Prolapse of the small intestine into the vagina is called an enterocele. When the upper part of the vagina loses its normal support, the small bowel can bulge into or push into it creating an enterocele. It is a type of hernia of the small bowel into the vagina (‘entero’ meaning related to the intestine and ‘cele’ meaning a hernia). Enterocele is often seen with a rectocele (prolapse of the rectum into the vagina).

Enterocele occurs sometimes in patients who have had a hysterectomy. In such cases, the top (vault) of the vagina has lost its support causing it to invert like an inside-out stocking. This is called as vault prolapse. However it may also occur in a woman who has an intact uterus.

What are the symptoms?

A small enterocele may not cause any symptoms. A larger one may however cause

  • Difficulty in bowel evacuation.
  • Feeling of pelvic heaviness or pain
  • A dragging sensation or low backache which may be relieved by lying down
  • A feeling of bulge in the vagina

How is it diagnosed?

A thorough pelvic examination may be all that you need for diagnosis of enterocele. The doctor may perform the examination in the lying down position as well as standing position.

If you have concomitant constipation or the doctor suspects that you are not relaxing your pelvic floor muscles properly, you may need to undergo a defecogram, which is an x ray evaluation of the evacuation sequence. A pelvic floor ultrasound also helps to look for paradoxical muscle contraction of the pelvic floor.

Treatment

A non-symptomatic small enterocele may not need any treatment.
There are various non-surgical and surgical treatment options available for the rest. It is important to avoid constipation and treat it properly if present, as straining to pass stools may lead to worsening of the enterocele. Performing pelvic floor strengthening exercises regularly may help. Avoiding lifting heavy weights and weight reduction in case of obesity also is important.

Vaginal estrogen therapy: Estrogen therapy vaginally may be beneficial in postmenopausal women who suffer from prolapse as it limits further weakening of supporting tissues.

Pessary: A pessary is a deviceworn in the vagina for supporting the vaginal wall. It may be useful in patients who want to avoid surgery or delay surgery or in patients with a small enterocele

Biofeedback and physical therapy: Biofeedback is a therapy in which a small probe is placed in the vagina that is attached to a visual or sound display. It helps to improve awareness of the pelvic floor muscles and helps the patient to learn to relax them during defecation.

Surgical treatment: The goal of surgical treatment is to restore normal anatomy, put the bowel back in place and resuspend and support the vaginal vault. The repair of enterocele is combined with repair of other types of prolapse that may be co-existing. Typcially the surgery is completed vaginally. You can read more about vaginal surgery for enterocele here.

In patients who have recurrent prolapse or prolapse of the vaginal vault following hysterectomy, the surgery may be performed laparoscopically. You can read about laparoscopic sacrocolpopexy here.

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