Vaginal herniation: case report and review of the literature

OBJECTIVE: The purpose of this study was to discuss the treatment of a case of spontaneous intestinal herniation per vagina in a patient who had undergone previous transabdominal hysterectomy and to review the related literature. STUDY DESIGN: A computer-based search of the English literature from January 1900 to October 2004 with the use of the terms vaginal herniation, vaginal evisceration, and vaginal trauma/injury was performed. Causes, presentation, and treatment were discussed and compared with a recent case that was treated locally in our hospital. RESULTS: Vaginal evisceration was described in the literature as early as 1864; since then <100 cases have been reported in the literature. It is more common in menopausal women with previous hysterectomy pelvic or vaginal surgery. Vaginal trauma, as in rough coitus, instrumentation, obstetric injury, is a recognized cause in premenopausal women. CONCLUSION: Vaginal evisceration is a rare, distressing emergency that requires aggressive resuscitation and urgent surgical intervention.     

Vaginal evisceration after hysterectomy: a rare condition a gynecologist should be familiar with

Purpose  To report a case of vaginal vault rupture with intestinal herniation per vagina after hysterectomy and highlight the risk factors, clinical presentation and treatment options of this rare gynecologic emergency. Methods  A 70-year-old woman presented to the emergency department with vaginal evisceration, emerged 4 years after vaginal hysterectomy for uterine prolapse. Approximately 30 cm of the terminal ileum was irreducibly protruding through the vagina. Results  The patient was transferred to the operating theatre. The prolapsed bowel was reduced via the combined vaginal-abdominal route and the vaginal cuff was closed with non-absorbable interrupted sutures. Conclusion  Awareness as well as high suspicion index among gynecologists and all involved care givers, is important for early diagnosis, given that vaginal evisceration is a potentially life-threatening condition necessitating prompt surgical intervention.     

Laparoscopic management of vaginal evisceration: case report and review of the literature

Vaginal evisceration is a rare condition that presents with protruding mass, vaginal bleeding, and pelvic pain. Vaginal evisceration is most commonly associated with previous vaginal surgery but may occur spontaneously, and represents a surgical emergency. We report a case of vaginal evisceration in a 42-year-old premenopausal woman 6 months after hysterectomy. This case shows the value of laparoscopy in management of vaginal evisceration.     

Vaginal evisceration after hysterectomy: a literature review

The purpose of this review is to highlight the risk factors, clinical presentation, and different surgical management options for vaginal evisceration after vaginal, abdominal, or laparoscopic hysterectomy. We identified all reports of vaginal evisceration after these procedures using sources in the literature from 1900 to the present. We found that a total of 59 patients were reported, 37 (63%) had a prior vaginal hysterectomy, 19 (32%) had a prior abdominal hysterectomy (2 of which were radical hysterectomy), and 3 (5%) had a prior laparoscopic hysterectomy. The majority of these patients were postmenopausal women. Also, the precipitating event was most often sexual intercourse in premenopausal patients and increased intra-abdominal pressure in postmenopausal patients. In addition, the small bowel was the most common organ to eviscerate. Most of the patients presented with vaginal bleeding, pelvic pain, or a protruding mass. We conclude that vaginal evisceration after hysterectomy remains a rare event. It is more often seen after vaginal hysterectomy than after other types of hysterectomy. It can also occur spontaneously or following trauma or vaginal instrumentation, or any event that increases intra-abdominal pressure. Vaginal evisceration represents a surgical emergency, and the approach to therapy for it may be abdominal, vaginal or a combination of the two.     

Transvaginal evisceration after radical abdominal hysterectomy

BACKGROUND: Intestinal evisceration through the vagina is rare and transvaginal evisceration after transabdominal surgery is far more rare. CASE: We present an unusual case of a postmenopausal woman who presented with transvaginal evisceration of the small bowel after radical abdominal hysterectomy and pelvic lymphadenectomy. CONCLUSION: This was a rare case of terminal ileal evisceration through a ruptured vaginal cuff after radical hysterectomy and bilateral pelvic lymphadenectomy. We performed a delayed closure of the vaginal defect through the vagina after manual reduction of the eviscerated small bowel, and the outcome was satisfactory.     

