What is the best treatment option for an elderly female with no co-morbidities (existing health conditions) and procidentia (uterine prolapse)?

Surgical Management of Procidentia in an Elderly Female Without Comorbidities

For an elderly female with no comorbidities and procidentia (complete uterine prolapse), vaginal hysterectomy with pelvic floor repair is the best option, offering definitive treatment with excellent anatomic outcomes and preservation of quality of life. 1

Primary Surgical Approach

Vaginal hysterectomy with concurrent repair of enterocele, cystocele, and rectocele should be performed as this addresses the complete prolapse while correcting all associated pelvic floor defects in a single procedure. 1 This approach is particularly appropriate for elderly patients as it:

• Provides definitive treatment with lower perioperative morbidity compared to abdominal approaches 2
• Allows simultaneous correction of all pelvic organ prolapse components 1
• Offers excellent long-term anatomic results when supporting structures are properly identified and approximated 1

Key Surgical Considerations

If Sexual Function is Important

If maintaining a functional vagina is a priority for the patient, the surgeon must have comprehensive understanding of pelvic support principles to preserve vaginal anatomy while achieving adequate support. 1 The vaginal hysterectomy should include:

• Careful dissection and identification of supporting structures 1
• Appropriate resection and approximation of cardinal and uterosacral ligaments 1
• Concurrent repair of anterior and posterior vaginal wall defects 1

If Sexual Function is Not a Priority

If a functional vagina is unimportant to the patient, a partial colpocleisis (Neugebauer-Le Fort operation) offers the best long-term results with a tight, coned-down vagina. 1, 3 This procedure:

• Is safe, simple, and rapid 3
• Achieves good anatomic results in 90.7% of cases 3
• Has low complication rates with only 3% recurrence and minimal urinary incontinence (6.4%) 3
• Is particularly suitable for elderly women who are certain they want to forego sexual intercourse 3

The main caveat is that partial colpocleisis makes the uterus inaccessible, which could be problematic if postmenopausal bleeding occurs (though this is rare, occurring in only 2 of 188 patients in one series). 3

Alternative Uterine-Preserving Option

For patients who strongly desire uterine preservation (though less relevant in elderly patients), the Manchester-Fothergill procedure is a viable alternative to vaginal hysterectomy. 4 However, given the patient's age and absence of fertility concerns, this is generally not the preferred approach.

What NOT to Do

Avoid abdominal approaches in elderly patients even when they lack comorbidities, as perineal/vaginal procedures have lower perioperative morbidity and are more frequently used in clinical practice for this population. 2 While transabdominal rectopexy has lower recurrence rates (0-8%), it carries higher surgical risk and 50% of patients develop severe constipation post-operatively. 2

Clinical Algorithm

1. Assess patient's sexual function priorities during preoperative counseling
2. If sexual function desired: Proceed with vaginal hysterectomy + comprehensive pelvic floor repair 1
3. If sexual function not desired: Offer partial colpocleisis as first-line option for superior long-term outcomes 1, 3
4. Ensure proper surgical technique: Complete dissection, identification, and approximation of all supporting structures regardless of approach chosen 1

Common Pitfalls to Avoid

• Do not perform isolated uterine suspension procedures without addressing associated cystocele, rectocele, and enterocele, as these commonly coexist with complete procidentia 1
• Do not choose abdominal approaches based solely on theoretical recurrence rates, as the increased perioperative morbidity outweighs this benefit in elderly patients 2
• Do not overlook patient counseling about sexual function implications, particularly if considering colpocleisis 3

The absence of comorbidities in this elderly patient actually makes her an ideal candidate for definitive vaginal surgery rather than necessitating more conservative approaches, allowing for optimal anatomic correction and quality of life improvement.