before deciding on
hysterectomy as the approach to treat a woman with pelvic floor dysfunction, the surgeon should evaluate
these risk factors and discuss them with the patient.
© 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction time elapsed since hysterectomy, from 1% at 3 years after hysterec-

Genital prolapse is a common gynecological condition that occurs
predominantly in middle and old age. Its true incidence is unknown,
and it frequently manifests itself soon after menopause. Little is known
about the risk factors for genital prolapse and specifically about the
risk factors for genital prolapse after hysterectomy, one of the most
common surgical procedures performed in women.
The International Continence Society defines posthysterectomy
(apical) vaginal prolapse as descent of the vaginal cuff scar below a
point that is 2 cm less than the total vaginal length above the plane of
the hymen [1].
It is not known whether vaginal posthysterectomy prolapse is the
consequence of pelvic floor relaxation or of a genetic predisposition or
how this problem could be postponed or avoided [2]. Hysterectomy
is the second most frequently performed surgical procedure (after
cesarean delivery) in women in the USA [3] and more than 30% of
hysterectomies are performed in women younger than 60 years of
age; pelvic organ prolapse (POP) is the indication for surgery in 33%
of women after the age of 55 years [4]. Mant et al. [5] reported that
the incidence of posthysterectomy POP that requires surgical repair is
3.6 per 1000 cases. The cumulative risk for surgery increases with the
⁎ Corresponding author. Department of Obstetrics and Gynecology, University
Medical Centre Ljubljana, Šlajmerjeva 3, SI-1000 Ljubljana, Slovenia. Tel.: + 386 1
522 62 00; fax: + 386 1 522 61 30.
E-mail address: adolf.lukanovic@guest.arnes.si (A. Lukanovič).
tomy to 5% at 15 years after hysterectomy [5].
It is questionable whether POP is more common after vaginal than
after abdominal hysterectomy, but Morely and DeLancey [6] state that
POP occurs equally often after either type of hysterectomy. Some
studies in the literature suggest that the risk of POP differs between
ethnic groups [7–9].
The aim of the present retrospective study was to investigate the
relationship between some known risk factors for the development
of POP and the incidence of posthysterectomy POP in a population
of women from central Europe. The data obtained from a self-
administered questionnaire and from medical records of women who
had undergone a hysterectomy and had required surgical vaginal
prolapse repair after the hysterectomy were compared with data from
a control group of women who by the start of the study period had not
required a vaginal prolapse repair after hysterectomy performed for a
benign gynecological disease.
2. Materials and methods
In 2004, a national multicenter retrospective matched case-control
study was carried out. The study was designed to compare 2 groups of
women after hysterectomy. The study group consisted of 121 women
who had undergone surgical correction of POP after hysterectomy at a
university department of obstetrics and gynecology between January
1, 2000 and December 31, 2003. The control group consisted of 241
women who had undergone a hysterectomy and had not developed

0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2010.01.025
28 A. Lukanovič, K. Dražič / International Journal of Gynecology and Obstetrics 110 (2010) 27–30

a vaginal prolapse by the time of data collection. The women in the Table 1
control group were selected from medical charts and were matched Characteristics of the study population at hysterectomy.a

to the women in the study group by age, parity, menopausal status, Characteristics Study group Control group P value b

hospital at which their hysterectomy had been performed, year (n = 82) (n = 124)
of surgery, indication, and type of surgery. The operations were POP as the indication for hysterectomy 46 (56.1) 50 (40.3) 0.026
performed in 10 different gynecological departments across Slovenia. Age, y 52.2 ± 9.5 53.3 ± 10.2 0.437 c

c
All hysterectomy procedures were performed for benign gynecological Body weight, kg 68.7 ± 10.5 70.3 ± 10.4 0.283
d
Vaginal deliveries 2.3 ± 1.1 1.9 ± 1.2 0.007
pathology according to the standard surgical protocol. The surgical
No. of cesarean deliveries
technique included plication of uterosacral ligaments to prevent 0 82 (100) 113 (91.1) 0.021
postoperative complications. We obtained additional data from the 1 0 (0) 9 (7.3)
hospital charts of women who had follow-up examinations, which 2 0 (0) 2 (1.6)
included pelvic examination by the surgeon who had performed the No. of difficult deliveries
0 40 (48.8) 80 (64.5) 0.020
hysterectomy.
