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ORIGINAL RESEARCH |
From the Section of Gynecologic Surgery, and the Division of Biostatistics, Mayo Clinic, Rochester, Minnesota.
Address reprint requests to: John B. Gebhart, MD, Section of Gynecologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: gebhart.john{at}mayo.edu.
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ABSTRACT |
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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
). In postmenopausal women, vaginal evisceration is frequently associated with chronic pelvic prolapse or prolapse repair.2,3 In premenopausal women, this condition is associated most often with coitus and may be accompanied by vaginal lacerations.4,5
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MATERIALS AND METHODS |
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JMP 4.0.4 statistical analysis software (SAS Institute, Cary, NC) was used to analyze the patient data. The Fisher exact test was used for data analysis with significance set at 
< .05. The power of the clinical data was limited because of the small number of cases. The non-homogeneous nature of the patient population (patients from outside Olmsted County, MN) and their follow-up may have introduced time bias in collecting a larger number of cases during the earlier decades of the study period.
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RESULTS |
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). The mean parity was 3 (standard deviation 1.88). The mean body mass index was 27.9 kg/m2 at the time of rupture; 5 patients (42%) had a body mass index higher than 27.0 kg/m2.
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The most common patient characteristic was a correlative history of pelvic surgery and postmenopausal status (9 of 12 patients [75%]). Four patients (33%) had a history of vaginal hysterectomy, and 5 (42%) had a history of abdominal hysterectomy. Other surgical procedures performed are listed in Table 2. The mean time of occurrence after a pelvic operation was 27 months (range 5–48 months). Before their recurrence, 2 patients (17%) had prior ruptures at 2 and 11 months.
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).
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). Rupture was significantly associated with previous hysterectomy (P = .007). Eight of the 12 patients (67%) had spontaneous rupture, and bowel was visible on vaginal examination in 6 patients (5 ileum, 1 colon). More precisely, 6 patients (50%) experienced only rupture, whereas 6 patients (50%) experienced both rupture and evisceration.
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). This high rate of vaginal repair was attributable to close surveillance of a previously known prolapse, prompt patient presentation, and lack of severe evisceration. Mayo-McCall culdoplasties were performed in all these patients. Three of the 4 patients (75%) requiring laparotomy needed bowel resection and reanastomosis for ischemic bowel. The young trauma patient required a uterosacral plication and a temporary diverting colostomy secondary to visceral puncture.
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A combination approach of vaginal bowel extraction with abdominal laparotomy was used in 3 of the 12 patients (25%). In the patient with postcoital rupture, laparoscopy was used to inspect the pelvic cavity after vaginal closure (Table 5
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The average hospital stay was 6 days. One wound infection occurred, and 1 bowel leak was repaired immediately. One postmenopausal patient with rupture received primary treatment elsewhere before referral to Mayo Clinic and required only secondary repair of her defects. No complications occurred with secondary pelvic repairs. The patient who had a history of traumatic rupture at 18 years of age re-presented in her 50s with an enterocele. None of the other patients had documented recurrence of their prolapse.
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DISCUSSION |
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Somkuti et al6 described 10 risk factors for apical vaginal rupture after an abdominal or vaginal hysterectomy: 1) poor technique, 2) postoperative infection, 3) hematoma, 4) coitus before healing, 5) age, 6) radiotherapy, 7) corticosteroid therapy, 8) trauma or rape, 9) previous vaginoplasty, and 10) use of the Valsalva maneuver. There are many other factors worthy of mention, eg, lifestyle, organic disease (hypothyroidism), and poor collagen structure. Risk factors applicable to this series of 12 patients include postmenopausal age in 9 (75%), corticosteroid therapy in 2 (17%), prior pelvic surgery in 10 (83%), Valsalva maneuvers (asthma, gastroesophageal reflux disease) in 5 (42%), constipation in 4 (33%), and obesity (body mass index more than 27.0 kg/m2) in 5 (42%).
