Edit concept Create issue ticket

Enterocele

Hernia Posterior Vaginal

Enterocele is defined as a hernia of the intestine and the peritoneum through the pouch of Douglas into the vagina.


Presentation

Symptoms of enterocele include pelvic discomfort and pain. These symptoms are most felt when patients assume a standing position and with increased intra-abdominal pressure. Enteroceles have been associated with obstructed defecation especially if the sigmoid colon is herniated, although there is limited evidence to support this association.

Generally, the symptoms of an enterocele are ill-defined because of concomitant conditions such as rectocele and intussusception.

Anorexia
  • Amenorrhea Ankylosing spondylitis Aplastic anemia, Amnesia Anorexia nervosa Appendicitis, Amyloidosis Anorgasmia ARDS, Amyotrophic lateral sclerosis Anthrax Arteriosclerosis / atherosclerosis, Anal cancer Antibiotic-associated diarrhea Arteriovenous fistula[sites.google.com]
Abdominal Tenderness
  • We report herein the case of a 70-year-old woman with a posthysterectomy enterocele presented with symptoms of small bowel obstruction and abdominal tenderness. The patient underwent exploratory laparotomy, which revealed small bowel incarceration.[ncbi.nlm.nih.gov]
Neglect
  • Neglected, obstructed labor and traumatic delivery, which weaken uterovaginal supports, should be avoided. Perineal exercises practiced after delivery help to prevent relaxation.[healthcentral.com]

Workup

Enteroceles were diagnosed by bimanual, vaginal, and rectal examinations in the past. However, not all enteroceles are detected by physical examination. A study by demonstrated that some enteroceles were detected by evacuation proctography but missed on physical examination. Evacuation proctography is the best diagnostic tool for enterocele. There are other imaging modalities including cystography and colpo-cysto-defecography which help to detect other pelvic abnormalities and prolapses. Less invasive imaging studies including dynamic magnetic resonance imaging and dynamic transperineal ultrasound have been introduced for the evaluation of pelvic organ prolapse. More evidence is required to determine the effectiveness of these new imaging studies.

Treatment

A number of surgical procedures have been developed for the treatment of symptomatic enteroceles. Earlier, the surgical obliteration of the pouch of Douglas was regarded as the best treatment of enterocele repair. Six to eight non-absorbable sutures were placed in a concentric arrangement starting from the distal part of the pouch of Douglas till the entire pouch was obliterated. Although, this procedure has formed the basis of transabdominal enterocele repair, data on the long-term advantages and demerits of the procedure is still insufficient.

There are two approaches for surgical repair of an enterocele: transabdominal and transvaginal. In transvaginal approach, a midline dissection of the posterior wall of the vagina is made with obliteration of the pouch of Douglas by excision and ligation of the enterocele followed by tight reapposition of the uterosacral ligaments. Several studies have suggested that the transvaginal approach of repair yields good results. Furthermore, data is lacking concerning the long-term effectiveness and complications of this approach. Complications of this approach, however, include urethral injury and dyspareunia.

More advanced transabdominal repair procedures have been developed recently. These techniques use synthetic graft materials for the repairs. In 1998, Silvis et al described a rectovaginovesicopexy in patients with enteroceles with urinary and defecation problems [15]. This procedure recorded 90% success as detected by evacuation proctography done three months after. Also in 1999, Gosselink et al demonstrated complete obliteration of the pelvic inlet in a procedure using with a U-shaped mersilene mesh [16]. The mesh was sutured to the vaginal apex anteriorly and to the presacral fascia posteriorly. Obliteration of the pelvic inlet is a good surgical repair basis for enteroceles. However, recurrent pelvic discomfort occurred in 25% of patients and obstructed defecation occurred in three-fourths of the patients. Jean et al reported similar complications after performing a somewhat similar procedure [17].

Laparoscopic enterocele sac excision and vaginal vault suspension have been shown to provide excellent anatomic repair. However, more data is required on the effectiveness and overall value of laparoscopic repair.

Prognosis

The prognosis is very good after successful repair of the enterocele. A high risk of recurrence is associated with surgical repair techniques in which the enterocele alone is repaired without repair of concomitant cystocele, rectocele, and uterine prolapse, and those in which the vaginal vault is suspended without obliterating the hernial sac.

Etiology

The risk factors for an enterocele include advancing age, previous hysterectomy, postmenopausal women, and prior surgery for an enterocele or pelvic prolapse [6]. A study has excluded weight and a history of hysterectomy as risk factors for an enterocele [7]. Furthermore, more recent studies have stated that advanced age is not a risk factor for pelvic organ prolapse in females [8] [9].

A study shows that vaginal birth is not associated with POP-Q stages 3 and 4, but may increase the risk of stage 2 prolapse [10].

A pelvic organ prolapse is 4-5 times commoner among latin and white women than African American women [11].

