Approach Considerations

Generally, the workup for massive vaginal eversion is based on the history and physical examination. Laboratory and imaging studies, procedures, and consultation with other specialties may be necessary at times, and they are discussed below.

Laboratory Studies

A urinalysis is routinely performed to rule out infection and/or hematuria depending on the patient's symptoms when she initially presents for consultation. Culture is done as needed based on the urinalysis results and the patient's symptoms.

In the case of massive vaginal eversion, blood urea nitrogen (BUN) and creatinine levels may be elevated because of obstruction and therefore may need to be evaluated.

A standard preoperative laboratory evaluation should be performed to screen for anemia, metabolic abnormalities, and clotting problems depending on the patient's age and medical history. Surgical procedures for the repair of massive prolapse frequently involve elderly patients, and the operations are often prolonged, involving the Trendelenburg position with the legs elevated in stirrups. It is important to pay special attention to the effects on patients with cardiac or pulmonary conditions, and appropriate tests such as an electrocardiogram (ECG), complete blood cell (CBC) count, and clotting studies are warranted.

Imaging Studies

Imaging studies to consider for the workup of enterocele and massive vaginal eversion, but in our experience seldom used are the following:

Intravenous pyelogram (IVP)
Renal ultrasound scan
Computed tomography (CT) urogram

Intravenous pyelogram (IVP) for cases of severe prolapse to rule out hydronephrosis has been traditionally performed. A renal ultrasound scan is the least invasive modality to rule out significant hydronephrosis. A CT urogram can be obtained if further evaluation of the upper urinary tract and bladder is needed.·

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).^[37]These studies may be reserved for difficult and inconclusive cases, especially for the diagnosis of enterocele and sigmoidocele but are not routinely necessary.

In cases of massive vaginal eversion, MRI or ultrasound may be used to determine which organ (bladder, small or large bowel) lies behind the prolapsed vagina. In patients with lower stage prolapse, these studies may be used to evaluate the levator muscles, to predict recurrence risk after pelvic reconstructive surgery, or for research purposes.^[38]

If intra-abdominal pathology is suspected, a CT scan of the abdomen and pelvis may be ordered to evaluate for ascites or a mass.

Diagnostic Procedures

Although controversial, multichannel urodynamic studies with prolapse reduction may be used to further evaluate the preoperative patient with significant prolapse.^[39] In the case of massive vaginal eversion, the urethra may be kinked by the prolapse, obstructing urinary incontinence, and prolapse reduction with a cough stress test (CST) should be performed in the office during the initial examination.

Studies often include initial uroflowmetry (with the prolapse not reduced) followed by insertion of a pessary or other methods to reduce the prolapse (speculum, Procto Swabs, 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 of less than 50-100 mL are considered normal range, if the patient voids at least 200 mL.^[40]

With the prolapse reduced and pessary placement checked so it is not obstructing the urethra, complex cystometry with provocative maneuvers can be 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.

Simple cystometry may also be performed in the office if multichannel urodynamics are not available.

Several diagnostic procedures are available for the assessment of accidental bowel leakage, which often coexists with prolapse and urinary incontinence and is beyond the scope of this article.

Treatment & Management

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Media Gallery

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 epithelium, 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 skin 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 epithelium. 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. LeFort colpocleisis begins with dissection and excision of a rectangular patch of epithelium 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 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. Mesh may come preformed or made in the operating room from two pieces of polypropylene mesh. If so, 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 2 (S2). 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.
Enterocele and massive vaginal eversion. Massive vaginal eversion in a patient with post hysterectomy vaginal vault prolapse.
Enterocele and massive vaginal eversion. A variety of pessaries that are available for the treatment of pelvic organ prolapse.
Enterocele and massive vaginal eversion. Uterosacral ligament suspension.
Enterocele and massive vaginal eversion. Iliococcygeus fixation.
Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum.

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Author

Rony A Adam, MD Professor of Clinical Obstetrics and Gynecology, Vanderbilt University School of Medicine

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

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Panza, MD, FACOG Assistant Professor of Clinical Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Rochester Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michel E Rivlin, MD Former 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Chief Editor

Kris Strohbehn, MD Professor and Vice Chair of Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and 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, Society of Gynecologic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Robert K Zurawin, MD Associate Professor, Chief, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

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

Disclosure: Received consulting fee from Ethicon for consulting; Received consulting fee from Bayer for consulting; Received consulting fee from Hologic for consulting.

Raisa O Platte, MD, PhD Urogynecology Associate, Department of Obstetrics and Gynecology, Geisinger Health System

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

Disclosure: Nothing to disclose.

Acknowledgements

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.