1 31 (37.8) 35 (28.2)
A postal questionnaire was sent to all of the women enrolled in 2 11 (13.4) 9 (7.3)
the study to obtain additional information on the period after the Postoperative complications 18 (22.0) 12 (9.7) 0.015
hysterectomy. The questionnaire required provision of demographic Type of work
Heavy 14 (17.1) 9 (7.3) 0.027
and personal data on age at hysterectomy; body weight at the time of
Not heavy 43 (52.4) 59 (47.6)
hysterectomy; increase in body weight from the time of hysterectomy Light 25 (30.5) 56 (45.2)
to the time of vaginal prolapse repair (study group) or to the time of Neurological disease 7 (8.5) 2 (1.6) 0.017
data collection (control group); number of vaginal deliveries; number Family history of pelvic organ prolapse 34 (41.5) 28 (22.6) 0.004
of cesarean deliveries; number of difficult deliveries (protracted labor, Abbreviations: POP, pelvic organ prolapse.
instrumental delivery, neonatal birth weight N4000 g, perineal tear); a
Values are given as number (percentage) or mean ± standard deviation unless
menopausal status; type of hysterectomy (vaginal or abdominal); otherwise indicated.
b
P values were calculated using the χ2 test unless otherwise indicated.
consequences of hysterectomy (pain and pressure sensation, urinary c
Calculated using the t test.
retention, urinary incontinence, fecal incontinence); symptoms of d
Calculated using the Mann-Whitney test.
vaginal prolapse after the hysterectomy (pelvic discomfort, pressure,
pain); type of work; neurological disease; and a family history of POP.
The sole inclusion criterion for the study was that hysterectomy complications (P = 0.015), heavy work (P = 0.027), vaginal deliveries,
had been performed in both groups for benign pathology (myomas, neurological disease (P = 0.017), and family history of POP (P = 0.004)
bleeding, POP, endometriosis, adenomyosis, chronic pelvic pain, in the study group. In the study group, none of the women had had a
infection, or endometrial hyperplasia). Exclusion criteria were hyster- cesarean delivery, whereas in the control group 9 (7.3%) women had
ectomy performed for malignant pathology and hysterectomy at had 1 cesarean delivery, and 2 (1.6%) women had had 2 cesarean
the time of cesarean delivery. The inclusion criterion for POP repair deliveries. Age and body weight did not differ between the groups.
was any prolapse of the vaginal cuff below the hymeneal remnants. Of the 46 (56.1%) women with POP as the indication for hysterectomy
Women were excluded from the control group if they reported on the in the study group, 25 (54.3%) women were postmenopausal. Of the 50
questionnaire that they had undergone surgery for POP in 1 of 10 (40.3%) women in the control group with POP as the indication for
gynecologic departments in Slovenia. Medical records revealed normal hysterectomy, 41 (82.0%) were postmenopausal.
pelvic status at the first 3 follow-up examinations after hysterectomy in In the study group, 40 (48.8%) women had an abdominal hysterec-
all women enrolled in the study (6 weeks, 6 months, and 1 year after tomy and 42 (51.2%) had a vaginal hysterectomy. In the control group,
hysterectomy). 57 (46.0%) women had an abdominal hysterectomy and 67 (54%) had a
Heavy work was defined as a job involving both long hours vaginal hysterectomy. There was no statistically significant difference
primarily in a standing position and lifting objects heavier than 5 kg. between the groups.
The term difficult delivery encompassed prolonged labor, perineal In the study group, the incidence of postoperative complications
tear of third degree or greater, forceps delivery, vacuum extraction, or after hysterectomy was significantly higher than in the control group
a birth weight greater than 4000 g. (Table 2).
The study was approved by the National Medical Ethics Committee. Among the study group, women who had undergone hysterecto-
The women in the study and control groups were given a detailed my because of POP had a vaginal prolapse repair an average of 9 years
explanation of the study objectives and provided written consent for after hysterectomy, whereas the women who underwent hysterecto-
participation in the study. my because of other benign pathology had vaginal prolapse repair an
Descriptive statistics (t test, χ2 test, Mann-Whitney test) and average of 18 years after hysterectomy (P b 0.001).
multivariate logistic regression models were used to investigate the With regard to postmenopausal status, women in the study group
factors that were associated with POP. Statistical analysis was who had undergone hysterectomy for POP and were postmenopausal
performed using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA). at the time of the procedure underwent vaginal prolapse repair an
Differences were considered significant when P b 0.05. average of 7 years after primary hysterectomy; whereas the women
who were still menstruating at the time of hysterectomy underwent
3. Results
Table 2
The study and control groups were homogeneous for age, number Postoperative complications.a
of deliveries, menopausal status at hysterectomy, and type of b
Complications Study group Control group P value
hysterectomy. Postal questionnaires were sent to 121 women in the (n = 82) (n = 124)
study group and 241 women in the control group, and 82 (67.8%) and
Pain and pressure sensation 40 (48.8) 0 b0.001
124 women (51.5%) responded, respectively. Urinary incontinence 31 (37.8) 13 (10.5) b0.001
The characteristics of the patients at hysterectomy are presented in Urinary retention 13 (15.9) 1 (0.8) b0.001
Table 1. Comparison between women in the study and control groups Fecal incontinence 6 (7.3) 0 0.002
demonstrated significantly higher rates of POP as the indication for a
Values are expressed as number (percentage).
hysterectomy (P = 0.026), difficult delivery (P = 0.020), postoperative b
P values were calculated using the χ2 test.
