Enterocele is one of the variants of pelvic prolapses, which is characterized by the lowering of the loops of the small intestine and the bulging of the formed hernia through the vaginal wall. The disease is manifested by pain and discomfort in the lower abdomen, soreness during sexual contacts. Constipation, bloating are characteristic, dysuric phenomena are less likely to bother. To diagnose enterocele, a vaginal examination is performed, after which instrumental studies are prescribed — transvaginal ultrasound, radiography, hysteroscopy. Enterocele treatment is mainly surgical: laparoscopic or open surgery is performed to fix and plasticize the vaginal walls.
ICD 10
N81.5 K46
General information
Omission and prolapse of the internal genitalia is a common condition that occupies up to 28% in the structure of gynecological morbidity. Among all varieties of genital prolapse, enterocele accounts for about 2-3%. The disease occurs only in women. Pathology may occur in patients of reproductive age, but manifestation in the postmenopausal period is more characteristic. Enterocele is of great medical and social importance, since it violates the quality of life and sexual relations of the patient.
Causes
Enterocele, like other types of prolapse, is a polyethological condition. The causes of the disease are directly related to the pathology of the female reproductive organs, as well as to systemic diseases. There is evidence of a hernia connection with a previous uterine removal operation. In modern gynecology , there are 3 main etiological factors of enterocele:
- Hormonal disorders. During menopause, women have a deficiency of sex hormones, which is associated with a weakening of the ligamentous apparatus of the pelvic organs and diaphragm. As a result, conditions are created for the omission of the parietal leaf of the peritoneum along with the bowel loop.
- Failure of connective tissue structures. A number of genetic syndromes based on connective tissue dysplasia throughout the body are described. For hereditary genesis, the formation of enterocele in young patients, a combination of hernia with joint or skin diseases is typical.
- Increased intra-abdominal pressure. The condition occurs with regular constipation, lifting weights, can develop against the background of bronchial asthma or chronic bronchitis, when there are attacks of suffocation and severe coughing. With increasing pressure in the abdominal cavity, the malleable abdominal organs begin to shift downward.
Risk factors
The most susceptible to the appearance of enterocele are women who have repeatedly given birth with overextension of the genital tract and ligamentous apparatus, weakening of the abdominal muscles. The risk of developing pathology increases if the obstetric history indicates prolonged labor, the birth of a large fetus, perineal ruptures during attempts. Independent risk factors for the occurrence of enterocele are chronic inflammatory diseases of the reproductive system, injuries of the pelvic diaphragm.
Pathogenesis
Under the influence of one of the predisposing factors, the failure of the ligamentous apparatus and the pelvic diaphragm occurs. Increased intra-abdominal pressure contributes to the exit of the loop of the small intestine into the pelvis. The formed hernia presses on the vaginal wall, causing it to descend down to the genital slit. The enterocele increases as it fills with intestinal contents, resulting in a vicious circle.
Classification
According to the number of organs that have undergone prolapse, isolated and combined forms of enterocele are distinguished. The new POP-Q classification is quite difficult for practical work and involves measurements at 9 points. According to POP-Q, prolapse is divided into 4 stages according to the distance between the most protruding part of the vagina and the hymen. Another classification is more popular among clinicians, which also includes 4 forms of enterocele:
- I degree. It is characterized by a slight protrusion of the wall or omission of the enterocele to less than half the length of the vagina.
- II degree. There is a hernia prolapse before exiting the vagina, but the outside of the perineum remains unchanged.
- III degree. Enterocele prolapse occurs outside the genital slit, but the uterus body is located in the pelvis.
- IV degree. The most severe variant of the disease is when the vaginal walls, enterocele and uterus completely come out.
Symptoms of enterocele
The main sign of a hernia is the sensation of a foreign body in the vagina. Often, a woman can independently probe the enterocele. At 3-4 degrees of the disease, patients complain of the presence of a reddish protrusion from the genital slit. There are pulling pains and discomfort in the suprapubic region, sometimes the pain is given to the lower back. One of the early symptoms of enterocele is dyspareunia — painful sensations during sexual intercourse.
