Does the Way Hysterectomy Is Performed Make a Difference? How to Prevent Prolapse at the Time of Hysterectomy
Victor Gomel, Bruno van Herendael in Female Genital Prolapse and Urinary Incontinence, 2007
An enterocele is defined as a herniation of bowel into the vagina; as a result the pelvic peritoneum gets into direct contact with the vaginal epithelium without any intervening fascia. Richardson divided enteroceles into three types: anterior, apical and posterior based on location of break in the fascia. An anterior enterocele occurs when the pubocervical fascia breaks from the cervix or vaginal cuff, and is common in patients with previous sacrospinous ligament suspensions since the vaginal apex is pulled posteriorly. An apical enterocele occurs when the pubocervical fascia is separated from the rectovaginal fascia, and is most common in post hysterectomy patients whose pubocervical and rectovaginal fascias are not reapproximated. A posterior enterocele occurs when the rectovaginal fascia detaches from the posterior cervix or vaginal cuff (6).
Urogynecologic Pelvic Floor Dysfunction
Laurence R. Sands, Dana R. Sands in Ambulatory Colorectal Surgery, 2008
An enterocele is formed when the intestine protrudes through a defect in the rectovaginal or vesicovaginal pouch and an enterocystocele is a double hernia in which both the bladder and the intestines protrude. Enterocele repair may be performed by abdominal, laparoscopic, and vaginal approach, although there are little data to support the superiority of one approach over another. Traditional enterocele repair involves identification of the enterocele sac and its contents, dissection of the sac, closure with multiple circumferential permanent purse-string sutures with incorporation of the cardinal–uterosacral ligaments or their remnants, and excision of the excess sac. At the time of hysterectomy, enterocele repair may be performed in conjunction with a McCall culdeplasty and high uterosacral vault suspension. An enterocele may also be encountered at the apex of the dissection of the posterior vaginal wall during rectocele repair. This defect most likely results from transverse avulsion of the rectovaginal fascia from its cervical or vault attachment. Repair of this defect can be performed by reattachment of the superior edge of the fascia to the posterior aspect of the cervix or vault in the midline and laterally at the level of the uterosacral ligaments using permanent sutures.
Rectal Prolapse and Associated Pelvic Organ Prolapse Syndromes
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
An enterocele is a vaginal bulge 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. A sigmoidocele describes the same phenomenon except the main content of the sac is colon. These are also covered briefly in the Gynaecology for the Colorectal Surgeon section (Chapter 1).
Presentation of two cases with uterine prolapse occuring in pregnancy
Published in Journal of Obstetrics and Gynaecology, 2020
Erkan Elci, Gulhan Elci, Sena Sayan
The 38-year-old patient, applied to our clinic for the first time during her 18th week of gestation, had second degree uterine prolapse (POP-Q-II) with four vaginal deliveries. The patient had no prolapse before pregnancy. The patient did not come to any subsequent follow-up. The patient was admitted to our clinic under emergency conditions due to her active vaginal bleeding in 34 weeks of gestation. On the examination, there was no cervical dilatation. Advanced cystocele and strangulated enterocele were observed. According to POP-Q, third degree uterine prolapse was observed (Figure 1(a,b)). The patient who had active vaginal bleeding had an emergency caesarean section. Uterine bicornis was detected during the caesarean section (Figure 1(c)). Uterine prolapse, cystocele and enterocele were partially regressed postoperatively.
Pelvic floor dysfunction in midlife women
Published in Climacteric, 2019
Prolapse presents with mechanical symptoms (pelvic heaviness, introital bulging, vaginal pain, and possibly low back pain). Prolapse can create relative mechanical obstruction, requiring manual prolapse reduction (splinting) or at least perineal pressure to achieve bladder or bowel emptying. It can additionally cause difficulty with coital penetration and/or dyspareunia. Findings on examination include laxity or descent of the anterior vaginal compartment (commonly referred to as cystocele), posterior compartment (rectocele/enterocele), and/or apical compartment (uterine/vault prolapse). Prolapse is in general diagnosed clinically when descent of the vaginal walls is identified on pelvic examination, ideally using a standardized and validated method such as the Pelvic Organ Prolapse Quantification system (POP-Q)23. Importantly, however, the diagnosis should not rest alone on examination, as most women are not significantly bothered by prolapse until its leading edge presents 1.0 cm beyond the hymen24.
Investigation of pelvic floor disorders
Published in Climacteric, 2019
Pelvic floor ultrasound can also be used to evaluate descent of the vaginal walls, the uterus, the small bowel, and the rectum. For women with anterior vaginal prolapse, ultrasound may distinguish between a true cystocele from other conditions such as urethral diverticulum, Gartner duct cyst, and anterior enterocele24. For those women with cystocele, ultrasound may distinguish between those who have cystourethrocele (Green type II cystocele) and those with an intact retrovesical angle (Green type III cystocele)37. The first is associated with good urine flow rates and USI, while the latter is associated with voiding dysfunction and a low likelihood of SUI38. Ultrasound can be particularly useful for women with posterior vaginal wall prolapse. In these cases, ultrasound may distinguish a true ‘rectocele’ due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum. Rectal intussusception, a condition that is found in approximately 4% of patients in a urogyneoclogy clinic, is strongly associated with symptoms of obstructed defecation39. The preoperative diagnosis of this condition is important for planning the optimal surgical technique. Finally, on translabial ultrasound, a descent of the bladder of 10 mm and of the rectum or uterus >15 mm below the symphysis pubis at maximum Valsalva manoeuvre are strongly associated with POP symptoms and are proposed as cut-off values for the ultrasonic diagnosis of significant prolapse40,41.
Related Knowledge Centers
- Laparoscopy
- Peritoneum
- Small Intestine
- Vagina
- Obstructed Defecation
- Dolichodouglas