Cul-de-sac hernia

Last updated
cul-de-sac hernia
Other namesperitoneocele (when contains only peritoneum), omentocele (when contains omental fat), [1] enterocele (when contains small bowel), [2] sigmoidocele (when contains sigmoid colon). [2]
Specialty Colorectal surgery, Gynecology

A cul-de-sac hernia (also termed a peritoneocele) is a herniation of peritoneal folds into the rectovaginal septum (in females), [2] or the rectovesical septum (in males). The herniated structure is the recto-uterine pouch (pouch of Douglas) in females, [2] or the rectovesical pouch in males. The hernia descends below the proximal (upper) third of the vagina in females, [2] or, according to another definition, below the pubococcygeal line (PCL). [3] [note 1]

Contents

According to a consensus statement by the USA, Australia and the UK, [note 2] a cul-de-sac hernia / peritoneocele is defined as "a protrusion of the peritoneum between the rectum and vagina that does not contain any abdominal viscera" (organs). [4] An enterocele is defined as "a protrusion of the peritoneum between the rectum and vagina containing the small intestine." [4] A sigmoidocele is defined as "a protrusion of the peritoneum between the rectum and vagina that contains the sigmoid colon." [4] An omentocele is defined as "a protrusion of the omentum between the rectum and the vagina." [4] As such, peritoneocele, enterocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia. [3] [4]

Anatomy

This hernia is so named because it is a herniation of the recto-uterine pouch (pouch of Douglas), which is also sometimes called the "cul-de-sac". This is the pocket formed by the reflection of the peritoneum from the rectum and the posterior wall of the uterus. The equivalent structure in males is the rectovesical pouch, which is the pocket formed by the reflections of the peritoneum from the rectum to the male bladder. In terms of pelvic organ prolapse, a cul-de-sac hernia is located in the posterior compartment of the pelvis. [5]

A true cul-de-sac hernia contains only omental fat, and often intraperitoneal liquid. [6] If the hernia contains omentum, sometimes the term "omentocele" is used. [7] If the cul-de-sac hernia contains loops of small bowel, the term enterocele is used. [2] If it contains sigmoid colon, the term sigmoidocele is used. [2] It has been suggested that the terms enterocele and sigmoidocele are inaccurate, since hernias are usually named according to location and not according to contents. [8] However, the terms are in widespread use. [8] As such, peritoneocele, enterocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia. [3] [4]

Classification

Cul-de-sac hernias may be classified as rectal, septal, or vaginal depending on the structure they herniate into. Rectal cul-de-sac hernias herniate into an internal or external rectal prolapse. Septal cul-de-sac hernias herniate into the recto-vaginal septum (rectovesical septum in males). Vaginal cul-de-sac hernias bulge into the vagina itself. Combinations of these types are also possible. [6]

Severity of the hernia may be classed as first degree if it is above the pubococcygeal line, second degree if it is below the pubococcygeal line but above the ischiococcygeal line, [note 3] or third degree if it is below the ischiococcygeal line. [9] Severity may also be graded according the distance between the pubococcygeal line and the lowest point of the sac as follows: small (less than 3 cm), moderate (3–6 cm) or large (more than 6 cm). [9]

Cul-de-sac hernias may also be classified as primary and secondary. Primary cul-de-sac hernias are associated with factors such as multiparity, old age, lack of elasticity, obesity, constipation, and increased abdominal pressure are present. [8] Secondary cul-de-sac hernias are those which develop after gynecologic procedures, especially after vaginal hysterectomy. [8]

Another classification of cul-de-sac hernias is internal, meaning those that are only visible on defecography, or external, which are associated with a clinically visible rectocele or rectal prolapse. [4]

Signs and symptoms

Symptoms are variable, and depend on the exact location and severity of the hernia. [10] Possible symptoms include:

Diagnosis

Cul-de-sac hernias are the most difficult to diagnose during physical examination, and to distinguish from anterior rectocele or enterocele. [2] Furthermore, rectocele and cul-de-sac hernia may occur together. [3] Combined vaginal and rectal digital palpation may be used (examiner's thumb in vagina, index finger in anal canal). [11] The peritoneal sac containing omentum may be palpable between the thumb and index finger. [11] The prolapse may be detectable at the upper posterior vaginal wall during Valsalva's maneuver. [11]