 A. Lukanovič, K. Dražič / International Journal of Gynecology and Obstetrics 110 (2010) 27–30
Table 3
Multivariate analysis. Odds ratios and 95% confidence intervals adjusted for other
predictive factors of pelvic organ prolapse in women who had undergone a
hysterectomy.
Variable B P value Odds ratio (95% CI)
POP indication for hysterectomy 1.03 0.01 2.80 (1.30–6.01)
Heavy work 1 (Reference)
No heavy work –0.80 0.12 0.45 (0.16–1.24)
Light work –1.09 0.04 0.34 (0.12–0.95)
Uncomplicated delivery 0.18 0.23 1.19 (0.90–1.59)
Difficult delivery 0.51 0.05 1.67 (1.01–2.78)
Age at hysterectomy –0.04 0.03 0.96 (0.92–1.00)
Family history of POP 0.81 0.015 2.2 (1.2–4.3)
Abbreviations: B, logistic regression coefficient; CI, confidence interval; POP, pelvic
organ prolapse.
vaginal prolapse repair an average of 16 years after hysterectomy
(P b 0.001).
The most important risk factors in the multivariate analysis were
POP as the indication for hysterectomy (adjusted OR 2.8; 95% CI, 1.30–
6.01) and family history of POP (adjusted OR 2.2; 95% CI, 1.2–4.3)
(Table 3). Other statistically significant factors were difficult deliver-
ies, heavy work, and younger age at hysterectomy (Table 3).
4. Discussion
The true incidence of vaginal prolapse after hysterectomy is
unknown, mainly because of the different classifications used. Data in
the literature are scarce and not uniform. Mattingly and Thompson [10]
reported that the incidence of severe vaginal vault prolapse after
hysterectomy was less than 0.5%, whereas Birnbaum [11] reported
the incidence of posthysterectomy vaginal vault prolapse as less than
1%. In their epidemiological study of POP, Mant et al. [5] estimated the
incidence of severe vaginal vault prolapse after hysterectomy to range
between 5% and 29%. Their results showed the risk of vaginal prolapse
after hysterectomy was 5.5 times higher among women whose initial
hysterectomy was for genital prolapse as opposed to other indications.
Olsen et al. [4] found that the incidence of posthysterectomy surgery
for vaginal prolapse was higher in women who had undergone
hysterectomy owing to POP (158 per 10 000 women) than in women
who had undergone hysterectomy for other benign pathologies
(29 per 10 000 women). These results are also in agreement with the
retrospective follow-up study by Marchioni et al. [12] of 448 women
who underwent hysterectomy. The study found that vaginal vault
prolapse followed 11.6% of hysterectomies performed for vaginal
prolapse and 1.8% of hysterectomies performed for other indications.
Swift and Theofrastous [13] also found a significant correlation between
vaginal prolapse and a previous hysterectomy performed for POP.
The results of the present study also confirm the correlation
between the initial indication for hysterectomy and a consecutive
vaginal prolapse. POP was a significantly more frequent indication for
hysterectomy in the study group. There was a statistically significant
difference in the time interval between hysterectomy and vaginal
prolapse repair between women who underwent hysterectomy for
POP and women who underwent hysterectomy for other benign
pathologies (9 vs 18 years; P b 0.001).
It is probable that women who undergo hysterectomy for POP are
more prone to postoperative vaginal prolapse and are also more prone
to its recurrence in a shorter time interval after primary surgery.
Therefore, it is of paramount importance that the surgeon recognizes
and corrects the vaginal support defect when performing hysterectomy
to prevent later complications.
Because the problem of POP is vast, there are at least 43 well-
documented descriptions of surgical procedures designed to repair
POP. Effective management of this condition requires knowledge of
anatomy, expertise in accurate physical diagnosis, and skill in the
29
assessment of clinical applicability of diagnostic tests. The surgeon
who treats POP of any degree must be able to tailor the surgery to meet
each patient's needs. This mandates proficiency in the performance of
a number of surgical approaches and precludes adherence to a single
approach. Current surgical procedures designed to correct pelvic floor
defects, including POP, need to follow 2 basic principles: to reapproach
the preserved structures and to use various types of mesh in case the
tissue has become dysfunctional.
