Enterocele and Massive Vaginal Eversion Workup

Updated: May 11, 2016
  • Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD  more...
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Workup

Laboratory Studies

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  • 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. Prophylactic anticoagulant therapy should be considered in all patients.

  • 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

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  • Imaging studies have traditionally included intravenous pyelogram (IVP) for cases of severe prolapse to rule out hydronephrosis. A renal ultrasound is now the preferred technique if needed for this indication.

  • Controversy exists regarding the utility of other imaging studies. These may include dynamic cystoproctography, magnetic resonance imaging (MRI), 3D and 4D transperineal ultrasound, and even peritoneography (ie, the injection of radiographic dye into the peritoneal cavity). [25] These studies may be reserved for difficult and inconclusive cases, especially for the diagnosis of enterocele and sigmoidocele but are not routinely necessary.

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Diagnostic Procedures

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  • 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 ultrasound or catheterization should suffice for the vast majority of cases. Postvoid residual volumes less than 50-100 mL are considered normal range, if the patient voids at least 200 mL. [26]

    • 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 obstructed voiding is obtained and may influence the choice of procedures.

  • Several diagnostic procedures are available for the assessment of anal incontinence, which often coexists with prolapse and urinary incontinence and is beyond the scope of this manuscript.

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