Imaging which may be used to detect cul-de-sac hernia includes standard defecography, magnetic resonance defecography and dynamic transperineal ultrasound. [5] Cul-de-sac hernias usually only appear on such imagining at the end of the simulated defecation, and require complete or near complete evacuation of the rectum before they are visible. [3] This feature may distinguish cul-de-sac hernia from rectocele. [1] However, a large rectocele that retains contrast medium may hide a cul-de-sac hernia. [3] Cul-de-sac hernia (peritoneocele / omentocele) may appear on fluoroscopic defecography as an un-opacified mass which deforms the anterior border of the rectum and the posterior border of the vagina, with widening of the recto-vaginal space in between. [1] On magnetic resonance defecography, the vagina and rectum may appear clearly "splayed" apart. [1]

Causes

Risk factors include prior hysterectomy and urethropexy because of the damage caused to the rectovaginal fascia. [2] Hysterectomy also increases the size of the pouch of Douglas. [1]

Notes

  1. ↑ The "pubococcygeal line" (PCL) is a reference line which may be drawn on defecography. It extends from the inferior (lower) border of the pubic symphysis to the last coccygeal joint. See Bordeianou et al. 2018.
  2. ↑ Consensus statement by the American Society of Colon and Rectal Surgeons (ASCRS), the Colorectal Surgical Society of Australia, and the Association of Coloproctology of Great Britain and Ireland. First published in 2001, revised statement in 2018. See Bordeianou et al. 2018.
  3. ↑ The "ischiococcygeal line" is a reference line which may be drawn on defecography. It extends from the inferior (lower) border of the ischium to the last coccygeal joint. See Bordeianou et al. 2018.

Related Research Articles

In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place", from the Latin prolabi meaning "to fall out".

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

<span class="mw-page-title-main">Rectal prolapse</span> Protrusion of the walls of the rectum outside the body

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

<span class="mw-page-title-main">Pelvic floor dysfunction</span> Medical condition

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma.

<span class="mw-page-title-main">Rectouterine pouch</span> Human female anatomical structure

The rectouterine pouch is the extension of the peritoneum into the space between the posterior wall of the uterus and the rectum in the human female.

<span class="mw-page-title-main">Cystocele</span> Protrusion of the bladder into the vagina

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Pelvic organ prolapse</span> Descent of the pelvic organs from their normal positions

Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.

<span class="mw-page-title-main">Pelvic examination</span> Physical medical examination

A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma. It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the vulva 2) the internal exam with palpation to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

<span class="mw-page-title-main">Defecography</span> Visualisation of the mechanics of a patients defecation

Defecography is a type of medical radiological imaging in which the mechanics of a patient's defecation are visualized in real time using a fluoroscope. The anatomy and function of the anorectum and pelvic floor can be dynamically studied at various stages during defecation.

An enterocele is a herniation of a peritoneum-lined sac containing small intestine through the pelvic floor, between the rectum and the vagina. Enterocele is significantly more common in females, especially after hysterectomy.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

Sigmoidocele is a medical condition in which a herniation of peritoneum containing loops of redundant sigmoid colon descends (prolapses) into the rectouterine pouch, between the rectum and the vagina. This can obstruct the rectum and cause obstructed defecation syndrome.

Genitoplasty is plastic surgery to the genitals. Genitoplasties may be reconstructive to repair injuries, and damage arising from cancer treatment, or congenital disorders, endocrine conditions, or they may be cosmetic.

<span class="mw-page-title-main">Vaginal support structures</span> Structures that maintain the position of the vagina within the pelvic cavity

The vaginal support structures are those muscles, bones, ligaments, tendons, membranes and fascia, of the pelvic floor that maintain the position of the vagina within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to pelvic organ prolapse. Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to incontinence and urinary retention.