Epidemiology

The prevalence of pelvic organ prolapse based on the POP-Q staging has shown to be [8]:

  • Stage 0 - 25%
  • Stage 1 - 36.5%
  • Stage 2 - 33%
  • Stage 3 - 5.0%
  • Stage 4 - 0.5%
Sex distribution
Age distribution

Pathophysiology

The precise cause of prolapse is largely unknown. There are several theories on the etiological basis. As noted by Allen-Brady et al, there is a strong genetic predisposition to uterovaginal prolapse; the genetic mutation is said to be on the short arm of chromosome 9 [12]. Other theories suggest a metabolic basis, identifying increased rate of cellular apoptosis and loss of mitochondrial DNA in the uterosacral ligaments as possible causes [13]. Other researchers have also suggested that sacral nerve dysfunction and collagen defects are possible etiologies of prolapse.

Generally, enterocele results when the support system of the pelvic floor is damaged. This weakening leads to prolapse of the pelvic organs and the small bowel. DeLancey gives a good description of the pelvic floor, dividing the structures therein into three levels of support [14]:

  • Level 1: This includes the cardinal-uterosacral ligament complex which supports the upper vagina and cervix. This level is the main support for the pelvic floor.
  • Level II: This level of support is provided by the arcus tendineus fascia pelvis for the mid vagina.
  • Level III: This level of support is provided by the distal rectovaginal septum and fusion of tissues along the basal aspect of the urethra.

Enterocele occurs mainly from damage to support level I. Depending on the location of the herniation, and its relation to the vaginal wall, enterocele can be described as apical, anterior, or posterior. Tearing of the cardinal-uterosacral ligament complex results in apical prolapse. An apical enterocele is the commonest form of enterocele and may develop after a hysterectomy.

Anterior enterocele is not as common as the apical forms and usually occurs after sacrospinous ligament fixation, in which the upper part of the vagina is pulled posteriorly, leaving a potential space anteriorly. Posterior enterocele occurs after tearing of the proximal rectovaginal fascia from the cardinal-uterosacral ligament complex. This tear results in descent of the peritoneum and the intestine posterior to the vagina.

Prevention

The risk of enterocele can be reduced by maintaining a proper weight, preventing constipation and straining, avoiding prolonged cough and weight lifting which tend to increase intra-abdominal pressure, and smoking cessation. Constipation can be prevented by eating a high-fiber diet, drinking lots of water and avoiding drugs which cause constipation.

Summary

Pelvic organ prolapse is defined as the descent of pelvic or abdominal organs causing an invagination of the anterior vaginal wall, posterior vaginal wall, the uterus, or the apex of the vagina [1]. This definition was coined by the International Urogynecological Association and International Continence Society. However, researchers are yet to draw the line between the physiologic descent of the pelvic organs and a true pathologic prolapse.

Pelvic organ prolapse may be asymptomatic and often times, the degree of prolapse is not directly proportional to the symptomatology or clinical presentation. Another ambiguity with pelvic organ prolapse is that the pelvic floor symptoms do not correlate well with the location of the prolapse [2]. Therefore, investigators have instituted the pelvic organ prolapse quantification (POP-Q) to provide clear description and categorization of the degree of prolapse. This helps to establish a diagnosis, the severity of disease, and appropriate treatment protocols.

In staging the extent of the prolapse, the hymen is used as the fixed reference point and it is noteworthy that the prolapse may be within or outside the vaginal canal. The stages include;

  • Stage 0 : This stage is characterized by the absence of prolapse.
  • Stage 1: This stage is characterized by a descent of the most distal segment of the prolapse at least 1cm above the hymen.
  • Stage 2: At this stage, the prolapse has descended to a point less than 1 cm above the hymen.
  • Stage 3: In this stage, the prolapse extends beyond the hymen by over 1 cm, however, the extension is within 2 cm of the vaginal length.
  • Stage 4: This stage is characterized by the complete protrusion.

Enterocele has been defined as a hernia of the intestines and the peritoneum through the pouch of Douglas into the vagina; being palpable in the pouch of Douglas on physical examination in the erect position. The definition has been modified by Richardson as the herniation of small bowel when the endopelvic fascia between the peritoneum and vagina is weakened or lost [3]. However, contrary to this theory, studies by Tulikangas et al [4] and Hsu et al [5] show that a break in the rectovaginal fascia may not necessarily be present. These studies, however, are limited and insufficient and further investigation is necessary.

It presents with vague symptoms including pelvic discomfort or pain and a vaginal bulge. Other symptoms may present depending on the organ which is prolapsed.

Diagnosis of enterocele can be made by physical examination and imaging studies including evacuation proctography. Treatment of enterocele depends on the stage; asymptomatic enterocele may be treated conservatively with lifestyle modifications and medical care while symptomatic prolapse is treated surgically with either a transabdominal or a transvaginal approach.

