Genital hiatus measurements predict cuff prolapse risk in prolapse surgery

Cuff prolapse risk in prolapse surgery



sacrospinous ligament fixation , pelvic organ prolapse, uterosacral ligament suspension


Background/Aim: Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse because there are no consensus or guidelines address the degree of apical support loss at which an apical support procedure should routinely be performed. The aim of this study was to evaluate whether preoperative genital hiatus (GH), perineal body (PB), and total vaginal length (TVL) are associated with prolapse recurrence after apical prolapse surgery.

Methods: Our cohort study included 98 patients who underwent vaginal hysterectomy apical suspension due to uterovaginal prolapse of grade 2 or higher according to Pelvic Organ Prolapse Quantification (POP-Q) staging between 2020 and 2021. Patients with a history of gynecologic malignancy, those who could not tolerate surgery or anesthesia, those who had previously undergone pelvic organ prolapse surgery, those with concomitant stress urinary incontinence, and those with abnormal cervical smear results were excluded. Patients were followed for 2 years at intervals of 3 months in the first year after the surgery. The last POP-Q was performed 24 months after surgical intervention. Surgical failure or recurrence was defined as apical descent greater than one third of the total vaginal length, anterior or posterior vaginal wall past the hymen, subsequent surgery, or bothersome vaginal bulge. Patients were given the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire before surgery and 6 months postoperatively, and the severity of symptoms was compared between the groups with and without postoperative recurrence. Logistic regression (LR) analysis was performed to determine the factors affecting recurrence. Areas under the ROC curve were calculated as a differential diagnosis for the presence of recurrence, and the predictive value (cut-off) of variables was determined using sensitivity, specificity, positive predictive value, negative predictive value, and LR (+) values.

Results: While surgery was successful in 80 patients, genital relapse was seen in 18 patients. The mean preoperative perineal body was 3.05 (0.28) cm, mean preoperative GH was 3.9 (0.39) cm, and mean preoperative TVL was 8.54 (1.33) cm. The mean GH of the group with recurrence was significantly higher than the group without recurrence (P=0.004). The mean preoperative POP-SS score was 15.14 (1.86), and the postoperative POP-SS score was 4.01 (3.74). The postoperative POP-SS score mean of the recurrence (+) group was significantly higher than the group without recurrence (P<0.001). For the genital hiatus, the cut-off >4 cm had a sensitivity of 61.11%, specificity of 76.25%, positive predictive value of 36.70%, negative predictive value of 89.70%, and LR (+) value of 2.57. For POP-SS Preop-Postop Change %, the cut-off <60 had a sensitivity of 94.44%, specificity of 98.75%, positive predictive value of 94.40%, negative predictive value of 98.80%, and LR (+) value of 75.56.

Conclusion: Apical vaginal support loss is highly associated with genital hiatus size. In particular, according to all study definitions, a Pelvic Organ Prolapse-Quantification measurement genital hiatus of >4 cm is a strong predictor of apical support loss. This simple measurement can be used to screen for apical support loss and further evaluate apical vaginal support before planning a hysterectomy or prolapse surgery.


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Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010 Nov;116(5):1096-100. doi: 10.1097/AOG.0b013e3181f73729. PMID: 20966694. DOI:

Brown HW, Hegde A, Huebner M, Neels H, Barnes HC, Marquini GV, et al. International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs. Int Urogynecol J. 2022 Feb;33(2):173-87. doi: 10.1007/s00192-021-05018-z. DOI:

Jha S, Cutner A, Moran P. The UK National Prolapse Survey: 10 years on. Int Urogynecol J. 2018 Jun;29(6):795-801. doi: 10.1007/s00192-017-3476-3. Epub 2017 Sep 15. PMID: 28914338; PMCID: PMC5948287. DOI:

Barber MD, Brubaker L, Burgio KL, Richter HE, Nygaard I, Weidner AC, et al. National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2015 Jun 9;313(22):2287. PMID: 24618964; PMCID: PMC4083455.

