Enterocele and Massive Vaginal Eversion Workup

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

Approach Considerations

Generally, the workup for massive vaginal eversion is based on the history and physical examination. Laboratory and imaging studies, procedures, and consultation with other specialties may be necessary at times, and they are discussed below. 

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Laboratory Studies

A urinalysis is routinely performed to rule out infection and/or hematuria depending on the patient's symptoms when she initially presents for consultation. Culture is done as needed based on the urinalysis results and the patient's symptoms.

In the case of massive vaginal eversion, blood urea nitrogen (BUN) and creatinine levels may be elevated because of obstruction and therefore may need to be evaluated.

A standard preoperative laboratory evaluation should be performed to screen for anemia, metabolic abnormalities, and clotting problems depending on the patient's age and medical history. Surgical procedures for the repair of massive prolapse frequently involve elderly patients, and the operations are often prolonged, involving the Trendelenburg position with the legs elevated in stirrups. It is important to pay special attention to the effects on patients with cardiac or pulmonary conditions, and appropriate tests such as an electrocardiogram (ECG), complete blood cell (CBC) count, and clotting studies are warranted.

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Imaging Studies

Imaging studies to consider for the workup of enterocele and massive vaginal eversion, but in our experience seldom used are the following:

  • Intravenous pyelogram (IVP)
  • Renal ultrasound scan
  • Computed tomography (CT) urogram

Intravenous pyelogram (IVP) for cases of severe prolapse to rule out hydronephrosis has been traditionally performed. A renal ultrasound scan is the least invasive modality to rule out significant hydronephrosis. A CT urogram can be obtained if further evaluation of the upper urinary tract and bladder is needed.·  

Controversy exists regarding the utility of other imaging studies. These may include dynamic cystoproctography, magnetic resonance imaging (MRI), 3D and 4D transperineal ultrasound, and even peritoneography (ie, the injection of radiographic dye into the peritoneal cavity). [37] These studies may be reserved for difficult and inconclusive cases, especially for the diagnosis of enterocele and sigmoidocele but are not routinely necessary.

In cases of massive vaginal eversion, MRI or ultrasound may be used to determine which organ (bladder, small or large bowel) lies behind the prolapsed vagina. In patients with lower stage prolapse, these studies may be used to evaluate the levator muscles, to predict recurrence risk after pelvic reconstructive surgery, or for research purposes. [38]

If intra-abdominal pathology is suspected, a CT scan of the abdomen and pelvis may be ordered to evaluate for ascites or a mass.

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Diagnostic Procedures

Although controversial, multichannel urodynamic studies with prolapse reduction may be used to further evaluate the preoperative patient with significant prolapse. [39]  In the case of massive vaginal eversion, the urethra may be kinked by the prolapse, obstructing urinary incontinence, and prolapse reduction with a cough stress test (CST) should be performed in the office during the initial examination.

Studies often include initial uroflowmetry (with the prolapse not reduced) followed by insertion of a pessary or other methods to reduce the prolapse (speculum, Procto Swabs, etc), performance of complex cystometry, and a pressure-voiding study with or without electromyography (EMG). Although uroflowmetry is ideal, measuring the patient's voided volume and a subsequent postvoid residual by ultrasound or catheterization should suffice for the vast majority of cases. Postvoid residual volumes of less than 50-100 mL are considered normal range, if the patient voids at least 200 mL. [40]

With the prolapse reduced and pessary placement checked so it is not obstructing the urethra, complex cystometry with provocative maneuvers can be used to assess for occult stress incontinence.

When initial uroflowmetry is combined with a pressure-voiding study, information regarding the potential for postoperative obstructed voiding is obtained and may influence the choice of procedures.

Simple cystometry may also be performed in the office if multichannel urodynamics are not available.

Several diagnostic procedures are available for the assessment of accidental bowel leakage, which often coexists with prolapse and urinary incontinence and is beyond the scope of this article.

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