It is important to note that although coitus may cause rupture in postmenopausal women, coitus causes rupture more commonly in premenopausal women. In a review of 121 historical cases describing the rupture location as "posterior fornix," 20 of 26 ruptures (77%) occurred after coitus in premenopausal women. Rupture after pelvic surgery in a premenopausal woman usually is caused by acute trauma that increases intrapelvic pressure on an unhealed vaginal cuff.7,8 A mechanism responsible for coital injuries includes asymmetric anterior-lateral cervical positioning during the excitement phase, consequently exposing the right fornix to vigorous phallic thrusting.9–11 Disproportion in size between male and female genitalia and loss of inhibition due to intoxication also may contribute.12
Although the series interval between the most recent pelvic operation and rupture ranged from 5 to 48 months, review of the literature revealed a larger range of 1 day to 25 years, with a mean of 34 months and a median of 10.5 months. Almost all historical patients presented within 24 hours after evisceration. Three of these patients did not seek treatment until 24–36 hours after evisceration because of coexisting sociomedical problems. Seven historical patients had seen a physician during the week before rupture. The time interval between rupture and treatment was not associated with higher rates of ileus, obstruction, or more extensive bowel incarceration in either our series or that reported in the literature.
Emergency management of vaginal evisceration is critical to the preservation of viable bowel. If the patient’s condition is stable, a complete history should be obtained. A thorough physical examination should be performed, paying attention to abdominal guarding, rigidity, rebound tenderness, distention, and hypoactive bowel sounds. On pelvic examination, close inspection for introital or vaginal lacerations and bleeding points should be completed. If viable bowel is protruding from the vagina, an attempt should be made to reposition it intraperitoneally. This may be accomplished by placing the patient in the Trendelenburg position and using moist sponge sticks.2,8,13,14
Guttman and Afilalo15 stressed 5 points that may aid in the acute management of rupture and evisceration: 1) stabilizing the patient; 2) managing the patient’s fluid status, especially in patients with shock; 3) preserving the bowel in a moist saline wrap; 4) administering broad-spectrum antibiotics to cover gastrointestinal flora; and 5) initiating immediate surgical repair. In addition, abdominal radiography may be ordered to rule out the presence of an intraperitoneal foreign body.16 Finally, tetanus toxoid should be administered.
The type of surgical repair varies depending on the situation. Bowel peristalsis, a lack of duskiness, blunt trauma (eg, with a penis or a douche nozzle), stable vital signs, no foreign bodies, and the ability to reduce the bowel intraperitoneally allow for vaginal closure. For example, a large defect in the levator plate with a traction enterocele or cystorectocele may be best repaired transvaginally. The approach most commonly used is based on Nichols’ model.16,17 Patients with no vault prolapse who have evisceration through a posterior enterocele may have the repair done vaginally if there is no severe bowel protrusion through the defect. Small eventrations of omentum or salpinges may be repaired transvaginally also.18 Laparoscopy has been used in cases of minor rupture to inspect the pelvic contents after vaginal repair.
Any question of organ viability or possibility of mesenteric trauma, which may be concealed intraabdominally, necessitates an exploratory midline laparotomy. A Pfannenstiel incision has been advocated only if visceral injury is unlikely or if the patient’s status is poor and the risk of wound separation is high.19 Laparotomy is crucial in those patients with a tight vault ring that has constricted the venous return of a crowded small-bowel mesentery. Laparotomy also allows for adequate examination of the remaining small and large intestines, assessment of the pelvic cavity, irrigation, drainage, and removal of all foreign bodies and necrotic tissue. An abdominal approach may be selected if the surgeon desires to obliterate the cul-de-sac with a procedure that incorporates endopelvic fascia (uterosacral plication).
In patients with a pulsion or traction enterocele with evisceration, a combined abdominal-vaginal approach is recommended to inspect the length of intestinal damage and to allow for bowel resection and vaginal extraction (especially if the bowel cannot be reduced vaginally), obliteration of the cul-de-sac, and repair of a levator plate defect by using posterior colporrhaphy.
Other repairs of the pelvic floor may follow these measures. However, some16 favor a delayed pelvic repair after the primary tissue rupture sites have healed. Fox19 reported a "marked reaction" at the vaginal apex presumed to be caused by an inadequate interval between operations in a patient whose repair was delayed. Friedel and Kaiser3 preferred delayed closure to reduce postoperative infection risk, and Rolf20 recommended secondary repair only when "gross healing defects" were observed. Powell and Gentry14 suggested cul-de-sac obliteration or colpocleisis in the asexual patient. The patients seen at Mayo Clinic underwent additional repairs at the time of surgery with no additional morbidity. Because of infection risk, the use of mesh should be avoided in a repair with concomitant bowel resection. Whether closure is abdominal or vaginal, Kowalski et al2 advocated examination of the rectal mucosa by rigid or flexible proctoscopy.