Evisceración transvaginal post-histerectomía radical y radioterapia adyuvante

Transvaginal evisceration is a rare situation, with few cases reported in the international literature. This situation normally occurs in postmenopausal women and is associated with previous vaginal surgery, especially hysterectomy. The defect in the vaginal fundus requires emergency surgery, and even resection of the affected section of the bowel, if necessary. We report a case of vaginal evisceration of the small bowel 14 years after radical hysterectomy in a patient with endometrial cancer and vaginal vault prolapse.     

Characteristics of patients with vaginal rupture and evisceration

OBJECTIVE: To characterize vaginal rupture and evisceration. METHODS: We reviewed medical records (1970-2001) for use of the diagnostic terms "vaginal rupture," "vaginal evisceration," and "ruptured enterocele." RESULTS: Twelve clinical cases were identified. Patients usually presented with pain, vaginal bleeding, and abdominal pressure. In 9 of 12 women, rupture was primarily associated with postmenopausal prolapse and a history of pelvic surgery. Women with a history of abdominal hysterectomy tended to rupture through the vaginal cuff, and those with a history of vaginal hysterectomy tended to rupture through a posterior enterocele. Premenopausal rupture in 1 woman occurred postcoitally and involved the posterior fornix. Prolapse recurrence after repair was limited to 1 woman. CONCLUSIONS: Vaginal rupture and evisceration should be considered in women presenting with acute vaginal bleeding and pelvic pain. Evaluation is especially important in postmenopausal women with a history of pelvic surgery. In some cases, surveillance after pelvic surgery may prevent rupture, evisceration, and incarceration. LEVEL OF EVIDENCE: II-3     

Vaginal cuff dehiscence: risk factors and management

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence.     

Postcoital Vaginal Rupture in a Young Woman with No Prior Pelvic Surgery

IntroductionReports of postcoital vaginal rupture in the literature are limited to cases involving women who are postmenopausal, have recently undergone pelvic surgery, or have suffered genitourinary trauma.AimWe report a case of postcoital vaginal rupture in a 23‐year‐old woman with no prior surgical history who complained of acute onset, severe vaginal pain after consensual intercourse.ResultsExamination under anesthesia revealed a 6‐cm laceration of the posterior fornix, which extended into the abdominal cavity. The laceration was repaired using a combined vaginal and laparoscopic approach.ConclusionsCoitus‐induced vaginal rupture in a reproductive aged woman with no prior pelvic surgery or other risk factors is a rare clinical presentation. Prior reports of rupture in premenopausal women have recommended repair via laparotomy. This case documents successful transvaginal and laparoscopic repair, and reviews the etiological mechanisms for coitus‐induced injury. Austin JM, Cooksey CM, Minikel LL, and Zaritsky EF. Postcoital vaginal rupture in a young woman with no prior pelvic surgery. J Sex Med 2013;10:2121–2124.     

Occult Vaginal Evisceration: A Case Report

BackgroundVaginal evisceration is a rare gynaecologic emergency that necessitates surgical intervention. It may manifest with obvious vaginal rupture, or it may be occult, specifically in patients with chronic pelvic organ prolapse.CaseA 66-year-old woman with a history of bowel cancer and irradiation presented with occult vaginal evisceration. This was discovered during a routine follow-up appointment. It was repaired in two layers with xenograft derived from porcine intestinal mucosa (Surgisis, Cook Medical, Bloomington, IN) interposition and a concomitant colpocleisis. Long-term complications of the procedure included recurrent prolapse, but her vaginal vault evisceration did not recur.ConclusionIn patients with chronic pelvic organ prolapse, especially in those with additional risk factors for poor tissue strength, the possibility of vaginal vault evisceration or dehiscence should be considered. These patients would benefit from close follow-up.     

Evisceración vaginal con antecedente de cirugía pélvica: 2 casos

We report 2 cases of vaginal evisceration after prior pelvic surgery that were treated in our hospital during a 4-month period.     

Small bowel and omentum evisceration after abdominal hysterectomy

Intestinal evisceration through the vagina is rare, and transvaginal evisceration after transabdominal surgery is even more rare. Vaginal evisceration is a very rare complication of abdominal hysterectomy, but when this occurs, it is a surgical emergency. Prompt attention is required to prevent further morbidity and potential mortality. The most common organ to eviscerate is the distal ileum, with only two cases of prolapsed omentum having been reported. We present an unusual case of a postmenopausal woman who presented with a vaginal evisceration of the small bowel and omentum after abdominal hysterectomy.     

