The pathophysiology of an enterocele and its management.

This paper describes 130 patients with enteroceles and their treatment. It includes analysis of all cases with enterocele over a 17-month period in a pelvic floor dysfunction database. Procedures performed included the Moschcowitz procedure with suspension of the vaginal vault to the sacrum in 13 patients (10%), colposacrosuspension (CSS) (mesh from the upper posterior half of the vagina to the sacrum with mobilisation and fixation of the rectum to the mesh) in 39 patients (30%), perineocolposacrosuspension (PCSS) (similar to CSS, but the mesh is inserted further down to the perineum) in 48 patients (37%) and perineopubo-colposacrosuspension (PPCSS) (as PCSS, but with a second mesh between the bladder and vagina extending to the sacrum) in 30 patients (23%). An additional modified Burch colposuspension was performed in 87 patients (67%). A failure was defined as a recurrent vaginal prolapse of Grade II or more, or urinary incontinence requiring surgical correction. The patients' mean age was 60.5 years, their mean parity 3.3 and 92.3% were white. Preoperatively, 33.8% of the patients complained of constipation, 33.1% of difficulty in defaecation and 77% had bladder symptoms, suggesting urinary stress incontinence or detrusor instability. In 74.6% of the patients part of the vagina protruded through the vaginal introitus. The mean period of follow-up was 7.4 months (range 1-26) with only 13 patients (10%) not followed. Only two patients (1.5%) developed Grade II vaginal prolapse (both cystoceles and both from the PCSS group). Urinary stress incontinence in need of further treatment developed in 13 patients (10%). The failure rate, therefore, was 11.5%. In six patients (4.6%) the mesh had to be removed due to mesh reaction. In all cases the mesh was unabsorbable. Vaginal suspension procedures with mobilisation of the rectum provided satisfactory results for severe enterocele over the short term.