Anatomic Aspects of Vaginal Eversion After Hysterectomy

Objective: Our aim was to understand how vaginal eversion after hysterectomy differs from other forms of prolapse.

Study Design: The role of individual structures involved in vaginal support was studied by pelvic dissection of 61 cadavers. Serial cross sections from 13 additional cadavers were examined.

Results: The upper third of the vagina (level I) is suspended from the pelvic walls by vertical fibers of the paracolpium, which is a continuation of the cardinal ligament. In the middle third of the vagina (level II) the paracolpium attaches the vagina laterally to the arcus tendineus and fascia of the levator ani muscles. The vagina's lower third fuses with the perineal membrane, levator ani muscles, and perineal body (level III). Dissection reveals that the paracolpium's vertical fibers in level I prevented prolapse of the vaginal apex and vaginal eversion.

Conclusions: The paracolpium in level I forms the critical factor that differentiates vaginal eversion from posthysterectomy cystocele-rectocele or enterocele in which the vaginal apex remains well suspended.