Evisceration occurred 1 year after vaginal vault repair for relapsed pelvic organ prolapse

This report describes the case of an 81-year-old woman with sudden evisceration of the small intestine through the vagina. It occurred one year after repair of a vaginal vault prolapse, which was initially treated by vaginal hysterectomy and colporrhaphy three years prior to the repair. On examination, we found a 70-80-cm loop of bowel prolapsing through a 3-cm oval defect in the vaginal vault. The patient underwent emergency exploratory laparotomy under general anesthesia. After careful reduction of the eviscerated small intestine, the hernia hiatus was closed and the widened cul-de-sac was obliterated by performing a Moschcowitz culdoplasty. Rapid intervention by abdominovaginal surgery may enable smooth repositioning of the eviscerated intestine, thus preventing subsequent morbidity.     

Uterine Avulsion: A Rare Cause of Cryptomenorrhea

BackgroundCryptomenorrhea at menarche is commonly due to mullerian duct anomalies. Uterine avulsion due to blunt pelvic trauma is a very rare cause of cryptomenorrhea. But so far no case of uterine avulsion has been reported due to a childhood trauma without pelvic fracture.CaseA 15-year-old young girl was evaluated for delayed menarche and the diagnosis of hematometra with obstruction at the level of internal cervical os was made on radiological examination. Detailed history revealed significant childhood blunt pelvic trauma when at the age of 3 years she was run over by a tractor. But the presence or absence of pelvic fracture was never documented as no radiographs were obtained. On abdominopelvic exploration cervix was well formed. Uterine body was found to be separated from the supravaginal cervix and there was a peritoneal window in between. During surgery hematometra was drained and the continuity of the uterine outflow tract was restored. Post surgery patient started having normal periods.Summary and ConclusionsThough very rare, uterine avulsion during pelvic trauma may cause cryptomenorrhea. Therefore such history should be sought in all cases of obstruction of the cervical canal because cryptomenorrhea has a much better prognosis than cervical congenital dysgenesis.     

Laparoscopic-assisted radical parametrectomy including pelvic and/or paraaortic lymphadenectomy in women after prior hysterectomy-three cases

BACKGROUND: Radical abdominal surgery in patients who have previously undergone a hysterectomy is a surgical challenge. This type of surgery for invasive cervical cancer after a hysterectomy or vaginal stump metastasis traditionally requires a major laparotomy; however, a minimal-access approach is now being applied to this type of procedure. CASE: A laparoscopic-assisted radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy was performed on two patients presenting invasive cervical cancer diagnosed after a simple hysterectomy and one patient with recurred endometrial cancer in the vaginal stump. All three patients had an excellent clinical outcome and made a rapid recovery with no major complications, even though two cases involved a bladder laceration. CONCLUSION: A laparoscopic radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy is a viable technique for women with invasive cervical cancer or recurrent endometrial vaginal cancer after a prior hysterectomy.     

Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap

BACKGROUND: Vaginal evisceration is generally repaired by vaginal or abdominal route. We describe two cases of vaginal evisceration using a combined laparoscopic and vaginal approach employing an omental flap. CASES: Case 1: A radical abdominal hysterectomy was performed in a premenopausal patient for a FIGO IB1 cervical cancer. Four months later, she was found to have a vaginal cuff dehiscence which was repaired by a vaginal approach. Two months later, she had a vaginal cuff evisceration which was repaired using a combined laparoscopic and vaginal approach employing an omental flap with good success. Case 2: A postmenopausal woman who underwent an abdominal hysterectomy and pelvic lymphadenectomy for a FIGO IB endometrial cancer was noted to have a vaginal evisceration two months after primary surgery. This was also successfully repaired using a combined laparoscopic and vaginal approach employing an omental flap. CONCLUSION: The combined laparoscopic and vaginal approach with omental flap is effective for repair of a vaginal cuff dehiscence with bowel evisceration. The addition of laparoscopy provides an opportunity for inspection of the small bowel, the peritoneal toilet, and mobilization of an omental flap.     

