How the Cardinal Ligament Contributes to Pelvic Organ Prolapse
The cardinal ligament (also called the uterine-cervical or transverse cervical ligament) causes prolapse when it becomes weakened, stretched, or damaged, leading to loss of lateral support for the cervix and upper vagina, which allows these structures to descend into the vaginal canal. 1, 2
Anatomical Basis of Cardinal Ligament Support
The cardinal ligament functions as a critical lateral support structure that:
- Attaches the lateral side of the vagina and cervix to the lateral pelvic wall, providing essential stabilization for the uterus and upper vagina 1
- Forms a perivascular sheath with proximal insertion around the origin of the internal iliac artery and distal insertion on the cervix and/or vagina 3
- Contains primarily vessels, nerves, connective tissue, and adipose tissue rather than a distinct band of connective tissue, making it a visceral ligament with a mesentery-like structure 3
Mechanism of Prolapse Development
When cardinal ligament integrity is compromised, a predictable cascade occurs:
- Loss of lateral support allows the cervix and vaginal apex to descend centrally and inferiorly, as the ligament can no longer maintain the normal horizontal position of these structures 2
- Collagen content and distribution changes have been documented in cardinal ligaments of women with uterine prolapse, suggesting structural degradation of the connective tissue matrix 1
- Excessive tension on the cardinal ligaments during hysterectomy may be an etiologic factor in subsequent vaginal vault prolapse, as this can permanently damage the ligament's structural integrity 4
Relationship to Multi-Compartment Prolapse
Cardinal ligament failure rarely occurs in isolation:
- Apical support loss from cardinal ligament weakness typically leads to anterior and posterior vaginal wall prolapse as secondary events, since the apex normally provides suspension for these compartments 2
- The cardinal ligament works in concert with the uterosacral ligaments to provide apical support; when both are compromised, complete vaginal vault prolapse can occur 2, 4
Risk Factors That Accelerate Cardinal Ligament Damage
- Chronic increases in intra-abdominal pressure from straining, obesity, or chronic cough progressively stretch and weaken the ligament over time 5
- Vaginal childbirth, particularly with prolonged labor or operative delivery, can cause acute ligament injury 6
- Aging and hormonal changes affect collagen metabolism and ligament strength 1
Clinical Implications
The cardinal ligament's role in prolapse is why surgical repairs targeting apical support (such as uterosacral ligament fixation or sacrocolpopexy) are essential for durable prolapse correction, as simply repairing anterior or posterior walls without addressing apical support leads to high recurrence rates. 7, 4