BACKGROUND: Multiple studies have shown sacrospinous ligament fixation to be highly effective therapy for vaginal vault prolapse. Several authors have suggested that the marked vaginal retroversion subsequent to sacrospinous ligament fixation may predispose to recurrent pelvic support defects in the anterior fascial segment, resulting in cystocele or urethrocele, or both. STUDY DESIGN: Thirty-six patients, 46 to 86 years of age, were examined at six weeks postoperatively and at long-term follow-up evaluation 15 to 79 months (median of 42 months) after sacrospinous ligament fixation and repair of associated pelvic support defects. The examinations, by an unbiased examiner, were done to identify and grade recurrent pelvic support defects. RESULTS: At the six week postoperative visit, one patient had a small enterocele, and none of the patients demonstrated vaginal vault prolapse. At the long-term follow-up visit, 33 (92 percent) of the patients had cystoceles, six (17 percent) had rectoceles, two (6 percent) had enteroceles, and three (8 percent) demonstrated recurrent vaginal vault prolapse. Most cystoceles were small and asymptomatic. CONCLUSIONS: A high rate of success in the treatment of prolapse of the upper vagina by sacrospinous ligament fixation was observed. Pelvic support defects at long-term follow-up evaluation occurred more commonly in the anterior fascial segment. Retroversion and fixation of the upper vagina predisposes the anterior fascial segment to excess pressure and a higher incidence of cystocele than could be attributed to the effects of aging and menopause.