Enterocele / Rectocele

Definition

Enterocele is a hernia of the intestine through the vagina. Rectocele is a hernia of the rectum through the vagina.

Causes and Risk Factors

Stretching, weakening, and tearing of the fascia (a fibrous membrane) and muscles of the female pelvic floor are often caused by the trauma from the descent of the baby's head through the pelvic diaphragm.

Additionally, the loss of estrogen (due to age), vaginal deliveries (perhaps breech extractions, forceps rotations), strenuous work and inadequate episiotomy (surgical incision of the vulva) can lead to these problems. Multiple births, large pelvic tumors, marked obesity, ascites (accumulation of serous fluid in the peritoneal cavity), and lifelong chronic constipation (rectocele-related only) are other elements that may produce weakening of the musculofascial (muscle and membrane) supports. This leads to the formation of rectocele and enterocele.

Symptoms

Rectocele and enterocele may produce no symptoms or may produce the following symptoms:

• bulging vaginal mass

• vaginal pressure and fullness

• constipation or difficult bowel movements (rectocele only).

Diagnosis

Diagnosis is made by a pelvic and a rectovaginal exam. The bulges (hernias) are felt by the doctor when the woman holds her breath and "bears down" during the pelvic examination. During the rectovaginal examination the woman is asked to stand and squat slightly while straining.

Treatment

With complete eversion of the vagina by the enterocele, ulcerations, edema, and fibrosis of the vaginal walls may occur to such a degree that the prolapsing mass cannot be reduced.

Rest in bed (with the foot of the bed elevated) and wet packs applied to the vagina will reduce edema and allow replacement of the vagina, and vaginal packing can be used to maintain reduction until local conditions permit operative correction (surgery).

Enterocele repair may be accomplished transabdominally or transvaginally.

Inasmuch as symptomatic enterocele almost always is associated with other forms of musculofascial weakness (rectocele, cystocele, uterine prolapse), a transvaginal operation provides the best route of repair and offers the greatest likelihood of permanent correction of the enterocele.

Operative correction by any means, whether by the vaginal or the abdominal route, should restore the vaginal axis to normal. In general, enterocele repair is performed as part of a comprehensive vaginal or abdominal repair of the pelvic floor relaxation (as with rectocele and cystocele).

Many people with large enteroceles are elderly; others are grossly obese. While the person's general health is being improved, the prolapsing vaginal hernia can be reduced with a pessary if it can be retained. Occasionally, packing the reduced vagina with cotton tampons or gauze impregnated with medicaments is more effective than using a pessary.

If immediate operative correction is not essential, a rigorous program of weight reduction for several months may be extremely beneficial for the very obese patient and may increase her chance of eventually obtaining a successful repair.

If the woman is postmenopausal, with mild to moderate symptoms, the doctor may suggest estrogen therapy. Estrogen hormone vaginal cream or oral hormone treatment may help restore a more normal, resilient vaginal and urethral lining as well as improve bladder control.

Simple exercises, called Kegel exercises, are also suggested to strengthened the muscular supports for the vagina and urethra, improve bladder control and experience effective penile stimulation during intercourse. "Kegels" involve contracting the muscle of the urethra, vagina and rectum for a set period of time and then relaxing them.

A vaginal pessary is another non-operative alternative. A pessary is a firm latex device, something like a contraceptive diaphragm without the rubber dome, placed inside the vagina to provide additional support to the bladder and uterus.

If bladder or bowel problems are severe and the non-operative treatments do not alleviate the symptoms, the doctor will recommend a vaginal hysterectomy (removal of the uterus and cervix through an incision inside the vagina) with posterior colporrhaphy (suturing of the vagina).

Prevention

With better obstetric care, better use of episiotomies to prevent tearing of the pelvic muscles, immediate repair of all tears, and the trend toward fewer pregnancies and births per woman, fewer women should require vaginal wall repairs late in life.

Neglected, obstructed labor and traumatic delivery, which weaken uterovaginal supports, should be avoided. Perineal exercises practiced after delivery help to prevent relaxation. Factors that increase intrabdominal pressure (obesity, chronic cough, straining, ascites, large pelvic tumors) should be corrected promptly.

Questions to Ask Your Doctor

Is surgery recommended? If so, which method will be used?

Is any medical treatment required before surgery?

Will a general or spinal anesthesia be used?

What is the procedure of the surgery?

What can be expected after the surgery?

What complications may occur after the surgery?

Will any medications be prescribed? What are the side effects?

What are the chances this may reoccur?