Enterocele and Massive Vaginal Eversion Clinical Presentation

Updated: Apr 05, 2021
  • Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD  more...
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Presentation

History

A detailed history is required to evaluate the patient who presents with massive vaginal eversion. See Overview/Practice Essentials for a description of the symptoms with which a patient typically presents.

The duration of symptoms of the prolapse, with any information regarding functional problems that may be caused by the prolapse, should be ascertained. Ask patients about prior treatments they have attempted for the prolapse (conservative or surgical). Patients should be questioned about their urinary, bowel, and sexual function symptoms. This includes evaluation of urinary incontinence, storage and voiding dysfunction symptoms, accidental bowel leakage (previously known as fecal incontinence), and defecation dysfunction symptoms, as well as difficulties with sexual intercourse. The patient’s desire for future sexual activity should also be brought up, as this may guide future treatment or concomitant procedures. A detailed medical and surgical history should be obtained with a focus on prior pelvic surgeries and any significant gynecologic pathology. 

Essential to the preoperative evaluation and surgical decision-making is the review of any prior pelvic surgery, including obtaining operative reports, especially if surgery was performed for prior pelvic floor dysfunction. It is imperative to evaluate and stabilize the patient’s general health to assess for and mitigate any increased surgical risks. The patient's general medical comorbidities may be important in the decision of how to proceed with treatment options.

Validated standardized questionnaires should be used to assess the degree of bother from the prolapse as well as urinary, bowel, and sexual function and symptoms. While an in-depth discussion of the questionnaires is beyond the scope of this article, they are a useful adjunct to a history obtained in the office and are helpful for gauging pre- and post-treatment success as well as for research purposes.

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Physical Examination

A commitment to treat all associated and relevant pelvic floor defects requires a careful and comprehensive urogynecologic examination.

A diligent search for all pelvic support defects and repair of these defects increases the likelihood of overall surgical success and patient satisfaction. The apical, anterior, and posterior compartments are evaluated separately, with and without straining and/or coughing in the supine position and again in the erect position if needed.

It is our preference to examine patients with a full bladder upon arrival to test for stress urinary incontinence with and without the prolapse reduced. The patient is then asked to void and the postvoid residual urine volume is measured either by straight catheterization or ultrasound (bladder scan). An abdominal examination should be performed because intra-abdominal masses or ascites may be a risk factor for or exacerbate existing pelvic organ prolapse (POP). [36] A comprehensive pelvic examination is then performed.

A standardized examination should be performed and documented. This examination begins on the outside of the vagina by examining the vulva, introitus, perineum, anal opening, urethral meatus, and any exteriorized prolapse. The prolapse should then be reduced and a careful speculum and bimanual examination performed. The authors prefer to use a half speculum to examine the anterior and posterior vaginal walls individually. The vaginal canal should be examined for evidence of prior surgical procedures such as scarring, suture or mesh exposure, and tenderness.

In cases of massive vaginal eversion, it may be difficult to reduce the prolapse. Use of lubricant or having the patient lie supine for a period of time before the examination may help with reduction. If it is not possible to reduce the prolapse in the office, an examination under anesthesia may be necessary. 

The pelvic organ prolapse quantification system (POP-Q) examination is helpful for quantifying the extent of prolapse and accurate follow-up (see Overview/Problem for more detail). Carefully evaluate the rectovaginal and pubocervical fascia for integrity, strength, and thickness along its entire length. Look for any signs of enterocele, such as bowel peristalsis, along the posterior vagina or near the apex. In addition, look for any obvious pubocervical/rectovaginal detachments at the periphery of an apical bulge as well as localized loss of rugations. Evaluate the cul-de-sac in the supine and standing positions, with and without Valsalva maneuvers. The levator muscles should be palpated for any tenderness and Kegel strength measured. A rectal examination should be performed to evaluate for any rectal masses, sphincter tone, and the presence of rectovaginal fistula defects. 

A neurologic examination to assess sacral dermatomes and reflexes is often performed.

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