Enterocele and Massive Vaginal Eversion Workup

  • Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD   more...
 
Updated: Oct 3, 2011
 

Laboratory Studies

  • Standard preoperative laboratory evaluation should be performed to screen for anemia, metabolic abnormalities, and clotting problems. Surgical procedures for the repair of massive prolapse frequently involve elderly patients, and the operations are often prolonged, involving Trendelenburg position with legs elevated in stirrups. Pay special attention to the effects on patients with cardiac or pulmonary conditions, and appropriate tests such as ECG, CBC, and clotting studies are important.
  • A urinalysis and culture are routinely sent to rule out infection and/or hematuria.
  • If the prolapse is extensive, BUN and creatinine may be elevated because of obstruction and should therefore be evaluated.
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Imaging Studies

  • Imaging studies may include an intravenous pyelogram (IVP) for cases of severe prolapse to rule out hydronephrosis. Otherwise, routine imaging studies are not indicated.
  • Controversy exists regarding the use of other imaging studies. These may include dynamic cystoproctography, magnetic resonance imaging (MRI), 3- and 4-dimensional transperineal ultrasonography, and even peritoneography (ie, the injection of radiographic dye into the peritoneal cavity).[21] These studies may be reserved for difficult and inconclusive cases, especially for the diagnosis of enterocele and sigmoidocele.
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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.

  • These studies often include initial uroflowmetry (with the prolapse not reduced) followed by insertion of a pessary, or other methods to reduce the prolapse (speculum, proctoswabs, 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 ultrasonography or catheterization should suffice for the vast majority of cases. A postvoid residual less than 50 mL is considered normal. An adequate voiding trial requires the patient to void at least 200 mL.[22]
  • With the prolapse reduced and pessary placement checked so it is not obstructing the urethra, complex cystometry with provocative maneuvers is used to assess for occult stress incontinence.
  • When initial uroflowmetry is combined with a pressure-voiding study, information regarding the potential for postoperative voiding dysfunction is obtained and may influence the choice of procedures.
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Contributor Information and Disclosures
Author

Rony A Adam, MD  Vice Chair, Quality and Performance Improvement, Department of Obstetrics and Gynecology, Geisinger Health System

Rony A Adam, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Coauthor(s)

Raisa O Platte, MD, PhD  Fellow, Department of Obstetrics and Gynecology, Geisinger Medical Center

Raisa O Platte, MD, PhD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American Medical Association, American Urogynecologic Society, and International Continence Society

Disclosure: Bard Grant/research funds fellowship support

Specialty Editor Board

Robert K Zurawin, MD  Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association

Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; ConMed Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Kris Strohbehn, MD  Professor of Obstetrics/Gynecology, Dartmouth Medical School; Director, Division of Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics/Gynecology, Dartmouth-Hitchcock Medical Center

Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, and Society of Gynecologic Surgeons

Disclosure: Astellas Grant/research funds Investigator

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Thinh H Duong, MD, FACOG to the development and writing of this article.

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Enterocele and massive vaginal eversion. Posthysterectomy vaginal vault prolapse.
Enterocele and massive vaginal eversion. Large apical endopelvic fascial defect representing an enterocele demonstrated by the transabdominal route. Note the proximal cervicovaginal and rectovaginal fascia separate from the peritoneum.
Enterocele and massive vaginal eversion. Levels of support as described by DeLancey (1992). Note that level I refers to apical (or uterovaginal) support.
Enterocele and massive vaginal eversion. Normal posthysterectomy vaginal vault. Note the presence of continuity of the endopelvic fascia at the vaginal apex, resulting from the fusion of cervicovaginal and rectovaginal fascia, and their fusion with the uterosacral ligament portion of endopelvic fascia.
Enterocele and massive vaginal eversion. Early enterocele with no vault prolapse. Note contact of peritoneal contents with vaginal mucosa, with no intervening endopelvic fascia.
Enterocele and massive vaginal eversion. Progressive enterocele now demonstrating true vaginal vault prolapse.
Enterocele and massive vaginal eversion. Massive enterocele with total vaginal vault prolapse.
Enterocele and massive vaginal eversion. Posterior enterocele in a patient with a uterus. Note that peritoneal contents have dissected between the vaginal mucosa and rectovaginal fascia through a proximal defect.
Enterocele and massive vaginal eversion. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier.
Enterocele and massive vaginal eversion. The anatomy surrounding the right ischial spine.
Enterocele and massive vaginal eversion. Note the pudendal neurovascular bundle at the lateral aspect of the sacrospinous ligament. Also note the proper penetration of the suture into the body of the coccygeus muscle.
Enterocele and massive vaginal eversion. Following penetration of the sacrospinous ligament, the permanent suture (on the left) is attached to the posterior vagina by a figure-eight stitch, incorporating rectovaginal fascia but not penetrating the mucosa. Once this stitch is tied, a pulley has been created whereby the vagina can be drawn up to the ligament by pulling on the free suture and then tied down. The delayed absorbable suture is driven through-and-through and is tied on the vagina.
Enterocele and massive vaginal eversion. Depiction of completed fascial reconstruction with uterosacral reattachment in the sagittal view. Note that the vaginal apex has been restored to its normal anatomic location and is directed to the hollow of the sacrum.
Enterocele and massive vaginal eversion. Le Fort colpocleisis begins with dissection and excision of a rectangular patch of mucosa on both the anterior and posterior vagina. Gradual inversion of the vaginal tube is accomplished by interrupted sutures that approximate anterior to posterior. Reapproximation of the lateral vaginal mucosal edges serves to maintain the tunnels on either side of the repair. From Thompson JD. Surgical correction of defects in pelvic support. In: Rock JR, Thompson JD, eds. TeLinde's Operative Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997.
Enterocele and massive vaginal eversion. Transabdominal repair of the large enterocele noted in Image 2. Note interrupted permanent sutures used for repair.
Enterocele and massive vaginal eversion. Mesh configuration for abdominal sacral colpopexy. The crux of the Y is formed by permanent sutures with the knots tied down on the side that faces the sacrum, not the vagina.
Enterocele and massive vaginal eversion. Note the anatomy of the lower presacral space. Take care to adequately mobilize the sigmoid colon and ensure the safety of the right ureter. Identification of the middle sacral vessels is important to avoid hemorrhage.
Enterocele and massive vaginal eversion. Note adequate bites taken into the anterior sacral fascia at sacral level 3 (S3). Take care not to attach the mesh too high (towards the sacral promontory) so that the normal vaginal axis is maintained. Also, take care to avoid excess tension on the vagina.
Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum at sacral level 3 (S3).
Enterocele and massive vaginal eversion. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus.
 
 
 
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