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ENTEROCELE
An enterocele is one of several pelvic organ support problems. Each year many women endure pelvic organ support problems (pelvic organ prolapse), and many undergo surgical procedures for correction of these problems. These disorders usually are the result of trauma to the pelvic connective tissue and muscles, and often are the result of childbirth. The surgical procedures used to correct these defects are considered elective since women are at no medical risk with these problems.
Q. What is an enterocele?
A. An enterocele is a downward displacement or herniation of the small bowel into the vagina. This pelvic organ defect often occurs in conjunction with other pelvic organ defects including cystocele (a downward displacement of the bladder), rectocele (a downward displacement of the rectum), and uterine prolapse (a downward displacement of the uterus and cervix toward the vaginal opening). An enterocele occurs when the small intestine bulges into the upper vagina.
An enterocele often occurs in women who have already undergone hysterectomy. Often women have a sensation of a vaginal bulge. The signs and symptoms are often difficult to differentiate from a rectocele. Some women are totally without symptoms.
Q. Who is most likely to get an enterocele?
A. Pelvic organ prolapse results from pelvic floor trauma that often is the result of childbirth. As a result of this trauma, pelvic support tissues are damaged. An enterocele usually develops after a hysterectomy, when the small bowel herniates into the vagina due to lack of normal support. As a woman ages, pelvic support problems may be worsened by loss of tissue integrity from loss of the female hormone estrogen. Other causes of loss of pelvic support include excess intraabdominal pressure over a prolonged period of time such as heavy lifting, excessive coughing such as in long-term smokers, or chronic constipation and straining with bowel movements.
Diagnosis of an Enterocele
The diagnosis of an enterocele is made by a clinical exam from your physician. A woman usually presents to her physician with a vaginal bulge or other associated symptoms of pelvic prolapse. To make an accurate diagnosis, your doctor will get your complete medical history and will then perform a pelvic exam. Your doctor may examine you in both the lying and standing positions. This will help differentiate an enterocele from a rectocele which requires a different surgical correction.
Treatments of an Enterocele
Your physician may recommend a variety of treatments for your enterocele ranging from just watching the problem to see if it worsens, to basic lifestyle changes, to exercises that strengthen pelvic floor muscles, to surgery.
Many women with enteroceles display no symptoms. If you have no discomfort from the vaginal bulge, it is reasonable to monitor your enterocele with no further treatment. An enterocele has no associated medical problems that must be addressed. It should only be treated surgically if you are having problems.
One nonsurgical treatment for pelvic prolapse, including an enterocele, involves performing Kegel's exercises. These exercises are used to strengthen the pelvic floor muscles. To perform these exercises a woman squeezes the pubococcygeus muscle, which is done by squeezing the muscles around the vagina (as if your were trying to stop your urine in mid-stream). These muscles are contracted for 10 seconds, and then relaxed for 10 seconds. This repetitive activity is done in sets of 10 to 20 about 3 to 5 times a day. Maximum results are obtained in 3 to 6 months.
Due to the increased deterioration of the integrity of the pelvic tissues as you age, your physician may ask you to start a regimen of estrogen if you are postmenopausal. Estrogen replacement therapy has many potential benefits for postmenopausal women including a decrease in heart disease and osteoporosis (thinning of the bones), as well as an improvement in pelvic support. Estrogen replacement therapy may be prescribed in many different forms, including pills or a transdermal patch. If you have not had a hysterectomy, progesterone therapy will be necessary to prevent endometrial hyperplasia (a precursor to endometrial cancer). Your physician can discuss the risks and benefits of hormone replacement therapy with you further.
Your physician may suggest a pessary for support of the vaginal vault and relief of your enterocele. A pessary is a rubber device that is inserted into the vagina. It is fitted to provide support to the vaginal walls. Your physician will teach you how to insert and remove your pessary. You will need to remove and clean your pessary on a regular basis.
Finally, your physician may suggest surgery as an option for correction of enterocele. This procedure is performed from a vaginal approach. Often, this procedure is done in conjunction with either a rectocele repair or cystocele repair or both. During this procedure the posterior wall of the vagina is opened and the peritoneal sac that houses the small bowel is identified. The excess peritoneal tissue is removed and the small bowel is returned to its intraabdominal site. The tissue below the small bowel (the perineal body) is then reinforced with suture. This surgery often requires you to remain in the hospital from 1 to 3 days depending on the extensiveness of the other surgical repairs.
Recovery from an enterocele repair is usually complete is approximately 4 to 6 weeks. Most patients feel well enough to return to work by 2 weeks.
Prevention of an Enterocele
Enteroceles commonly result from lack of good pelvic support after hysterectomy. Deterioration of tissue with aging may worsen an enterocele. At this point there is no recommendation for prevention of an enterocele except avoidance of prolonged increases in intraabdominal pressure, such as excessive coughing or straining.
Indu S. Anand, MD
Dr. Anand is a former Assistant Professor in the Department of Obstetrics and Gynecology at the University of Tennessee Health Science Center, in Memphis, Tennessee. She now is in private practice in Atlanta, GA.
Date Published: 2000-09-21
7800 Wolf Trail Cove, Germantown, TN 38138
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