Principles of prevention rely on avoiding the factors most associated with vaginal vault disorders. Repetitive vaginal operations, vaginal tension or shortening, unrecognized pelvic floor defects, and hypoestrogenism may be responsible. Vaginal surgery should try to restore the normal vaginal axis in a tension-free manner, to maintain appropriate length, and to correct and reinforce defects of tissue or support. If atrophy is coexistent, hormone therapy should be considered. An enterocele eventually develops in at least 3% of patients who have undergone vaginal hysterectomy.21 Kinzel21 believed that many enteroceles are overlooked at the time of initial surgery, whether it is performed abdominally or vaginally. Ideally, prophylactic obliteration should be performed at the time of hysterectomy. Yearly evaluation of patients with a history of pelvic surgery has been advocated to keep potential prolapse problems under surveillance.21 However, as evidenced in this review, seeing 5 patients (42%) within the week before rupture did not prevent this condition from occurring. Prompt access to a physician seems to be the key to successful treatment.
Vaginal rupture and evisceration are potentially life-threatening but rare. They should be considered in the differential diagnosis of patients presenting with acute vaginal bleeding and pelvic pain. More importantly, annual surveillance, especially of postsurgical patients and patients with prolapse, may in some cases prevent rupture, evisceration, and incarceration.
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Footnotes |
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Received August 14, 2003. Received in revised form November 14, 2003. Accepted November 20, 2003.
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REFERENCES |
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2. Kowalski LD, Seski JC, Timmins PF, Kanbour AI, Kunschner AJ, Kanbour-Shakir A. Vaginal evisceration: presentation and management in postmenopausal women. J Am Coll Surg 1996;183:225–9.[Medline]
3. Friedel W, Kaiser IH. Vaginal evisceration. Obstet Gynecol 1975;45:315–9.
4. Hall BD, Phelan JP, Pruyn SC, Gallup DG. Vaginal evisceration during coitus: a case review. Am J Obstet Gynecol 1978;131:115–6.[Medline]
5. Haney AF. Vaginal evisceration after forcible coitus with intraabdominal ejaculation. J Reprod Med 1978;21: 254–6.
6. Somkuti SG, Vieta PA, Daughtery JF, Hartley LW, Blackmon EBJr. Transvaginal evisceration after hysterectomy in premenopausal women: a presentation of three cases. Am J Obstet Gynecol 1994;171:567–8.[Medline]
7. Cardosi RJ, Hoffman MS, Roberts WS, Spellacy WN. Vaginal evisceration after hysterectomy in premenopausal women. Obstet Gynecol 1999;94:859.
8. Cullins V, Anasti J, Huggins GR. Vaginal evisceration with pneumoperitoneum: a case report. J Reprod Med 1989;34:426–8.[Medline]
9. Dickenson RL. Atlas of human sex anatomy. Baltimore (MD): Williams & Wilkins; 1949.
10. Masters WH, Johnson VE. Human sexual response. Boston (MA): Little, Brown; 1966.
11. Metsala P, Nieminen U. Traumatic lesions of the vagina. Acta Obstet Gynecol Scand 1968;47:482–8.[Medline]
12. Van de Velde TH. Ideal marriage. New York (NY): Random House; 1963.
13. Ferrera PC, Thibodeau LG. Vaginal evisceration. J Emerg Med 1999;17:665–7.[Medline]
14. Powell JL, Gentry JK. Vaginal evisceration. J Pelvic Surg 2001;7:94–7.
15. Guttman A, Afilalo M. Vaginal evisceration. Am J Emerg Med 1990;8:127–8.[Medline]
16. Nichols DH, DeLancey JOL. Clinical problems, injuries and complications of gynecologic and obstetric surgery. 3rd ed. Baltimore (MD): Williams & Wilkins; 1995. p. 179–81.
17. Wheeless CR Jr. Vaginal evisceration following pelvic surgery. In: Nichols DH, DeLancey JOL, editors. Clinical problems, injuries and complications of gynecologic and obstetric surgery. 3rd ed. Baltimore (MD): Williams & Wilkins; 1995. p. 203–13.
18. Symmonds RE, Pratt JH, Ellis FHJr. Ruptured enterocele. Am J Obstet Gynecol 1957;74:1150–3.[Medline]
19. Fox PC. Eventration of the intestine through the vagina following a vaginal hysterectomy. Ill Med J 1949;96: 321–2.[Medline]
20. Rolf BB. Vaginal evisceration. Am J Obstet Gynecol 1970; 107:369–75.[Medline]
21. Kinzel GE. Enterocele: a study of 265 cases. Am J Obstet Gynecol 1961;81:1166–74.[Medline]
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