Prolapsed Enterocele – Causes, Symptoms, Treatment

Prolapsed Enterocele Small bowel prolapse, also called enterocele (EN-tur-o-seel), occurs when the small intestine (small bowel) descends into the lower pelvic cavity and pushes at the top part of the vagina, creating a bulge. The word “prolapse” means to slip or fall out of place.

An enterocele prolapse occurs when the small bowel (also known as the small intestine) drops down sufficiently enough against the upper wall of the vagina to create a bulge in the vagina. It can slip further, between the rectum and vagina, resulting in discomfort along the back posterior wall of the vagina and causing issues with bowel movements.

The muscles and ligaments that support your small bowel, and other organs within the pelvis, are part of the framework of muscles called the pelvic floor muscles. These muscles can become weak or stretched and therefore become unable to hold everything in the pelvis where it should be. This can result in the small bowel dropping out of its normal position and down into the gap between the muscular walls of the rectum and the vagina.

An enterocele prolapse can be disruptive, embarrassing, and inconvenient, but it is treatable.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of recurrence. To avoid unnecessary delays and speak to your doctor if you have any concerns.

Causes of a Prolapsed Enterocele

There are a few lifestyles and medical reasons why you might experience an enterocele prolapse. All of which contribute to a weakened pelvic floor:

• Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot, or forceps were used, may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse.
• Tissue damage due to surgery – Having surgery to any area within the pelvis can weaken those all-important pelvic floor muscles.
• Previous or current prolapses – A rectocele prolapse, a prolapse of the rectum into the vaginal space, can also cause a prolapse of the small bowel.
• Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
• Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Bodyweight – Being overweight or obese can increase your chances of suffering a rectal prolapse due to the weight on your pelvic area.
• Age – The older you get, the more likely a small bowel prolapse becomes, as you tend to lose muscle mass.
• Genetics – If you have a family history of small bowel prolapse, then this may put you at a distinct disadvantage. As can having a condition that results in weakened muscles.

Symptoms of Prolapsed Enterocele

During the early stages of a prolapsed small bowel, you may not experience any symptoms at all. As it progresses, you may begin to feel more of the symptoms below, especially when having a bowel movement. Once an enterocele prolapse becomes significant, you’re more likely to experience more pronounced symptoms, more regularly and with more intensity:

• a pulling sensation in the pelvic area that eases when you lie down
• lower back pain that eases when you lie down
• a feeling of pressure in the pelvic area
• a feeling of fullness in the pelvic area
• pain in the pelvic area
• a dragging down sensation in the pelvic area
• abnormal vaginal discharge
• vaginal bleeding that isn’t associated with your period
• a soft bulge of tissue in your vagina
• vaginal pain and discomfort
• pain or an uncomfortable feeling when having sex
• difficulty passing a stool
• a feeling of incomplete emptying of the bowel when you’ve been to the toilet

You can also feel for yourself if you think you have a small bowel prolapse. Lay in a warm bath and gently place your thumb in your vagina and your ring finger in your rectum. By doing this, you would feel a cylindrical loop of bowel between your thumb and ring finger (i.e. between your vaginal and rectal walls) if you have an enterocele prolapse. If you feel only smooth layers of tissue and no bumps or bulges, you don’t have an enterocele prolapse. If you do, it’s best to speak to your doctor to assess the severity of it.

Diagnosis of Prolapsed Enterocele

Medical history

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history
• over-the-counter and prescription medicines
• bowel habits

History

Rectoceles have a broad range of symptoms. Some patients may present as asymptomatic while others may demonstrate a significant impact on the quality of life, including the following symptoms[rx]:

• Pelvic pain/pressure
• Posterior vaginal bulge
• Obstructive defecation
• Incomplete defecation
• Constipation
• Dyspareunia
• Erosions and bleeding of mucosa if there is tissue exposure to the outside environment

Physical Exam

A thorough examination will include a vaginal exam, rectal exam, abdominal exam, and focused neurological exam.

The focused neurological exam consists of levator ani muscle tone and contraction strength.

