An enterocele is a protrusion of the small intestines and peritoneum into the vaginal canal. It may be treated transvaginally or by laparoscopy. An enterocele may also obstruct the rectum, leading to symptoms of obstructed defecation.[rx] Enteroceles can form after treatment for gynecological cancers.[rx]
An enterocele is a pelvic hernia formed from the separation of endopelvic fascia, associated with the posterior or anterior vaginal fornix, and most commonly located in the posterior superior vaginal segment. Rectal prolapse is a debilitating condition in which the mucosa of the rectum protrudes circumferentially from the anus. Surgical repair is the recommended treatment for rectal prolapse, and though there are many different surgical options, there is no consensus on which approach is best. We present a case of anterior rectal prolapse due to enterocele which was treated by correction of enterocele with a vaginal approach and propose some clinical features and diagnostic techniques that may distinguish this entity from traditional rectal prolapse.
Causes of Enterocele
When the support system which holds pelvic organs in place become distressed, stretched, or torn, it allows pelvic organs to shift into new positions, thus causing a prolapse. Damage to these support systems can be caused by a number of different factors such as:
- Childbirth – Vaginal delivery causes stress on pelvic organs and support structures. Risk increases with number and size of children delivered vaginally.
- Surgery, such as a hysterectomy, or radiation treatment in the pelvic area.
- Menopause – A woman’s ovaries stop producing hormones that regulate her monthly cycle. The hormone estrogen, which helps keep pelvic muscles strong, is in lower supply.
- Extreme physical activity or lifting of heavy objects.
- Being overweight
- Chronic constipation
- Chronic cough (as seen in smokers or asthmatics)
- Genetic or hereditary factors – One person’s pelvic support system may be naturally weaker than another’s.
This shows the bladder which has herniated, or “dropped” into the vagina.
Factors that increase your risk of developing small bowel prolapse include:
- Pregnancy and childbirth – Vaginal delivery of one or more children contributes to the weakening of your pelvic floor support structures, increasing your risk of prolapse. The more pregnancies you have, the greater your risk of developing any type of pelvic organ prolapse. Women who have only cesarean deliveries are less likely to develop prolapse.
- Age – Small bowel prolapse and other types of pelvic organ prolapse occur more often with increasing age. As you get older, you tend to lose muscle mass and muscle strength — in your pelvic muscles as well as other muscles.
- Pelvic surgery – Removal of your uterus (hysterectomy) or surgical procedures to treat incontinence may increase your risk of developing small bowel prolapse.
- Increased abdominal pressure – Being overweight increases pressure inside your abdomen, which increases your risk of developing small bowel prolapse. Other factors that increase pressure include ongoing (chronic) cough and straining during bowel movements.
- Smoking – Smoking is associated with developing prolapse because smokers frequently cough, increasing abdominal pressure.
- Race – For unknown reasons, Hispanic and white women are at higher risk of developing pelvic organ prolapse.
- Connective tissue disorders – You may be genetically prone to prolapse due to weaker connective tissues in your pelvic area, making you naturally more susceptible to small bowel prolapse and other types of pelvic organ prolapse.
Symptoms of Enterocele
In many cases a woman will feel no symptoms from prolapse and will find out about it only during an normal pelvic exam.
In cases where symptoms do occur, the following are most common:
- A feeling of fullness, heaviness or pain in the pelvic area. Often this feeling gets worse as the day goes on or gets worse after standing, lifting or coughing.
- Lower back pain.
- Bulging in the vagina.
- Leakage of urine.
- Frequent bladder infections.
- Problems with sexual intercourse.
- Problems inserting tampons.
- A feeling of pelvic fullness, pressure or pain. The discomfort is often worse at the end of the day or with heavy lifting.
- Low back pain that improves when lying down
- A soft bulge of tissue in the vagina that increases in size with standing or with activity, and decreases in size when lying down.
- Vaginal discomfort and painful intercourse (dyspareunia)
Diagnosis of Enterocele
Often a physical exam is all that is needed to diagnose prolapse. If additional information is needed, a number of tests may be done that measure how well each of the pelvic organs is working.
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
Diagnosis of anterior prolapse may involve
- 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
Treatment of Enterocele
- Hysterectomy – Surgical removal of the uterus in cases of severe uterine prolapse.
- Uterine suspension – Putting the uterus back in its normal position, either by connecting support tissue to the lower part of the uterus, or by using a mesh material that forms a sling to hold it in place.
- Kegel exercises – Tightening and relaxing the muscles used to control the flow of urine in order to strengthen the muscles that support the pelvic organs.
- Taking the hormone estrogen – Helps prevent further weakening of pelvic support muscles but has a number of possible negative side effects.
- Vaginal pessary – A removable rubber or plastic device inserted into the vagina to provide support in the area of the prolapse. Pessaries are most often used when the patient wants to avoid surgery or has medical problems that make surgery too risky.
A surgeon can perform surgery to repair the prolapse through the vagina or abdomen, with or without robotic assistance. During the procedure, your surgeon moves the prolapsed small bowel back into place and tightens the connective tissue of your pelvic floor. Sometimes, small portions of synthetic mesh may be used to help support weakened tissues.
You may be able to lower your chances of small bowel prolapse with these strategies:
- Maintain a healthy weight. If you’re overweight, losing some weight can decrease the pressure inside your abdomen.
- Prevent constipation. Eat high-fiber foods, drink plenty of fluids and exercise regularly to help prevent having to strain during bowel movements.
- Treat a chronic cough. Constant coughing increases abdominal pressure. See your doctor to ask about treatment if you have an ongoing (chronic) cough.
- Quit smoking. Smoking contributes to chronic coughing.
- Avoid heavy lifting. Lifting heavy objects increases abdominal pressure.
Pelvic organ prolapse is strongly linked to labor and vaginal delivery. So you may want to delay surgical repair of a rectocele or enterocele until you have finished having children.
Surgical repair may relieve some, but not all, of the problems caused by a rectocele or enterocele.
- If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may still occur after surgery.
- Symptoms of constipation may return following surgery.
- The success rate is lower if you have had previous pelvic surgery or radiation therapy to the pelvis.
You can control many of the activities that contributed to your rectocele or enterocele or made it worse. After surgery:
- Avoid smoking.
- Stay at a healthy weight for your height.
- Avoid constipation.
- Avoid activities that put strain on the lower pelvic muscles, such as heavy lifting or long periods of standing.