Enterocele and Massive Vaginal Eversion - Causes, Symptoms, and Treatment

What Is Enterocele and Massive Vaginal Eversion?

Pelvic organ prolapse (POP) is a prevalent healthcare issue many women suffer for years, causing pain and lowering their quality of life. However, massive vaginal eversion is uncommon compared to mild to moderate POP and can have disastrous implications if not treated properly. Enterocele is a condition of hernia in which the peritoneum and abdominal intestinal contents come into direct touch with and displace the vaginal epithelium. With massive vaginal eversion, determining what is behind the vaginal epithelium might be challenging (bladder, small intestine, colon, or rectum). Enterocele usually accompanies massive vaginal eversion.

What Could Be the Pathophysiology?

Enterocele is the protrusion of the small intestine into the vagina in the event of weakened pelvic floor muscles. The factors like childbirth, aging, hormonal changes, or chronic straining contribute to herniation of intestines into the vaginal space. The pathophysiology involves the stretching or weakening of the vagina that allows the vaginal walls to protrude.

What Are the Causes of Enterocele and Massive Vaginal Eversion?

The following conditions increase the risk of developing these conditions-

• Advancing age.

• Parity.

• Postmenopausal status.

• Hysterectomy.

• Prior corrective surgery for prolapse.

• Chronic obstructive pulmonary disease (COPD).

• Constipation.

• Hereditary.

• Racial.

What Are Some of the Common Symptoms of Enterocele and Massive Vaginal Eversion?

The following symptoms can be observed-

• There may be no signs or symptoms in mild cases of small bowel prolapse.

• Vaginal bulging.

• Pelvic pressure.

• Vaginal bleeding, infection, and discharge.

• Low back pain.

• Constipation.

• A feeling of incomplete bowel emptying.

• Straining to defecate.

• Fecal urgency.

• Urinary and occult incontinence.

• Recurrent urinary tract infection.

• Slowed urinary stream and intermittent stream.

• Dysuria.

• Dyspareunia (genital pain occurring before, during, or after intercourse).

• Vaginal laxity.

• Loss of libido.

The following are the characteristic signs of massive vaginal eversion-

• Advanced stage III or IV on the pelvic organ prolapse quantification system (POP-Q).

• A digital rectovaginal examination shows breaks in the rectovaginal fascia.

• Defects in levator and pelvic floor muscles.

• Decreased Kegel strength.

• Occult urinary incontinence with prolapse reduction.

• Postvoid residual urine.

How Is Enterocele and Massive Vaginal Eversion Diagnosed?

A detailed history of the patient based on the symptoms.

1. Physical Examination- To determine the level of prolapse using the POP-Q technique and any evident pathology such as abdominal masses or ascites, vaginal wall breakdown, fistulas, or infection. On physical examination, massive vaginal eversion is clear; however, minor degrees of prolapse and the presence of enterocele are more challenging to detect, necessitating a thorough assessment of all anterior, posterior, and apical compartment abnormalities.

2. Imaging- Imaging techniques can be used to see which organs are behind the prolapsed vaginal wall or look for intra-abdominal diseases. The following imaging techniques can be used-

• Intravenous pyelogram (IVP): This is done to rule out hydronephrosis in severe cases.

• Renal ultrasound scan.

• Computed tomography (CT) urogram.

• MRI (magnetic resonance imaging).

3. Other Tests Include-

• Urinalysis: To rule out any infections or hematuria.

• Urine culture.

• Blood urea nitrogen (BUN) and creatinine levels.

• Depending on the severity and patient's condition, other tests can be done, such as complete blood cell (CBC) count, electrocardiogram (ECG), or clotting studies.

What Is the Treatment for Enterocele and Massive Vaginal Eversion?

Massive vaginal eversion is a devastating disorder that causes discomfort as well as genitourinary and defecatory problems. Pelvic organ prolapse is common, and it has a substantial influence on one's health and economic well-being. Therefore, if pelvic organ prolapse is generating symptoms or related morbidity, it should be treated. After ruling out significant related functional difficulties, asymptomatic prolapse with minor degrees of protrusion that create no additional problems does not necessarily need treatment.

1. Medical Therapy- Estrogen therapy is used to aid in the healing of ulcers and to prepare the vagina for subsequent pessary use. Topical treatments are favored because of their quick action and low systemic absorption. Estrogens or estradiol cream are used two to three times per week for at least four to six weeks before an impact. This will only help with the symptoms of the prolapse, not the prolapse itself. A pessary may be used as a primary treatment or as a temporary fix until the prolapse operation can be finished. The primary reason for using a pessary is to provide nonsurgical relief from the symptoms of pelvic organ prolapse.

2. Surgical Therapy- The underlying defect-specific pathophysiology of the patient's condition should be addressed, and normal anatomy should be restored after surgery to treat enterocele and vaginal eversion. The following surgical procedures are available for correction of enterocele and massive vaginal eversion.

1. Culdoplasty- After the uterus and cervix have been removed from the apex of the vagina, the angles of the vagina are sutured to their respective uterosacral ligaments, and the Cul-de-sac is surgically obliterated for postoperative support.

2. Vaginal Approaches- Vaginal approaches to repair prolapsed vaginal vault (following prior hysterectomy) include:

• Sacrospinous ligament fixation (unilateral or bilateral).

• Bilateral iliococcygeus fascia suspension.

• Uterosacral vaginal vault suspension.

1. Colpocleisis Without Hysterectomy (Lefort)- The uterus is retained, and the endometrium is sampled either with dilatation and curettage (D & C) or preoperative endometrial biopsy in colpocleisis without hysterectomy (LeFort). Patients who are experiencing postmenopausal bleeding must avoid this procedure. To accommodate a frail patient, this technique might be conducted under a local or regional anesthetic.

2. Transvaginal Mesh for Pop Repair- A mesh is placed transvaginally to augment a repair in the anterior or posterior compartment.

3. Biologic Grafts- These grafts are used for the augmentation of the pelvic organ prolapse. The graft can be:

• Autologous: From the patient's tissue (rectus fascia or fascia lata).

• Allografts: From human tissue banks.

• Xenografts: From other species.

1. Abdominal Approaches- Sacral colpopexy or uterosacral reattachment are two abdominal approaches to vaginal vault suspension. Concurrent abdominal procedures, such as paravaginal repair, Burch colposuspension, or adnexa removal, can be performed using the abdominal approach (depending upon associated pelvic floor defects, preoperative urodynamics, concomitant pelvic pathology, and medical history).

3. Dietary Changes- As an adjunct to prolapse's medical or surgical care, dietary adjustments and fiber supplementation may be undertaken based on patient bowel symptoms. The complications associated with reparative or reconstructive surgery include operative site infection and damage to the bowel, bladder, and ureters.

How About the Prognosis?

Outcomes following surgical repair of enterocele are generally positive, with many patients experiencing resolution or significant improvement in symptoms such as vaginal pressure, discomfort, or bowel dysfunction. However, as with any surgical procedure, there are risks and potential complications, including recurrence of enterocele, infection, and urinary issues. Overall, the prognosis for enterocele is favorable with appropriate medical care and intervention.

Conclusion:

Massive vaginal eversion is extremely unlikely to reverse over time. It might present with acute symptoms that require immediate surgical intervention. Long-term advanced-stage prolapse is more likely to cause consequences such as ulceration, vaginal epithelial hemorrhage, and discomfort. Early diagnosis and treatment usually have good outcomes.