Several procedures are recommended to prevent vaginal prolapse
at the time of hysterectomy. One procedure is McCall culdoplasty, a
recommended measure to prevent enterocele formation at the time of
vaginal hysterectomy [14–17]; another procedure involves suturing
the cardinal and uterosacral ligaments to the vaginal cuff [18]; and a
further procedure is sacrospinous fixation at the time of vaginal
hysterectomy when the vault descends to the introitus during closure
[19]. However, no comparative studies are available to assess the true
value of these preventive procedures.
In the present study, there was a significant difference in the time
interval between hysterectomy and the vaginal prolapse repair ac-
cording to the women's menopausal status. Women who had a
hysterectomy for POP and were postmenopausal had a vaginal
prolapse correction done an average of 7 years later, whereas those
who were premenopausal at the time of hysterectomy for POP had a
repair an average of 16 years after hysterectomy (P b 0.001). When
estimating the impact of menopausal status in women who had
undergone hysterectomy for POP, we found that 25 (54.3%) women in
the study group and 41 (82%) women in the control group were
postmenopausal. These results could indicate the role of circulating
estrogen levels and their impact on the synthesis of collagen type 3,
which is responsible for tissue elasticity.
In line with a published study [20], we did not find any difference
in the incidence of vaginal prolapse between women who underwent
hysterectomy by the vaginal or abdominal route.
Pregnancy and delivery are thought to be the main cause of POP—
whether the prolapse occurs immediately after pregnancy or 30 years
later. High birth weight of the newborn and the physical trauma of
labor and birth both stress and strain the pelvic muscles, and liga-
ments might become damaged and never fully regain their strength
and elasticity. Mant et al. [5] found that after 4 vaginal deliveries
the risk of developing POP is 11 times higher. A positive correlation
between multiparity, birth weight (N4500 g), and the incidence of
POP was also found in the study by Samuelsson [21].
In the present study, we also found that women in the study
group had a significantly higher number of vaginal deliveries, fewer
cesarean deliveries, and a significantly higher number of difficult
deliveries. It is possible that these factors influence the incidence of
posthysterectomy vaginal prolapse.
We did not investigate the influence of obesity or chronic cough on
the posthysterectomy incidence of vaginal prolapse, but we could
confirm a significant impact of heavy work and heavy lifting on the
incidence of vaginal prolapse in the women in the study group. Similar
results were obtained in a previous national survey [22].
The integrity of pelvic nerves and a possible correlation with pelvic
floor relaxation is not only influenced by pregnancy and delivery but
also by congenital and postnatal neurological diseases. In the present
study, neurological disability was reported by significantly more
women in the study group than in the control group.
Collagen metabolism undoubtedly plays a major role in the
incidence of POP. A lower synthesis and portion of collagen type 3,
impaired metabolism, and a changed proportion of the different types
of collagen influence the laxity and integrity of the endopelvic fascia
[23–25] and play a role in the incidence of POP.
Genetic impact on the incidence of vaginal prolapse after hysterec-
tomy was evaluated in the present study by obtaining information from
the patients in both groups about relatives with symptoms of POP. The
number of relatives with POP symptoms was statistically significantly
30 A. Lukanovič, K. Dražič / International Journal of Gynecology and Obstetrics 110 (2010) 27–30
higher in the women in the study group than in the women in the
control group.
The outcomes of hysterectomy, such as pain and pressure
sensation, urinary retention, and urinary and fecal incontinence,
were more frequently reported in the study group women. It is still
unclear whether there is a correlation between the onset and quality
of postoperative wound healing, possible neurovascular damage of
the vaginal supportive structures, and basic surgical technique. In the
present study, postoperative pelvic floor discomfort, pressure, and
pain, which predict pelvic floor dysfunction, were present more
often in the study group than in the control group. However, it is not
known whether the women in the control group did in fact have
pelvic floor discomfort, but did not report the problems to the
healthcare provider.
The present study shows that in Slovenian women, the risk of
vaginal prolapse after hysterectomy is significantly higher if the
indication for hysterectomy is POP, if the woman has a positive family
history of POP, has been doing a substantial amount of heavy work, or
has had difficult deliveries with birth weight greater than 4000 g.
It is important that before deciding on hysterectomy as the
approach to treat a woman with pelvic floor dysfunction, the surgeon
should evaluate these risk factors and discuss them with the patient so
that she is aware of the complication rates.
Conflict of interest
The authors have no conflict of interest to declare.
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