Patient Information

Overview:

An enterocele is a prolapse of a part of the small bowel into the vaginal wall. In a healthy individual, such prolapse is prevented by the tough support provided by the pelvic floor muscles and ligaments. The pelvic floor separates the abdominal and pelvic organs from the perineal or genital organs.

Etiology:

Several factors predispose to damage the pelvic floor muscles and the consequent weakening of this partition between the abdominal and the perineal or genital organs. These factors include childbirth, aging, a previous surgery for enterocele or prolapse of other organs, and being in the menopausal phase of life.

Furthermore, there are several common factors which foster weakening of the pelvic floor and these include a chronic cough, straining during defecation, constipation, being obese or overweight, pregnancy, childbirth, and weight lifting. These factors tend to weaken the pelvic floor, increasing the chances of an organ herniating or falling through the areas of the weakness to the perineal region.

Prolapse of the small bowel may also come with prolapse of other organs above the pelvic floor such as the bladder and rectum into the wall of the vagina.

Presentation:

Some cases of mild prolapse may not produce any noticeable symptom or sign. In moderate to severe cases, however, the patient may feel heaviness or pressure in the pelvis, low back pain, a bulge in the vagina, vaginal discomfort, and pain during sexual intercourse.

Workup:

Although doctors can diagnose enteroceles and pelvic floor prolapse by physical examination, imaging techniques are the most reliable method of diagnosis.

Treatment:

Mild to moderate prolapse might not need treatment, however, disturbing and severe cases are treated by surgical repair of the weakened pelvic floor and repositioning of the prolapsed organ. In cases where surgery may be risky, doctors may decide to wait and observe the progression of the prolapse. In this case, several self-care exercises such as kegel exercises are recommended for the patient to aid strengthening of the pelvic floor.

The surgical techniques to repair an enterocele are many and each comes with its merits and demerits. However, complications such as difficulty defecating and recurrent pelvic fullness may occur.

To reduce the risk of pelvic floor weakening and enterocele, a patient may be instructed to avoid straining as can be seen during the passage of hard stools and weight-lifting, follow a high-fiber diet such as fruits and vegetables, drink sufficient water to soften the stool so as to avoid straining. Those who are overweight and obese are advised to reduce their weight to prevent excessive load on the pelvic floor.

References

Article

  1. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010; 29(1):4-20.
  2. Miedel A, Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M. Symptoms and pelvic support defects in specific compartments. Obstet Gynecol. 2008 Oct; 112(4):851-8.
  3. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976 Nov 1; 126(5):568-73.
  4. Tulikangas PK, Walters MD, Brainard JA, Weber AM. Enterocele: is there a histologic defect?. Obstet Gynecol. 2001 Oct; 98(4):634-7.
  5. Hsu Y, Chen L, Delancey JO, Ashton-Miller JA. Vaginal thickness, cross-sectional area, and perimeter in women with and those without prolapse. Obstet Gynecol. 2005 May; 105(5 Pt 1):1012-7.
  6. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol. 2000 Aug; 183(2):277-85.
  7. Samuelsson EC, Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol. 1999 Feb; 180(2 Pt 1):299-305.
  8. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Sep; 20(9):1037-45.
  9. Dietz HP. Prolapse worsens with age, doesn't it?. Aust N Z J Obstet Gynaecol. 2008 Dec; 48(6):587-91.
  10. Sze EH, Hobbs G. Relation between vaginal birth and pelvic organ prolapse. Acta Obstet Gynecol Scand. 2009; 88(2):200-3.
  11. Whitcomb EL, Rortveit G, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK. Racial differences in pelvic organ prolapse. Obstet Gynecol. 2009 Dec; 114(6):1271-7.
  12. Allen-Brady K, Norton PA, Farnham JM, Teerlink C, Cannon-Albright LA. Significant linkage evidence for a predisposition gene for pelvic floor disorders on chromosome 9q21. Am J Hum Genet. 2009 May; 84(5):678-82.
  13. Sun MJ, Cheng WL, Wei YH, Kuo CL, Sun S, Tsai HD. Low copy number and high 4977 deletion of mitochondrial DNA in uterosacral ligaments are associated with pelvic organ prolapse progression. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jul; 20(7):867-72.
  14. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992 Jun; 166(6 Pt 1):1717-24; discussion 1724-8.
  15. Silvis R, Gooszen HG, Kahraman T, et al. Novel approach to combined defaecation and micturition disorders with rectovaginovesicopexy Br J Surg 1998; 85:813-817.
  16. Gosselink MJ, van Dam JH, Huisman WM, Ginai AZ, Schouten WR Treatment of enterocele by obliteration of the pelvic inlet Dis Colon Rectum 1999; 42:940-944.
  17. Jean F, Tanneau Y, Le Blanc-Louvry I, Leroi AM, Denis P, Michot F. Treatment of enterocele by abdominal colporectosacropexy – efficacy on pelvic pressure Colorectal Dis 2002; 4:321-325.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2017-08-09 17:50