In addition to general manifestations, signs of intestinal damage develop. Enterocele is characterized by moderate pain in the umbilical region or in the lower abdomen. Unpleasant sensations increase after eating, usually accompanied by flatulence. Constipation is periodically bothered. After defecation, there is a feeling of incomplete bowel emptying. Dysuric disorders are less common: pain during urination, urine excretion in small portions.
Complications
Enterocele is often complicated by urological and gastroenterological problems. In 20-25% of patients, persistent urinary incontinence is noted, requiring constant use of pads. Less often, with enterocele, the opposite situation occurs — chronic stagnation of urine, which leads to inflammatory diseases of the bladder and the cup-pelvic system of the kidneys. Due to sharp pains and mechanical obstacles, sexual relations become impossible.
On the part of the intestine, the main complication of enterocele is chronic constipation, which lasts for 5-7 days. Defecation in such patients is possible only after enema. When the intestinal loop located in the hernial sac is blocked, intestinal obstruction occurs with a characteristic clinical picture. Due to compression of the veins, enterocele is often complicated by varicose veins of the pelvic vessels, which increases pain.
Diagnostics
An informative method for detecting enterocele is a vaginal examination conducted by an experienced gynecologist. During the study, the doctor determines the degree of vaginal prolapse, defects in the urogenital diaphragm. Stress tests (Valsalva, cough test) are necessarily performed. The following instrumental methods are used to confirm the diagnosis:
- Transvaginal ultrasound. The noninvasive diagnostic method provides the most complete information about the contents of the enterocele and the condition of the surrounding tissues. With the help of sonography, the doctor receives detailed information about the anatomical features of a hernia, which is necessary in preparation for surgery.
- X-ray examination. The results of an overview radiograph are usually uninformative, therefore, an X-ray of the barium passage is performed to visualize the intestinal loops. This study is prescribed to verify the diagnosis of enterocele. Sometimes patients undergo CT scans of the abdominal cavity and pelvis.
- Hysteroscopy. Endoscopic examination of the inner surface of the uterus is indicated in the presence of alarming symptoms: intermenstrual spotting, enlargement of the uterus in the absence of pregnancy. Hysteroscopy is required when visualizing nodular formation on ultrasound.
Enterocele treatment
Conservative therapy
Non-drug treatment is recommended at stage 1 of enterocele, if there is no severe pain or discomfort. Assign special exercises to strengthen the pelvic floor muscles — physical therapy according to Atabekov. In case of estrogen deficiency, hormone replacement therapy is carried out by using local remedies — vaginal candles, cream. To eliminate constipation, a high-fiber diet and laxatives are indicated.
Surgical treatment
The main tasks of surgical interventions are to restore the anatomical integrity of the pelvic diaphragm and perineum, as well as to ensure the normal functioning of the intestine. Laparoscopic or vaginal access is used for surgical correction of the enterocele. Standard laparotomy has a higher percentage of traumatism and postoperative complications, so it is rarely performed.
The choice of surgery tactics is made taking into account the size and degree of enterocele, age and general condition of the woman. In young and middle-aged patients, it is preferable to strengthen the walls of the vagina with their own tissues. In elderly patients, synthetic mesh implants are installed for plastic surgery. Full recovery after surgical intervention with enterocele takes 3-6 weeks.
Prognosis and prevention
With the beginning of the use of modern surgical methods of treatment, the prognosis for enterocele has improved significantly. In most patients, it is possible to completely eliminate the hernia and stop the symptoms of the disease. Preventive measures include careful management of childbirth to prevent obstetric injuries and treatment of extragenital pathology. In menopausal women, it is advisable to prescribe hormone therapy to prevent hypoestrogenemia.