Vaginal rugae are structures of the vagina that are transverse ridges formed out of the supporting tissues and vaginal epithelium in females. Some conditions can cause the disappearance of vaginal rugae and are usually associated with childbirth and prolapse of pelvic structures. The rugae contribute to the resiliency and elasticity of the vagina and its ability to distend and return to its previous state. These structures not only allow expansions and an increase in surface area of the vaginal epithelium, they provide the space necessary for the vaginal microbiota. The shape and structure of the rugae are supported and maintained by the lamina propria of the vagina and the anterior and posterior rugae.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

Ventral rectopexy is a surgical procedure for external rectal prolapse, internal rectal prolapse, and sometimes other conditions such as rectocele, obstructed defecation syndrome, or solitary rectal ulcer syndrome. The rectum is fixed into the desired position, usually using a biological or synthetic mesh which is attached to the sacral promontory. The effect of the procedure is correction of the abnormal descended position of the posterior compartment of the pelvis, reinforcement of the anterior (front) surface of the rectum, and elevation of the pelvic floor. In females, the rectal-vaginal septum is reinforced, and there is the opportunity to simultaneously correct any prolapse of the middle compartment. In such cases, ventral rectopexy may be combined with sacrocolpopexy. The surgery is usually performed laparoscopically.

References

  1. 1 2 3 4 5 Grajo, JR; Sahani, DV; Samir, AE (11 March 2021). Abdominal Imaging: The Core Requisites. Elsevier Health Sciences. p. 316. ISBN   978-0-323-68062-2.
  2. 1 2 3 4 5 6 7 8 9 Kanmaniraja, D; Arif-Tiwari, H; Palmer, SL; Kamath, A; Lewis, SC; Flusberg, M; Kobi, M; Lockhart, ME; Chernyak, V (April 2021). "MR defecography review". Abdominal Radiology (New York). 46 (4): 1334–1350. doi:10.1007/s00261-019-02228-4. PMID   31544226.
  3. 1 2 3 4 5 6 7 8 Azadi, A; Cornella, JL; Dwyer, PL; Lane, FL (1 September 2022). Ostergard's Textbook of Urogynecology: Female Pelvic Medicine & Reconstructive Surgery. Lippincott Williams & Wilkins. pp. 212, 213. ISBN   978-1-9751-6235-1.
  4. 1 2 3 4 5 6 7 Bordeianou LG, Carmichael JC, Paquette IM, Wexner S, Hull TL, Bernstein M, et al. (April 2018). "Consensus Statement of Definitions for Anorectal Physiology Testing and Pelvic Floor Terminology (Revised)" (PDF). Diseases of the Colon and Rectum. 61 (4): 421–427. doi:10.1097/DCR.0000000000001070. PMID   29521821.
  5. 1 2 Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB (20 November 2021). The ASCRS Textbook of Colon and Rectal Surgery (4th ed.). Cham, Switzerland: Springer Nature. pp. 990, 991. ISBN   978-3-030-66049-9.
  6. 1 2 Bremmer, S; Mellgren, A; Holmström, B; Udén, R (March 1998). "Peritoneocele and enterocele. Formation and transformation during rectal evacuation as studied by means of defaeco-peritoneography". Acta Radiologica. 39 (2): 167–75. doi:10.1080/02841859809172172. PMID   9529448.
  7. ↑ Parkman, H, ed. (8 September 2020). Modern Approaches for Evaluation and Treatment of GI Motility Disorders, An Issue of Gastroenterology Clinics of North America, E-Book: Modern Approaches for Evaluation and Treatment of GI Motility Disorders, An Issue of Gastroenterology Clinics of North America, E-Book. Elsevier Health Sciences. p. 265. ISBN   978-0-323-71300-9.
  8. 1 2 3 4 5 Wexner, SD; Stollman, N, eds. (2016). Diseases of the Colon. CRC Press. pp. 124, 125. ISBN   9780429163791.
  9. 1 2 Oliveira, LCC (11 August 2020). Anorectal Physiology: A Clinical and Surgical Perspective. Springer Nature. pp. 60, 61. ISBN   978-3-030-43811-1.
  10. 1 2 3 4 Srisajjakul, S; Prapaisilp, P; Bangchokdee, S (November 2020). "Diagnostic clues, pitfalls, and imaging characteristics of '-celes' that arise in abdominal and pelvic structures". Abdominal Radiology (New York). 45 (11): 3638–3652. doi:10.1007/s00261-020-02546-y. ISSN   2366-0058. PMID   32356005.
  11. 1 2 3 Wexner, SD; Duthie, GS, eds. (2010). Constipation: Etiology, Evaluation and Management (2nd. ed.). Springer London. pp. 40, 41. ISBN   978-1-84996-901-7.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.