Anterior and Posterior Vaginal Repair
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Direct answer
Native-tissue anterior and posterior vaginal wall repair remains the standard operations for symptomatic cystocele and rectocele: anterior colporrhaphy plicates the pubocervical fascia beneath the bladder after the vaginal epithelium is opened, and posterior colpoperineorrhaphy reapproximates the rectovaginal fascia and perineal body to restore support and vaginal calibre. Surgery is reserved for prolapse that is symptomatic — a bulge or drag, voiding difficulty, incomplete emptying, defecatory dysfunction or sexual complaints — while asymptomatic prolapse is observed; pessaries offer a genuine alternative for women unfit or unwilling to undergo surgery. Synthetic mesh augmentation of these repairs has been suspended or withdrawn across major jurisdictions after complication and consent reviews, so native-tissue technique, with its honest recurrence rates, is what the current-generation trainee must master.
What you must remember
- Indication threshold: symptoms, not the examination grade, drive surgery; a woman feeling a bulge (the symptom correlating best with severity) qualifies for repair, a merely asymptomatic descent does not.
- Anterior repair steps: hydrodissection or infiltration, midline vertical epithelial incision, dissection of the vaginal wall off the bladder, plication of pubocervical fascia with interrupted sutures, trimming of excess epithelium, closure — often with cystoscopy to confirm ureteral patency and bladder integrity.
- Posterior repair steps: triangular midline incision, breaking through the fascial defect to the rectovaginal plane, plication of the rectovaginal fascia over the rectum, reconstruction of the perineal body, and calibrating the introitus to avoid stenosis and dyspareunia.
- Concomitant surgery: vaginal hysterectomy for uterovaginal prolapse, a sacrospinous ligament fixation or uterosacral plication for vault support, and a suburethral sling only where occult stress incontinence was demonstrated preoperatively.
- Mesh status: transvaginal synthetic mesh for prolapse was halted by regulators (the United States FDA in 2019, after the United Kingdom pause in 2017) following erosion, pain and consent controversies; native tissue is the default, with biological grafts or native-tissue alternatives considered selectively.
- Recurrence reality: anterior compartment recurs most often — commonly quoted around a third or more over the long term — which is honest to state in counselling and vivas alike.
- Postoperative essentials: voiding trial before discharge, treatment or prevention of constipation, avoidance of heavy lifting for about six weeks, and oestrogen cream in postmenopausal women sometimes used to improve tissue quality.
- Site-specific principle: repair only the compartment demonstrated to be deficient on examination — a posterior repair added "routinely" narrows a normal vagina and manufactures dyspareunia.
Walking through a combined case
A 58-year-old para 4 presents with a vaginal bulge for two years, incomplete bowel emptying needing digital splinting, and a dragging backache. Examination shows a stage 3 cystocele, a grade 2 rectocele with a widened genital hiatus, a descended uterus at the level of the hymen and deficient perineal body. Preoperative work-up: cough stress test with the prolapse reduced (occult stress incontinence check), urodynamics if unclear, bowel symptom assessment, and counselling that vaginal hysterectomy with anterior and posterior repair plus a vault suspension procedure is planned — the compartments are addressed together to prevent recurrence.
In theatre, sequence matters: hysterectomy first, then the anterior repair with careful plication and cystoscopy — jets of urine from both ureters confirm safety — then the posterior repair, rebuilding the perineal body to a calibre admitting two fingers, closing the vaginal epithelium without tension. A vaginal pack and catheter typically stay overnight. The morning after, remove both, then check post-void residual; retention from oedema settles in most. Discharge on stool softeners and a graded return to activity. At six weeks, examine the vault, discuss the recurrence odds honestly, and treat any granulation tissue. The anatomy was rebuilt; the physiology — bowel and bladder habits, weight, smoking, occupation — determines whether it stays rebuilt.
Where students slip
Three recurring errors cost marks. First, answering "surgery" for every prolapse: pessary fitting, pelvic floor physiotherapy for mild disease, and watchful waiting for the asymptomatic are all correct answers in the right stem. Second, describing a "routine posterior repair" — the operation creates dyspareunia when the posterior wall is normal, a lesson written into every textbook discussion of the levator ani "tightening" era. Third, endorsing mesh: candidates quoting mesh augmentation as standard prolapse care reveal outdated reading; the examinable current position is that transvaginal synthetic mesh for prolapse has been withdrawn in most jurisdictions, and its legacy patients need dedicated mesh-complication services.
Frequently asked questions
What are the indications for an anterior colporrhaphy?
Symptomatic cystocele — bulge, drag, voiding difficulty or recurrent urinary infections — once pessary and conservative options are declined or unsuitable.
Why is the posterior repair calibrated carefully?
Over-narrowing the introitus and vaginal tube causes dyspareunia, the commonest functional complication of posterior colpoperineorrhaphy.
Why has transvaginal mesh for prolapse been withdrawn?
Regulators halted its use after mesh erosion, chronic pain and consent failures outweighed modest anatomical benefit; native-tissue repair is now the standard.
What confirms ureteral integrity during anterior repair?
Intraoperative cystoscopy visualising urine efflux from both ureteric orifices after plication, because a caught ureter is a recognised complication.
Which complication is most common after anterior repair long-term?
Recurrence of the anterior compartment prolapse — it has the highest recurrence rate of all compartments, often quoted around a third or more over time.