Enterocele

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Enterocele
Other namesEnterocoele, posterior direct vaginal hernia, [1] posterior peritoneal vaginal hernia, [1] hernia of the cul-de-sac of Douglas. [1]
Specialty Gynecology, Colorectal surgery

An enterocele is a herniation of a peritoneum-lined sac containing small intestine through the pelvic floor, between the rectum and the vagina (in females). [2] [3] [1] Enterocele is significantly more common in females, [4] especially after hysterectomy. [5]

Contents

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. [6] However, the terms are in widespread use. [6] As such, enterocele, peritoneocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia. [7] [3]

Classification

Anterior enterocele is rare. [2] It may occur after cystectomy or hysterectomy. [2] In these cases, the anterior wall of the vagina is weakened or missing due to loss of support from the bladder. [2]

On defecography, enterocele is defined as the presence of small bowel between the rectum and the vagina. [3] The hernia must reach lower than the upper third of the vagina when the patient is attempting to defecate. [3]

The severity of enterocele can be described with reference to lines drawn on defecography:

Another way of classifying the severity of an enterocele (or peritoneocele, omentocele, sigmoidoceles) is according to the distance between the pubococcygeal line and the most inferior (lowest) point of the hernia:

Enteroceles may be obstructive or nonobstructive:

Signs and symptoms

Often enterocele appears in combination with other detectable defects of the pelvic floor. Therefore it is difficult to state what symptoms are specific to enterocele, [1] which may not cause any symptoms at all. [8] Possible symptoms include:

Diagnosis

It may be possible to detect an enterocele during physical examination. [1] However, enteroceles are difficult to detect by physical examination alone. [4] An enterocele may also be distinguishable from a high rectocele using the following palpation technique. The doctor places his index finger in the rectum, and the thumb (or index finger of the other hand) in the vagina, while the patient is standing and / or straining. [1] [4] If an enterocele is present, the hernia sac will come down into the rectovaginal space, between the rectum and the vagina, when the patient strains. [1]

Imagining is usually needed to accurately detect an enterocele since physical examination is unreliable. [1] Standard defecography does not show the small intestine or the peritoneal lining of the hernia sac of an enterocele, therefore it is not useful to detect an enterocele. [1] Oral contrast is usually given in order to opacify the small intestine. [4] Opacification of the vagina on defecography suggests that the vagina has been displaced. Upwards displacement may represent an enterocele. [4] On defecography enterocele is more evident after defecation, once the rectum / bladder are empty and more space becomes available in the pelvic cavity. [5]

Simultaneous dynamic proctography and peritoneography (injection of contrast into peritoneum) is effective at detection of enteroceles. However, it is difficult to inject contrast agent into the peritoneal cavity and there is a risk of contamination of the peritoneum. [1] Dynamic pelvic magnetic resonance imaging is accurate and can detect enterocele, but it is not widely available. [1] Dynamic transperineal ultrasound has also been used to detect enterocele. [12]

Causes

Several factors are thought to be involved in the development of enterocele, such as age, [10] multiple pregnancies, [10] previous pelvic surgery, [4] excessive pelvic floor descent, [10] weakened pelvic floor, [13] long term chronic straining, [13] Enteroceles can form after treatment for gynecological cancers. [14] Hysterectomy or urethropexy increase the rectovaginal space and reduce support from adjacent organs. [5] This is thought to promote the development of an enterocele. [5]

Different pelvic floor defects may co-exist with enterocele. About 40% of patients with rectal prolapse or rectal intussusception also have enterocele. [4] In some cases an enterocele may prolapse externally along with an external rectal prolapse. [11] It is not clear in such situations if the enterocele caused or aggravated the rectal prolapse, or if the pouch of Douglas is merely pulled down by the rectal prolapse. It is thought that enterocele may initiate or aggravate a rectal intussusception (internal rectal prolapse). The hernia may descend into and impinge upon the rectal wall. [5] Enterocele or sigmoidocele may be associated with descending perineum syndrome. [11]

The enterocele can remain confined in the space between the rectum and the vagina. [5] An enterocele may co-exist with a rectocele. [5] During defecation, the enterocele may occupy a posterior colpocele before the rectocele or after it empties. [5] An enterocele may also co-exist with a cystocele. [5] In such cases, the enterocele will be visible only after emptying of the cystocele. [5]

Treatment

It has been recommended that initial treatment should be conservative or medical (non-surgical). [1] Surgical treatment may be considered if the hernia is substantial and is suspected to be the cause of obstructed defecation. [12]

Surgical options usually involve obliteration of the deep pouch of Douglas. [1] Surgical approach may be vaginal or transanal. According to a Cochrane review, the vaginal approach has a lower rate of recurrence of enterocele compared to transanal approach. [15] Posterior colporrhaphy is one surgical option for enterocele. [4] Surgical repair of enterocele may not improve constipation. [10] Laparoscopic ventral mesh rectopexy has successfully been used to treat enterocele. [11] [16] This may be a combined procedure (sacrocolpopexy), [12] if there is also prolapse of the middle compartment.

Epidemiology

The frequency in the general population is unknown. [4] Enterocele is significantly more common in females compared to males. [4] In a review of 912 patients who underwent defecography because of defecatory or other pelvic symptoms, 104 patients (11%) had detectable enterocele. 18 of those were male. [1] According to one report, enterocele develops after hysterectomy in 64% of cases, and after cistopexy in 27% of cases. [5]

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. ↑ 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

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

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.

<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">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">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.

Solitary rectal ulcer syndrome or SRUS is a chronic disorder of the rectal mucosa. It commonly occurs with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation. Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.

<span class="mw-page-title-main">Anismus</span> Failure to relax the pelvic floor muscles during defecation

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

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.

Descending perineum syndrome refers to a condition where the perineum "balloons" several centimeters below the bony outlet of the pelvis during strain, although this descent may happen without straining. The syndrome was first described in 1966 by Parks et al.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

<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.

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.

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

References

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  9. ↑ Zbar, Andrew P., ed. (2010). Coloproctology. Springer Specialist Surgery Series. Dordrecht Heidelberg: Springer. ISBN   978-1-84882-755-4.
  10. 1 2 3 4 5 6 Tsunoda, A; Takahashi, T; Kusanagi, H (2022). "Reappraising the Role of Enterocele in the Obstructed Defecation Syndrome: Is Radiological Impaired Rectal Emptying Significant in Enterocele?". Journal of the Anus, Rectum and Colon. 6 (2): 113–120. doi:10.23922/jarc.2021-064. PMC   9045857 . PMID   35572488.
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  13. 1 2 Marzouk, D. "Obstructed Defaecation Web".
  14. ↑ Ramaseshan, Aparna S.; Felton, Jessica; Roque, Dana; Rao, Gautam; Shipper, Andrea G.; Sanses, Tatiana V. D. (2017-09-19). "Pelvic floor disorders in women with gynecologic malignancies: a systematic review". International Urogynecology Journal. 29 (4): 459–476. doi:10.1007/s00192-017-3467-4. ISSN   0937-3462. PMC   7329191 . PMID   28929201.
  15. ↑ Mowat, A; Maher, D; Baessler, K; Christmann-Schmid, C; Haya, N; Maher, C (5 March 2018). "Surgery for women with posterior compartment prolapse". The Cochrane Database of Systematic Reviews. 2018 (3): CD012975. doi:10.1002/14651858.CD012975. PMC   6494287 . PMID   29502352.
  16. ↑ Ris, F; Gorissen, KJ; Ragg, J; Gosselink, MP; Buchs, NC; Hompes, R; Cunningham, C; Jones, O; Slater, A; Lindsey, I (August 2017). "Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception". Techniques in Coloproctology. 21 (8): 627–632. doi:10.1007/s10151-017-1643-7. PMID   28674947.
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