The vaginal exam can be evaluated using the Baden-Walker or POP-Q exam. The Baden-Walker system utilizes one measurement. The distance of the most distal portion of the prolapse from the hymen while the patient is completing the Valsalva maneuver.[rx]

Evaluation

• A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
• Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
• Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
• Urodynamics – Measures the bladder’s ability to hold and release urine.
• Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone
• A special test – that can be done to confirm a rectocele is defecography. The patient will have a contrast medium instilled in the vagina, bladder, and rectum. Using a special commode, the patient will be instructed to defecate while the X-ray is taken. This test can be useful to determine the size of the rectocele, larger than 2 cm is considered abnormal.[rx]
• Urodynamic studies – can be helpful in patients with rectocele and complex voiding issues. If a patient is receiving surgery, it may be useful to determine if the patient has urinary incontinence with the prolapse reduced. If there is incontinence with reduction with prolapse, it may be helpful to include a procedure to prevent urinary incontinence in the plan.[rx]
• Pelvic floor strength test – During the pelvic examination, the doctor tests the strength of the pelvic floor, the sphincter muscles, and muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. Irregularities in this test can help diagnose vaginal prolapse and determine if kegel exercises would be helpful to the patient.
• Bladder function test – Otherwise known as urodynamics, bladder function tests determine the ability of the bladder to store and eliminate urine. This is measured in two ways. Uroflowmetry measures the volume and force of the urine stream. Cystometrogram is a procedure that fills the bladder with water via a catheter. Measurements of the volume are noted when the patient indicates the urgency of urination.

Another useful diagnostic tool for surgical planning is dynamic MRI (DMRI) which provides visualization of the rectocele and movements of the pelvic floor.[rx] DMRI is a valuable adjunct test when a patient’s symptoms are more significant than the physical examination findings suggest. Its use for preoperative planning has made it more widespread.[rx]

Treatments of Prolapsed Enterocele

Sometimes, the only treatment you’ll need for a mild to moderate enterocele prolapse is regular pelvic floor exercises and some lifestyle changes. Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as there is a risk of further damage in the case of complications. Non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures:

• Kegel exercises – Performing daily pelvic floor exercises could be all you need to keep your urethrocele prolapse under control. Using an electronic pelvic toner such as the Kegel8 Ultra 20 Pelvic Toner will make them more beneficial.
• Avoid constipation – Eating a healthy diet, rich in fiber, and ensuring you drink plenty of water will help to keep your bowels regular. High fiber foods include fruit, vegetables, and wholegrain cereals. Regular, gentle exercise will also help to keep things moving as they should.
• Avoid straining – Straining on the toilet when trying to empty your bowels will put unnecessary pressure on your pelvic floor area. Causing the pelvic floor muscles to weaken and eventually allow a rectal prolapse. Going to the toilet using a toilet stool will bring your knees up and force you into the ideal posture for fully eliminating your bowels. For children, using a potty-training toilet can offer this support.
• Keep to a healthy weight – The National Institute for Health and Care Excellence (NICE) recommend keeping your BMI under 30.
• Treat chronic diarrhea – If you have a persistent stomach bug and/or you’re constantly passing loose stools, seek medical help to resolve the problem.
• Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week.
• Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
• Avoid straining on the toilet – Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
• Lifestyle changes – Maintain a healthy weight and avoid constipation, heavy lifting, and prolonged coughing.
• Wearing a vaginal pessary – A vaginal pessary will support a pelvic organ prolapse. It’s a small, usually silicone, device that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary every four to six months. This is commonly the favored treatment for those unable to undergo surgery due to medical conditions or those wishing to have children in the future.

In the circumstance of non-surgical treatments not fully relieving your symptoms and they remain severe, you may be advised to have a surgical intervention for your enterocele prolapse. However, as enterocele prolapse is a long term condition that requires long term treatment, you will be advised to undergo lifestyle changes and daily Kegel exercises to compliment any successes following surgery.

