| Vaginal evisceration | |
|---|---|
 Vaginal bowel evisceration with bright red blood oozing. | |
| Specialty | emergency medicine |
Vaginal evisceration is an evisceration of the small intestine that occurs through the vagina, typically subsequent to vaginal hysterectomy, and following sexual intercourse after the surgery. It is a surgical emergency. [1]
Vaginal evisceration is typically obvious upon presentation, as intestine (typically ileum) can be seen protruding from the introitus. Other symptoms include a sense of pressure in the pelvis and vaginal bleeding. [1]
Complications of surgery can include injury to the bladder, rectum, or ureter, especially in cases where there has been tissue necrosis. Surgeons typically perform intraoperative cystoscopy with dye to assess potential bladder or ureter injuries. [1]
Vaginal evisceration is a serious complication of dehiscence (where a surgical wound reopens after the procedure), which can be due to trauma. [1] 63% of reported cases of vaginal evisceration follow a vaginal hysterectomy (where the uterus removal surgery is performed entirely through the vaginal canal). [2] Most instances of vaginal evisceration following a laparoscopic hysterectomy result from sexual intercourse among women approaching menopause, and from the combination of heightened pressure within the abdomen and weakened vaginal muscles among those who have experienced menopause. [3] [4] Other risk factors include regular Valsalva maneuver, advanced age, obesity, smoking, immunosuppressive therapy, vaginoplasty, anemia, poor surgical technique, malnutrition, and postoperative/perioperative infection. [5] [6] One case has been reported as of 2015 where placement of a pessary caused an evisceration. [5] [7]
Dehiscence is more common in laparoscopic hysterectomy than in open hysterectomy. [8]
When performing a vaginal hysterectomy, surgeons should aim to avoid damaging surrounding tissue or drying the vaginal cuff. Surgeons should take extra care to align the tissues, and include sufficient undamaged tissue. Instead of single-layer figure-of-eight sutures, two-layer sutures can aid in preventing vaginal evisceration. [3]
Emergently, vaginal eviscerations are treated by keeping the exposed intestines moist and wrapped, while waiting for definitive surgical treatment. [1] Vaginal evisceration is usually treated by removing damaged tissue along the edges of the vaginal cuff, re-suturing the opening, and giving the patient broad-spectrum antibiotic prophylaxis. [3]
Surgery can be conducted via a laparotomy, though research from the 2010s shows that a transvaginal or laparoscopic approach can also be used safely and successfully if an infection has not developed. If left untreated, it can cause peritonitis or injury to the exposed bowel, including strangulation or mesenteric tears. Cellulitis, abscesses, hematomas, and other complications can appear at the same time as an evisceration. Abscesses and hematomas can be resolved after surgery with a surgical drain. [1]
Post-surgical treatment includes continuation of antibiotics and, in some postmenopausal people, vaginal estrogen to speed recovery. After surgery, people with vaginal evisceration are advised to avoid intercourse until the surgical site is fully healed. [1]
Though it is a rare complication, as the popularity of laparoscopic hysterectomy has risen, the rate of vaginal evisceration has also risen. Vaginal cuff dehiscence occurs in 0.24–0.39% of cases; of these, vaginal evisceration occurs in 35%–67%. [1] When all surgical procedures are considered, the rate of vaginal evisceration is 0.032–1.2%. [2]
The first report of vaginal evisceration in the medical literature was published in 1864 by Belgian obstetrician Léon Hyernaux; it occurred secondary to traumatic rupture of the vagina during an unsuccessful attempt at forceps delivery. The patient, a 42-year-old woman, survived and made a complete recovery. [6] [9]
Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.
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".
Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.
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.
Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.
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.
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.
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.
Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF).
Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.
Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.
Camran Nezhat, FACOG, FACS is an American laparoscopic surgeon, reproductive endocrinology and infertility sub-specialist who has been teaching and practicing medicine and surgery as an adjunct clinical professor of surgery, and obstetrics and gynecology at Stanford University Medical Center in Palo Alto, California since 1993. Nezhat is also chair of the Association of the Adjunct Clinical Faculty, Stanford University School of Medicine, and a clinical professor of OB/GYN at the University of California, San Francisco.
In gynecologic oncology, trachelectomy, also called cervicectomy, is a surgical removal of the uterine cervix. As the uterine body is preserved, this type of surgery is a fertility preserving surgical alternative to a radical hysterectomy and applicable in selected younger women with early cervical cancer.
Wound dehiscence is a surgical complication in which a wound ruptures along a surgical incision. Risk factors include age, collagen disorder such as Ehlers–Danlos syndrome, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.
The vaginal cuff is the upper portion of the vagina that opens up into the peritoneum and is sutured shut after the removal of the cervix and uterus during a hysterectomy.
An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.
A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pregnancy – it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage.
A lymphocele is a collection of lymphatic fluid within the body not bordered by epithelial lining. It is usually a surgical complication seen after extensive pelvic surgery and is most commonly found in the retroperitoneal space. Spontaneous development is rare.
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.
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.
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