Edenfield AL, Amundsen CL, Weidner AC, Wu JM, George A, Siddiqui NY. Vaginal prolapse recurrence after uterosacral ligament suspension in normal-weight compared with overweight and obese women. Obstet Gynecol. 2013 Mar;121(3):554-9. doi: 10.1097/AOG.0b013e3182839eeb. PMID: 23635618. DOI:

Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996 Jul;175(1):10-7. doi: 10.1016/s0002-9378(96)70243-0. PMID: 8694033. DOI:

Dunivan GC, Lyons KE, Jeppson PC, Ninivaggio CS, Komesu YM, Alba FM, et al. Pelvic Organ Prolapse Stage and the Relationship to Genital Hiatus and Perineal Body Measurements. Female Pelvic Med Reconstr Surg. 2016 Nov/Dec;22(6):497-500. doi: 10.1097/SPV.0000000000000323. PMID: 27661212; PMCID: PMC5111866. DOI:

Siff LN, Barber MD, Zyczynski HM, Rardin CR, Jakus-Waldman S, Rahn DD, et al; NICHD Pelvic Floor Disorders Network. Immediate Postoperative Pelvic Organ Prolapse Quantification Measures and 2-Year Risk of Prolapse Recurrence. Obstet Gynecol. 2020 Oct;136(4):792-801. doi: 10.1097/AOG.0000000000004043. PMID: 32925609; PMCID: PMC7526641. DOI:

Lowder JL, Oliphant SS, Shepherd JP, Ghetti C, Sutkin G. Genital hiatus size is associated with and predictive of apical vaginal support loss. Am J Obstet Gynecol. 2016 Jun;214(6):718.e1-8. doi: 10.1016/j.ajog.2015.12.027. Epub 2015 Dec 21. PMID: 26719211. DOI:

Blomquist JL, Muñoz A, Carroll M, Handa VL. Association of Delivery Mode With Pelvic Floor Disorders After Childbirth. JAMA. 2018 Dec 18;320(23):2438-47. doi: 10.1001/jama.2018.18315. PMID: 30561480; PMCID: PMC6583632. DOI:

Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016 Apr;27(4):655-84. doi: 10.1007/s00192-016-3003-y. PMID: 26984443. DOI:

Madhu C, Swift S, Moloney-Geany S, Drake MJ. How to use the Pelvic Organ Prolapse Quantification (POP-Q) system? Neurourol Urodyn. 2018 Aug;37(S6):S39-S43. doi: 10.1002/nau.23740. PMID: 30614056. DOI:

Özengin N, Kaya S, Orhan C, Bakar Y, Duran B, Ankaralı H, Akbayrak T. Turkish adaptation of the Pelvic Organ Prolapse Symptom Score and its validity and reliability. Int Urogynecol J. 2017 Aug;28(8):1217-22. doi: 10.1007/s00192-016-3251-x. Epub 2017 Jan 6. PMID: 28062904. DOI:

Hagen, S., Ierna, M., & Frawley, H. International use of the Pelvic Organ Prolapse Symptom Score (POP-SS): results on an online survey. Pelvic, Obstetric and Gynaecological Physiotherapy. 2021;128:39-45.

Lee RA. Vaginal hysterectomy with repair of enterocele, cystocele, and rectocele. Clin Obstet Gynecol. 1993 Dec;36(4):967-75. doi: 10.1097/00003081-199312000-00021. PMID: 8293597. DOI:

Shull BL, Capen CV, Riggs MW, Kuehl TJ. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: an effective method of cuff suspension. Am J Obstet Gynecol. 1993 Jun;168(6 Pt 1):1669-74; discussion 1674-7. doi: 10.1016/0002-9378(93)90676-a. PMID: 8317507. DOI:

DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol. 2007 Feb;109(2 Pt 1):295-302. doi: 10.1097/ PMID: 17267827.. DOI:

Ghetti C, Gregory WT, Edwards SR, Otto LN, Clark AL. Severity of pelvic organ prolapse associated with measurements of pelvic floor function. Int Urogynecol J Pelvic Floor Dysfunct. 2005 Nov-Dec;16(6):432-6. doi: 10.1007/s00192-004-1274-1. Epub 2005 Jan 20. PMID: 15660182. DOI:

Kikuchi JY, Muñiz KS, Handa VL. Surgical Repair of the Genital Hiatus: A Narrative Review. Int Urogynecol J. 2021 Aug;32(8):2111-7. doi: 10.1007/s00192-021-04680-7. Epub 2021 Feb 19. PMID: 33606054. DOI:

Muñiz KS, Voegtline K, Olson S, Handa V. The role of the genital hiatus and prolapse symptom bother. Int Urogynecol J. 2021 Apr;32(4):829-34. doi: 10.1007/s00192-020-04569-x. Epub 2020 Oct 20. PMID: 33079211. DOI:

Hill AM, Shatkin-Margolis A, Smith BC, Pauls RN. Associating genital hiatus size with long-term outcomes after apical suspension. Int Urogynecol J. 2020 Aug;31(8):1537-44. doi: 10.1007/s00192-019-04138-x. Epub 2019 Nov 27. PMID: 31776617. DOI:

Garcia AN, Ulker A, Aserlind A, Timmons D, Medina CA. Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation. Int J Gynaecol Obstet. 2022 Apr;157(1):96-101. doi: 10.1002/ijgo.13828. Epub 2021 Jul 30. PMID: 34270804. DOI:

Jelovsek JE, Barber MD, Brubaker L, Norton P, Gantz M, Richter HE, et al. Pelvic Floor Disorders Network. Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial. JAMA. 2018 Apr 17;319(15):1554-65. doi: 10.1001/jama.2018.2827. PMID: 29677302; PMCID: PMC5933329. DOI:

Verma A, Kashyap M, Gupta A. High Uterosacral Ligament Fixation Versus McCall's Culdoplasty for Vaginal Vault Suspension in Utero-Vaginal Prolapse Surgery. Cureus. 2022 Jul 27;14(7):e27368. doi: 10.7759/cureus.27368. PMID: 36046323; PMCID: PMC9417864. DOI:

Milani R, Frigerio M, Vellucci FL, Palmieri S, Spelzini F, Manodoro S. Transvaginal native-tissue repair of vaginal vault prolapse. Minerva Ginecol. 2018 Aug;70(4):371-7. doi: 10.23736/S0026-4784.18.04191-6. Epub 2018 Jan 26. PMID: 29376621. DOI:

Kanter G, Jeppson PC, McGuire BL, Rogers RG. Perineorrhaphy: commonly performed yet poorly understood. A survey of surgeons. Int Urogynecol J. 2015 Dec;26(12):1797-801. doi: 10.1007/s00192-015-2762-1. Epub 2015 Jul 4. PMID: 26142348; PMCID: PMC4670594. DOI:

Bonglack M, Maetzold E, Kenne KA, Bradley CS, Kowalski JT. Prospective evaluation of genital hiatus in patients undergoing surgical prolapse repair. Int Urogynecol J. 2022 Nov;33(11):3247-54. doi: 10.1007/s00192-022-05157-x. Epub 2022 Mar 17. PMID: 35301543; PMCID: PMC8929254. DOI:

Vaughan MH, Giugale LE, Siddiqui NY, Bradley MS. Impact of Genital Hiatus Size on Anatomic Outcomes After Mesh-Augmented Sacrospinous Ligament Fixation. Female Pelvic Med Reconstr Surg. 2021 Sep 1;27(9):564-8. doi: 10.1097/SPV.0000000000000986. PMID: 33411455. DOI:

Mothes AR, Raguse I, Kather A, Runnebaum IB. Native-tissue pelvic organ prolapse (POP) repair with perineorrhaphy for level III support results in reduced genital hiatus size and improved quality of life in sexually active and inactive patients. Eur J Obstet Gynecol Reprod Biol. 2023 Jan;280:144-9. doi: 10.1016/j.ejogrb.2022.11.023. Epub 2022 Nov 24. PMID: 36493583. DOI:

Handa VL, Blomquist JL, Carroll M, Roem J, Muñoz A. Longitudinal Changes in the Genital Hiatus Preceding the Development of Pelvic Organ Prolapse. Am J Epidemiol. 2019 Dec 31;188(12):2196-201. doi: 10.1093/aje/kwz195. PMID: 31565742; PMCID: PMC7036657. DOI:






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How to Cite

Şahin F, Adan R, Bademler N, Demirel EA, Toplu M İbrahim, Mihmanlı V. Genital hiatus measurements predict cuff prolapse risk in prolapse surgery: Cuff prolapse risk in prolapse surgery. J Surg Med [Internet]. 2023 Jun. 22 [cited 2024 Jul. 16];7(6):364-8. Available from: