Pelvic Prolapse: Diagnosing and Treating Cystoceles, Rectoceles, and Enteroceles

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Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Diagnosing and Treating an Enterocele

An enterocele is essentially a vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space between the posterior surface of the vagina and the anterior surface of the rectum (Fig. 8). Table I shows a commonly used system for grading each site of pelvic relaxation. After a hysterectomy has been performed, an enterocele occasionally may be found anteriorly between the posterior wall of the bladder and the anterior wall of the vagina.

Figure 8. Diagram of enterocele.

Enteroceles have been placed into 4 categories based on the mechanism of acquisition: congenital, iatrogenic, traction, and pulsion.[32] Congenital enteroceles are extremely rare and occur when incomplete fusion of the rectovaginal septum leaves an open cul-de-sac. Iatrogenic enteroceles typically occur following procedures that alter the vaginal axis, such as those used for the treatment of stress urinary incontinence (for example, a Burch procedure or a needle bladder-neck suspension). The probable mechanism of an iatrogenic enterocele is an anterior and vertical rotation of the vaginal axis that allows the normally closed cul-de-sac to open and become unprotected. The incidence of iatrogenic enterocele may be as high as 26% after incontinence procedures. Many studies, however, give no indication of whether a previously performed hysterectomy may have given rise to a small enterocele that was subsequently exacerbated by the anterior rotation of the vaginal axis.[33] Iatrogenic enterocele can also be a complication of a prior hysterectomy in which there has been inadequate obliteration of the cul-de-sac. The incidence of enterocele requiring treatment after vaginal hysterectomy in a prospective modern series has not been reported; however, in a prospective 1958 series, Hawksworth and Roux[34] reported a 6.3% incidence at 1 year.

Traction enteroceles are relatively common and are usually found in conjunction with uterine prolapse, cystocele, and rectocele. The preferred treatment is vaginal hysterectomy with concurrent repair of the enterocele, cystocele, and rectocele. Lastly, a pulsion enterocele can occur secondary to conditions that cause chronically raised intra-abdominal pressure, such as chronic cough or severe physical exertion. These enteroceles can be severe enough to require vaginal vault suspension.

Enterocele Diagnosis

Enteroceles are not usually symptomatic until they become so large that they descend to the hymenal level. A pulling sensation or lower back pain aggravated by prolonged standing may also occur and may be due to traction on an ovary, Fallopian tube, or small-bowel mesentery within the enterocele. Pulling sensation or lower back pain that improves when the patient lies down suggests prolapse as the source of pain.

If the symptoms are atypical or out of proportion to the size of the enterocele, a pessary can be inserted to ascertain whether the patient's complaints are truly related to the prolapse itself. If a pessary is placed and the pain remits or significantly diminishes, it can be assumed that the pain is secondary to prolapse and that surgery would indeed correct the problem. A pessary can also be inserted in a patient who desires conservative therapy. Periodic vaginal examinations should be performed to document the progression of the prolapse, and surgical treatment can be instituted when symptoms justify it. In the older patient there is little reason to treat a small and minimally symptomatic enterocele on the notion that it might progress, since the iatrogenic complications of dyspareunia, stress incontinence, or damage to local structures may occur.

Certain objective findings, however, indicate when surgery is the best choice. One such finding is intractable vaginal mucosal ulcerations. Suspicious mucosal ulcers should be biopsied for possible carcinoma. Although these ulcers can be treated with topical estrogens, relief is rarely complete. Another serious condition that mandates therapy is ureteral obstruction due to severe prolapse. The diagnosis can usually be made with either an upright intravenous pyelogram (IVP) or renal ultrasound. In these cases, renal function may be lost if repair is not performed expeditiously.

Ureteral stenting is a reasonable temporary procedure until the prolapse can be repaired. Surgical intervention is also called for when urethral obstruction or persistent, large postvoid residuals, in the presence of a coexisting cystocele, result in recurrent urinary tract infections. A rare but serious concern in an elderly patient with a very large enterocele and atrophic tissues is evisceration.[35] Lastly, note that extreme age is not an absolute contraindication to surgery. At any age, surgery is indicated if the condition is lifestyle-altering and cannot be managed conservatively.

To diagnose an enterocele, the anterior vaginal wall should be elevated with the lower blade of a Graves speculum to expose the vaginal apex and posterior vaginal wall. An enterocele is usually seen as a vaginal bulge near the apex of the vagina, which then protrudes distally, whereas a rectocele is typically an isolated protrusion just proximal to the perineal body. If, upon examining the patient in the lithotomy position, it is unclear whether an enterocele exists, have the patient stand with one leg on a short stool and repeat the physical exam. Place one finger in the rectum and another finger in the vagina, and palpate for a thickening or widening of the rectovaginal septum as the patient bears down maximally.

Enterocele Management

Nonoperative therapy is usually reserved for patients with minimal symptoms, patients desiring additional children in the near future, or patients who would be high-risk surgical candidates. The most important nonsurgical option for treating enteroceles is use of one of the various available pessaries. Treatment with a pessary requires knowledge of a variety of pessaries and persistent trials until the right one is found. After the correct pessary is identified, the patient must be taught to remove, clean, and reinsert it, on a regular basis. Many patients in this group also have a large urogenital hiatus, and the pessary may not remain in place. A perineorrhaphy and distal rectocele repair can be performed with minimal anesthesia requirements and may allow the pessary to stay in place.[36]

Conversely, in some women, the introitus is so small that the patient has difficulty placing and removing a pessary. In our experience, many elderly patients are not proficient at inserting and maintaining a pessary and, therefore, their satisfaction with this treatment is poor. Additionally, long-term complications such as erosions into the vaginal mucosa or adjacent structures can occur if the pessary is too large, placed inappropriately, or not removed for long periods of time. Definitive surgical procedures with lower morbidity and minimal anesthesia requirements, such a colpocleisis, can also be performed in appropriate patients, ie, those who no longer desire sexual intercourse.[36]

The goals of an enterocele repair are the same as for any hernia procedure: reduction of the hernia sac and closure of the defect. A large number of enteroceles occur after hysterectomy, typically when obliteration of the cul-de-sac and vaginal reapproximation of the supporting structures were not performed. A good vaginal suspension and cul-de-sac obliteration are prophylactic and should prevent the later occurrence of an enterocele.

Once an enterocele has been identified, the 4 principles of enterocele repair, as enumerated by Nichols and Randall,[37] are to (1) identify the enterocele and probable etiology by careful preoperative evaluation; (2) mobilize or obliterate the enterocele sac; (3) occlude the sac with suture ligation as high as possible; and (4) close the hernia defect by providing support below the hernia sac and restore the normal vaginal axis.

Repair of an enterocele via an abdominal approach is rarely necessary unless performed with other abdominal procedures. When necessary, however, such as during an abdominal hysterectomy or sacrocolpopexy, the cul-de-sac can be closed in 1 of 2 ways. A Halban approach involves placing permanent sutures in a continuous sagittal fashion just beneath the peritoneum, starting at the posterior wall of the vagina, proceeding to the cul-de-sac, and then continuing to the anterior wall of the rectum (Fig. 9). It is essentially a vertical purse-string closure. The lateral sutures should be approximately 1cm medial to the ureters, to minimize angulation. A Halban approach is often preferred because the course of the ureters is affected minimally.

Figure 9. Sagittal view of Halban (vertical purse-string) enterocele repair. This type of cul-de-sac closure prevents enterocele formation with minimal effect on ureters.

Alternatively, a Moschcowitz repair can be used to obliterate the cul-de-sac by placing multiple horizontal purse-string sutures beginning distally (deep in the cul-de-sac) and proceeding proximally. Care must be taken to avoid obstructing the ureters (by pulling them medially) or entering the rectum. To add strength to the closure, the remnants of the uterosacral ligaments should be sewn together in the midline, if they can be identified. When an enterocele coexists with a cystocele, rectocele, or vault prolapse, the enterocele is usually repaired first.

To repair an enterocele vaginally, the vaginal mucosa overlying the enterocele is opened and the enterocele sac is gently dissected free. The dissection is usually slow and tedious, especially at the site of the vaginal cuff. Once sufficiently free, the sac can be carefully opened and the small -bowel contents can be replaced in the abdomen. The opened enterocele sac is closed using permanent suture material to make 2 sequential purse-string sutures. The redundant sac is resected.

Unfortunately, we have seen redundant bladder, small bowel, and rectum all misidentified as "the sac" and subsequently opened. In many cases, we are able to dissect the sac completely off the vaginal mucosa without opening it. The hernia sac can then be safely reduced into the abdomen, and the hernia defect can be closed by placing 2 purse-string sutures, one above the other, incorporating the uterosacral remnants, superficial bladder wall, and rectum together below the sac (Fig. 10). Superficial bites must be taken to ensure that the sutures do not enter the lumen of the bladder or rectum. If good purchase into the uterosacral ligaments is obtained, these sutures can be used to help support the vaginal cuff if desired. Cystoscopy should be performed after intravenous administration of indigo carmine to ensure ureteral patency.

Figure 10. Transvaginal treatment of enterocele. Peritoneal sac is ligated and resected with fascial defect closed below it.

Lastly, excess vaginal mucosa is trimmed and closure is performed with an absorbable 2-0 suture. It is important not to foreshorten the vagina; otherwise, dyspareunia may occur. Note that an enterocele repair will not correct vaginal vault prolapse. This requires one of the procedures designed specifically for that purpose.

Although enterocele repair is commonly performed, few long-term studies of the procedure exist. Raz and associates[38] reported an 82% cure rate in 49 patients who underwent simple enterocele repair and a 96% cure rate n 25 patients with concurrent vault prolapse, with a mean 15-month follow-up. Symmonds and colleagues[39] reported an 89% cure rate in 160 patients using a similar technique. Phaneuf[40] reported a 90% cure rate in 91 patients in a 1953 study. Overall, the enterocele recurrence rate appears to be approximately 10% in most series.

Major surgical complications are uncommon and consist of ureteral injury (1.4%), bladder injury (1.4%), bowel incarceration (1.4%), and lastly, the very rare postoperative complications of small-bowel or rectal injury (0%) and evisceration (0%).[38] Symptomatic complications such as dyspareunia can occur due to vaginal foreshortening or inadequate vaginal caliber.

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