Several surgical procedures are currently available and may be completed in conjunction to repair all prolapses you are experiencing:

• Surgical enterocele prolapse repair – If your enterocele prolapse is causing severe discomfort, then you can opt for a 30-60 minute vault fixation surgery. Your surgeon will move the small bowel back into place and then tighten the muscles that support the small bowel using surgical stitches and occasionally biological or synthetic mesh. Using a synthetic mesh lining as additional support is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient. Your surgeon will repair your prolapse either via the vagina or the abdomen, depending on your circumstances. The benefit of completing the surgery through the vagina is no scarring, the negative however is the risk of further complications due to possible nerve damage in the vaginal opening. It is important to note that surgery is unable to repair the pelvic floor muscles. You will need to perform pelvic floor exercises after your recovery to prevent the prolapse from returning and to support any synthetic or biological mesh from stretching which could lead to a prolapse recurrence.

How Long Does it Take to Recover from Enterocele Prolapse Surgery?

Following an enterocele repair surgery, a catheter and vaginal packing soaked with estrogen cream will be inserted and not removed until your appointment the following day. After the catheter is removed, you may notice some difference in your urine flow as a result of swelling. You would normally expect to be up and about as normal within four to six weeks. During this time showers are recommended, over baths, as the stitches are still present. Throughout the six week recovery, you will also likely experience bleeding and a creamy white discharge, which you can use pads (not tampons) to manage. You may be recommended to avoid driving, and some insurance companies may not even cover you during the first-fortnight post-operation.

After six weeks, you should be able to have sex, but should refrain from heavy lifting or completing any strenuous exercise for three months post-op. After the six weeks, most women can go about their daily business, and comfortably resume having sex. If, during the surgery, another prolapse was located or damage was done to the surrounding organs, the procedure may have been extended to incorporate these further repairs. This could result in a slightly longer recovery time.

There are a number of other complications that you may also experience during the surgery. These include damage to the bladder or bowel, excessive bleeding, deep vein thrombosis (blood clot in the leg), and pulmonary embolism (blood clot in the lungs). The risk of these occurring will be discussed with you before your operation, and if any do occur, they can affect your recovery time. If you are at risk of blood clots following the surgery, you will be advised to begin gentle exercise as early as possible. You may also be prescribed blood-thinning medication.

20% of patients experience bright red bleeding from the vagina following a prolapse surgery involving mesh, this suggests the mesh is coming through into the vagina as you move. If this happens you need to treat it as an emergency and the exposed mesh will be removed during a second operation.

If you do opt for surgery, it is important to note that surgery cannot repair your pelvic floor muscles. You will need to perform pelvic floor exercises after you recover from your surgery, to prevent the prolapse from recurring and to support any synthetic or biological mesh from stretching. There is a 30% chance of developing a future prolapse following a vaginal surgery, due to the damage to the vaginal tissue. Other non-surgical treatments should also be followed to prevent future prolapses; such as eating well to avoid constipation and maintaining a healthy weight.

It is important to note that no operation can be guaranteed to cure your prolapse, and some women may experience a reoccurring prolapse, among other symptoms, in the future.

In some cases, the repair of vaginal prolapse can uncover other related underlying conditions such as damage to the bladder or bowel. Your doctor will discuss whether these require further treatment following your recovery.

References

People Also Reading

Enterocele – Causes, Symptoms, Diagnosis, Treatment Enterocele Prolapse – Causes, Symptoms, Treatment Prolapsed Uterine Bladder – Causes, Symptoms, Treatment Prolapsed Urethrocele – Causes, Symptoms, Treatment Prolapsed Rectal – Causes, Symptoms, Treatment Prolapsed Rectocele – Causes, Symptoms, Treatment Prolapsed Cystocele – Causes, Symptoms, Treatment Sigmoidocele – Causes, Symptoms, Treatment Pouch of Douglas Descent – Symptoms, Treatment Prolapse After Childbirth – What To Know, How To Do Uterine Prolapse at a Young Age Bladder Prolapse – Causes, Symptoms, Treatment