Dr Gillian with a patient

Vaginal Vault Prolapse After Hysterectomy: What’s Happening and How to Fix It

So, you’ve had a hysterectomy, and now you’re dealing with something that feels… off. Maybe there’s a dragging sensation, a bulge, or discomfort that wasn’t there before. If that sounds familiar, you might be dealing with vaginal vault prolapse—a condition where the top of the vagina (the vault) loses its support and starts to drop down. Frustrating? Absolutely. Fixable? Definitely.

Let’s break it down and talk about what’s going on, why it happens, and—most importantly—what you can do about it.

Why Does Vaginal Vault Prolapse Happen?

A hysterectomy removes the uterus, and usually the cervix, but your pelvic organs—like the bladder, bowel, and top of the vagina—still need support. Normally, a network of ligaments and pelvic floor muscles holds everything in place. But when the uterus and cervix is removed, particularly via the tummy, these supporting structures can weaken over time and in the post menopausal phase. Without that central “anchor” of the uterus and its supporting ligaments, the top of the vagina (the vault) can start to descend, leading to a bulge felt int he lower vagina.

Factors that increase the risk of vaginal vault prolapse include:

  • Weak pelvic floor muscles – If your pelvic floor was already struggling before surgery, removing the uterus can tip things over the edge.
  • Previous childbirth trauma – If you’ve had a tough delivery, forceps, or big babies, your pelvic support may already be compromised.
  • Heavy lifting or straining – Chronic constipation, heavy unsupported lifting, or lots of high-impact exercise can put extra pressure on the pelvic floor.
  • Hormonal changes – Lower oestrogen levels after menopause can weaken vaginal tissues, making prolapse more likely.
  • Genetics – If the women in your family have struggled with prolapse, there’s a higher chance you might too. Some conditions such as hyper flexibility or ‘Ehlers Danlos’ and its variants can predispose to lax ligaments and a weak pelvic floor too.

Symptoms of Vaginal Vault Prolapse

The symptoms vary from person to person, but common signs include:

  • A feeling of heaviness, dragging, or pressure in the vagina
  • A bulging sensation or seeing/feeling tissue at the vaginal opening
  • Discomfort or pain during sex
  • Difficulty emptying the bladder fully or needing to lean forward/backwards to wee
  • Constipation or needing to support the vaginal wall to empty the bowels

If any of this sounds familiar, don’t panic—there are plenty of treatment options available.

What Can Be Done?

There are both non-surgical and surgical options for managing vaginal vault prolapse, depending on how severe it is and what works best for your body and lifestyle.

1. Pelvic Floor Physiotherapy

One of the first (and best!) things you can do is strengthen the muscles that support your pelvic organs. Pelvic floor physio is a great option if you still have some muscle tone and the degree of prolapse isn’t too bad, but there often becomes a pint where pelvic floor physio just isn’t going to improve things.

2. Supportive Vaginal Pessaries: A Non-Surgical Game-Changer

Pessaries are small, removable devices worn inside the vagina to support the prolapse. They come in different shapes and sizes, and when fitted properly, they can be life-changing.

One of the best pessaries for vaginal vault prolapse? The cube pessary.

Why the cube pessary?

  • It provides strong, suction-like support for more advanced prolapses where there is no cervix to use as a brace.
  • It’s great for women who haven’t had success with traditional ring pessaries.
  • It’s easy to remove and reinsert yourself (once you get the hang of it!).

Cube pessaries are especially useful when other pessaries don’t stay in place or when the vaginal walls are particularly lax. You usually need to take them out overnight to allow the vaginal tissue to rest, but for many women, they provide instant relief from symptoms. A removable, self managing option can be a really good choice for women who find they only have symptoms from their prolapse occasionally or when performing certain activities, for example when going on long walks or taking part in an exercise class as they can be inserted before the activity then removed afterwards as required.

Other pessary options include ring, Gellhorn, and donut pessaries—each suited to different types and severities of prolapse.

3. Hormone Replacement Therapy (HRT) and Vaginal Oestrogen

If you’re postmenopausal, vaginal oestrogen can help strengthen the vaginal walls, making them thicker, more elastic, and better able to support a pessary or hold a repair. Vaginal oestrogen (such as Vagifem, Ovestin, or Imvaggis) is a low-dose option that works locally, meaning it doesn’t carry the same risks as systemic HRT. I would always recommend a loading dose of vaginal oestrogens before inserting a pessary if you’re post menopausal as this will almost certainly improve the result.

For some women, full-body HRT can also help improve tissue quality and pelvic support. It won’t reverse a prolapse, but it can slow progression and improve symptoms.

4. Lifestyle Changes

Since pressure on the pelvic floor makes prolapse worse, managing daily habits can make a big difference:

  • Avoid heavy lifting and straining—if you need to lift, engage your core, be aware of your pelvic floor and clench like you’re holding onto a wee, and exhale as you do.
  • Manage constipation—eat plenty of fibre (beans, rice, potatoes and veggies!), drink water, and use a footstool when sitting on the loo to help open up the pelvis.
  • Keep weight within a healthy range—extra weight, especially around your middle = extra pressure on the pelvic floor.
  • Switch to low-impact exercise—walking, swimming, exercise bike and Pilates are great alternatives to running and high-intensity workouts.

5. Surgical Options

If symptoms are severe and non-surgical options aren’t working, there are surgical procedures that can correct vaginal vault prolapse. These include:

  • Sacrocolpopexy – A mesh is used to attach the vaginal vault to the sacrum (tailbone), providing long-term support.
  • Sacrospinous fixation – The vaginal vault is stitched to a strong pelvic ligament to hold it in place.
  • Anterior and posterior wall (bowel and bladder prolapse) repairs can be performed at the same time also. The scar tissue generated from these creates supporting tissue to hold the bowel/bladder back from sagging into the vaginal cavity.
  • Colpocleisis – If vaginal function isn’t a priority (e.g., for women who aren’t sexually active), the vaginal canal can be partially closed to provide support. This is a very extreme and rarely performed pelvic floor surgery in the UK though.

Surgery can be highly effective, but it’s not always a permanent fix and failure rates vary between surgeons, surgical techniques and from woman to woman—the pelvic floor still needs to be looked after to prevent recurrence too.

The Takeaway: You Don’t Have to Just ‘Live With It’

Vaginal vault prolapse is common after hysterectomy, but that doesn’t mean you have to put up with discomfort, bulging, or bladder issues. Whether it’s through pelvic floor rehab, pessaries, lifestyle changes, or surgery, there are plenty of ways to get back to feeling like yourself again.

If you suspect you have a prolapse or are struggling with symptoms, book in a pelvic floor assessment—help is available, and you deserve to feel comfortable in your own body.

Have you tried a pessary or found treatments that work well for you? I’d love to hear your experiences in the comments!