DeLancey Levels of Vaginal Support
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Direct answer
DeLancey described three levels of vaginal support, each anchored to a different structure. Level I is the upper vagina held by the cardinal and uterosacral ligaments, Level II is the middle vagina attached to the arcus tendineus fasciae pelvis, and Level III is the lower vagina fused to the perineal body. Level I failure causes uterine or vault prolapse, Level II failure causes cystocele or rectocele, and Level III failure causes distal urethrocele or perineal descent.
What you must remember
- Level I: the upper third of the vagina and cervix, held by the cardinal and uterosacral ligaments; failure gives uterine prolapse, vault prolapse after hysterectomy and enterocele.
- Level II: the middle third, attached laterally to the arcus tendineus fasciae pelvis through paravaginal endopelvic fascia; failure gives the lateral defect behind most cystoceles.
- Level III: the lower third, fused to the perineal body and urogenital diaphragm; failure gives distal urethrocele, low rectocele and perineal descent.
- Anterior compartment: the bladder and urethra in front of the vagina, with cystocele from Level II defects and urethrocele from Level III defects.
- Posterior compartment: the rectum behind the vagina, with rectocele from Level II defects in the rectovaginal septum and enterocele from Level I defects.
- Staging: the POP-Q system grades prolapse severity by point measurements, while DeLancey levels localise which attachment has failed.
- Surgical match: Level I defects are repaired by uterosacral or sacrospinous fixation, Level II by anterior colporrhaphy with paravaginal repair, and Level III by perineorrhaphy.
Mapping each level to its defect
Prolapse is best understood by asking which attachment has failed, because each attachment produces its own bulge. The table links each level to its anatomy and the defect it produces, and it is the form in which examiners expect the material to be recalled.
| Level | Attachment | Typical defect | Prolapse seen |
|---|---|---|---|
| Level I | Cardinal and uterosacral ligaments | Apical loss of support | Uterine, vault or enterocele |
| Level II anterior | Arcus tendineus fasciae pelvis | Paravaginal defect | Cystocele |
| Level II posterior | Rectovaginal septum | Lateral rectovaginal defect | Rectocele |
| Level III | Perineal body and urogenital diaphragm | Distal support loss | Urethrocele, low rectocele |
A bulge at the vaginal apex points to Level I failure, whereas a bulge confined to the lower vagina points to Level II or III loss. Surgeons who identify the failed level can choose a repair that targets that specific attachment. Many women have defects at more than one level, so every bulge should be mapped before any repair is chosen.
Where the exam tries to catch you
Questions usually give a bulge and ask you to name the level or the operation.
- Trap: Calling every bladder descent a Level III defect. Correct: Bladder descent is a Level II anterior paravaginal defect, while Level III governs the distal urethra and perineal body.
- Trap: Calling apical descent after hysterectomy a uterine prolapse. Correct: After hysterectomy the apex fails at Level I, giving vault prolapse or enterocele, since there is no uterus left to descend.
- Trap: Using DeLancey levels to grade severity. Correct: The levels localise the defect, while the POP-Q system measures how far the prolapse descends.
Frequently asked questions
Which DeLancey level is lost in uterine prolapse?
Uterine prolapse results from Level I failure, in which the cardinal and uterosacral ligaments lose their attachment to the upper vagina and cervix. The same apical failure underlies vault prolapse after hysterectomy.
What defect causes a cystocele in DeLancey's classification?
A cystocele most often results from a Level II anterior defect, where the lateral attachments of the upper anterior vagina to the arcus tendineus fasciae pelvis tear. Level I and Level III defects can contribute to the same bulge.
Which DeLancey level does sacrospinous fixation repair?
Sacrospinous fixation repairs Level I support by anchoring the vaginal apex to the sacrospinous ligament. Uterosacral suspension is an alternative apical repair that addresses the same level.
Why does DeLancey's classification matter for prolapse surgery?
Each level needs a different repair, so the surgeon must know which attachment has failed. Matching the repair to the failed level is the logic behind most prolapse surgery.