Total laparoscopic radical parametrectomy, partial colpectomy, and pelvic lymphadenectomy in patients with occult cervical cancer

Objective

To assess total laparoscopic radical parametrectomy (TLRP) with pelvic lymphadenectomy and partial colpectomy as a safe and feasible treatment option for patients with occult cervical cancer.

Methods

Twelve patients with occult invasive cervical cancer underwent TLRP after prior extrafascial hysterectomy.

Results

No intraoperative complications occurred. Two patients experienced postoperative complications: an iliac lymphocyst with pyelectasis, and a vaginal evisceration that occurred during sexual intercourse. Nine patients required no further treatment. One patient with residual disease received brachytherapy as adjuvant treatment. Two patients with positive nodes not detected at preoperative work-up received adjuvant concomitant radiochemotherapy.

Conclusion

TLRP with pelvic lymphadenectomy is a safe and feasible treatment in patients with occult invasive cervical cancer discovered after extrafascial hysterectomy.     

Evisceración intestinal tardía a través de la vagina tras histerectomía

Intestinal evisceration through the vagina is a rare complication of hysterectomy but constitutes an emergency. Both the pathogenesis and prevention of this event are controversial. The average time of onset is 128 days. We report the case of a patient, with onset at 390 days. Surgical treatment was performed by laparotomy with bowel resection and closure of the vaginal vault.     

Evisceración vaginal. Abordaje abdominal y reparación con malla sintética

Spontaneous vaginal evisceration is a rare phenomenon in daily clinical practice. Since McGregor reported the first case at the beginning of the past century, more than 70 cases have been reported to date. Spontaneous vaginal evisceration usually occurs in patients with postmenopausal hypoestrogenism associated with previous gynecologic surgery. This entity has recently been described in non-gynecological conditions after perineal proctectomy. We present a new case of spontaneous vaginal evisceration in a postmenopausal woman with previous gynecological surgery. Surgical mesh repair was performed through conventional laparotomy.     

Modified Inflatable Penile Prosthesis Reservoir Placement Into Space of Retzius: Comparing Outcomes in Men With or Without Prior Pelvic Surgery

BackgroundTraditional inflatable penile prosthesis (IPP) reservoir placement has rare but potentially serious complications including damage to local structures, and Levine and Hoeh (J Sex Med 2012;9:2759–2769) described a modified technique designed to avoid these complications.AimTo determine whether the modified Jorgenson scissors technique is safe and effective in patients who have had prior pelvic surgery.MethodsA retrospective chart review was performed on all patients who had a three-piece IPP placed by a single urologist from 2011 to 2015. Complication rates between the prior pelvic surgery group and the virgin pelvis group were compared using χ² test. Differences between the two groups were considered statistically significant at a P value less than .05.OutcomesReservoir-related complication rate and rate of converting to ectopic placement.ResultsA total of 246 procedures were included, with 174 having no prior pelvic surgery and 72 with prior pelvic surgery. The reservoir-related complication rates were 2.8% (2 of 72) in the prior pelvic surgery group and 3.4% (6 of 174) in the virgin pelvis group. This difference was not statistically significant (P = .79). The two complications from the prior pelvic surgery cohort were inguinal hernias requiring surgical repair, which occurred in the same patient. In the virgin pelvis cohort, there were five inguinal hernias and one autoinflation. There were 16 patients who required ectopic placement of the reservoir owing to difficulty in entering the space of Retzius (SOR), 14 of whom had prior pelvic surgery.Clinical ImplicationsWe believe this modified technique for IPP reservoir placement into the SOR is a safe alternative because the Jorgenson scissors allow perforation into the SOR away from vital structures.Strengths and LimitationsThe study is limited by the fact that it is a retrospective, single-center, chart review of a non-randomized surgical procedure with variable follow-up in a limited number of patients. Its strength is its applicability to provide surgeons a modified technique that can be used routinely for IPP reservoir placement that appears to be safe and effective, even in men who have had prior pelvic surgery.ConclusionIn our experience, the modified Jorgenson scissors technique allows for safe entry into the SOR through a transverse scrotal incision and is a viable alternative to the standard SOR placement and the ectopic approach.Capoccia EM, Phelps JN, Levine LA. Modified Inflatable Penile Prosthesis Reservoir Placement Into Space of Retzius: Comparing Outcomes in Men With or Without Prior Pelvic Surgery. J Sex Med 2017;14:968–973.