Enterocele

Enterocele is herniation of the small bowel (with peritoneum) through the rectovaginal pouch (pouch of Douglas) into the vagina, or rarely the rectovaginal septum.

• It most commonly follows hysterectomy (vault enterocele), but also occurs after prolapse repair, Burch colposuspension, childbirth, chronic straining and postmenopausal weakening of pelvic support.
• It frequently coexists with rectocele, cystocele and uterine or vault prolapse.
• Deeper pouch of Douglas increases risk; ascites and obesity add pressure.

Pelvic heaviness, dragging sensation, lower backache relieved on lying down, vaginal bulge, dyspareunia, incomplete defecation and sometimes bowel obstruction symptoms.

• Examination: bulge at the upper posterior vaginal wall or vault, bimanual rectovaginal examination feels bowel between the examining fingers (small bowel impulse on cough); distinguish from a rectocele by the high position.
• Differential diagnosis: high rectocele, vault prolapse, sigmoidocele, vaginal vault mass, ovarian cyst, cystocele.
• Complications: incarceration, strangulation, small bowel obstruction, vaginal erosion or ulceration, evisceration (rare), and recurrent prolapse.

Pelvic examination in lithotomy and standing positions with Valsalva.

• Dynamic MRI or evacuation proctography with oral contrast (small bowel opacified) shows loops descending between the vagina and rectum.
• Pelvic ultrasound or CT when obstruction or a pelvic mass is suspected.
• Rectal examination and colonoscopy if alarm features.

Supportive: avoid heavy lifting and straining, weight loss, fibre 25 to 30 g daily, pelvic floor exercises.

Pharmacological

• Macrogol 17 g daily to soften stool.
• Vaginal oestrogen: oestradiol 10 microgram tablet daily for 2 weeks then twice weekly for atrophy.
• Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily).

Procedures

• Pessary (ring or space-filling) for mild to moderate disease or unfit patients.
• Surgery for symptomatic enterocele: obliteration of the cul-de-sac with purse-string sutures, closure of the neck of the sac, repair of the rectovaginal fascia, and vaginal vault suspension (uterosacral ligament suspension or sacrocolpopexy, abdominal or laparoscopic); sacrospinous fixation is an alternative.
• Repair of coexisting rectocele and cystocele at the same operation.
• Emergency laparotomy for incarcerated or strangulated bowel.

Special groups: women with obesity or chronic cough (address first), older women with comorbidities (pessary), those planning pregnancy (defer surgery).

Red flags: acute pain with vomiting and obstipation (incarceration), vaginal bleeding from ulceration, bulge that cannot be reduced.

Follow-up: review at 6 weeks and 6 months after surgery; prevent recurrence with weight control and cough or constipation treatment.