Spontaneous transvaginal bowel evisceration.

Transvaginal prolapse of bowel segments after major abdominal surgery is of rare occurrence and is commonly reported to follow after hysterectomy and enterocele repair. However, spontaneous bowel evisceration through vagina following cystectomy is even rare. We report and discuss a case of spontaneous transvaginal bowel evisceration in a postmenopausal woman with the intent of increasing its awareness among surgeons and proposing a precautionary measure for this entity.

INTRODUCTION

Spontaneous bowel evisceration through vagina is an extremely rare event with approximately 80 cases documented so far.[12] Bowel evisceration is more commonly seen (~68%) in postmenopausal older women.[123] Risk factors identified for evisceration include hypoestrogenism, coital or obstetric trauma, previous vaginal surgery, presence of enterocele and ageing.[2456] Previous gynecological surgeries, mainly hysterectomy and enterocele repair, were accountable in majority (73%) of patients diagnosed with transvaginal bowel evisceration.[2678] We report a female patient who underwent radical cystectomy for transitional cell carcinoma of the urinary bladder and now presenting with spontaneous transvaginal bowel evisceration.

CASE REPORT

A 51-year-old postmenopausal female presented to the emergency department with complaints of continuous, dull aching pain in the lower abdomen and an irreducible mass protruding per vagina for the past 6 hours. Patient's past history was significant for high-grade muscle invasive transitional carcinoma of bladder. She underwent anterior pelvic excentration with ileal conduit 3 months back. Histopathology reported high-grade papillary urothelial carcinoma with muscle and urethral invasion without involvement of the ureters. There was no lymph node metastasis. Postoperative period was uneventful.

At the current visit, general survey showed features suggestive of dehydration with pulse rate of 94/min and blood pressure recording of 130/88 mm of Hg. On examination, about 30 cms of small bowel was found protruding through the vaginal introitus [Figure 1]. The bowel loops were congested and a small defect was palpable in the pelvic floor communicating with the peritoneal cavity. Systemic examination was completely normal. Abdominal examination showed ileostomy site draining clear urine, midline incision healed by primary intension. Hematological and biochemical investigations were normal. Exploratory laparotomy was done after stabilizing the patient which showed 30 cms of jejunal and ileal loops prolapsing through pelvic floor and vaginal introitus. Bowel loops were congested but found to be viable after reduction into peritoneal cavity. Full-thickness tear was present in jejunal loop 25 cms from duodeno-jejunal flexure; resection anastamosis was hence performed. Pelvic floor was repaired with prolene mesh and vagina closed from the perineum. Postoperatively patient had uneventful recovery. Follow-up after 1 month was normal.

Figure 1

Congested small bowel loops seen protruding through the vaginal introitus in a 51-year-old woman

DISCUSSION

Transvaginal bowel evisceration is a rare, life-threatening situation needing immediate attention. As reviewed by Kowalski et al. transvaginal bowel evisceration is more commonly seen in elderly postmenopausal women.[2] This may be attributed to the fact that postmenopausal vaginal wall is thin, scarred and shortened with diminished vascularity which makes it more prone to rupture.[4] The risk factors for evisceration for premenopausal women include trauma due to coitus, rape, obstetric procedures, or foreign-body insertion and postmenopausal women risks are older age, previous vaginal surgery, enterocele repair, a sudden increase in intra-abdominal pressure (i.e., straining, coughing, defecating) and medical conditions which predispose to inadequate wound healing.[1256] Other risk factors include history of irradiation, abdominal or vaginal hysterectomy, perineal proctectomy and is rarely known to occur spontaneously.[126789] Spontaneous rupture is commonly occurs at the posterior fornix.[5]

The plausible explanation for this event can be attributed to any departure from the normal state in the maintenance of normal pelvic pressure distribution. The upper vaginal axis in normal circumstances is directed parallel to the levator plate and perpendicular to the direction of intra-abdominal pressure. Alteration in the above-mentioned anatomical relationship during surgery may alter the normal axis of the vagina; hence the vagina assumes a more vertical position. As a result, raised intra-abdominal pressure would now be directed at an axis parallel to the vaginal vault, thus making it vulnerable to rupture.[3]

Bowel evisceration is a grave surgical emergency. The mortality reported with this condition is 6-10% which is attributed mainly to septicemia and thromboembolism. Bowel infarction, infection, ileus and deep vein thrombosis are other known complications of transvaginal bowel evisceration. Early recognition and urgent surgical intervention is imperative for adequate management, to lessen the associated morbidity and mortality and also to preserve the bowel viability.[2356] Emergency management of bowel evisceration consists of few vital elements which include stabilization of the patient, intravenous fluid replacement therapy, cleaning and packing the bowel with moist saline sponges, early prophylactic antibiotic cover for gastrointestinal flora, and immediate surgical repair and controlling hemorrhage with vaginal packs.[4]

Surgical management necessitates an abdominal approach with pelvic laparotomy through a midline incision. The bowel is retrieved into abdomen and nonviable segment is excised and reanastomosis performed. Definitive treatment of transvaginal bowel evisceration is achieved by correction of the pelvic floor defect by pelvic floor enforcement at the time of the initial surgery. The vaginal defect should be examined. Necrotic tissue, if present, around the vaginal defect and stumps of the supporting ligaments should then be excised and the defect closed with absorbable suture material.[8] On the contrary, Nichols and Randall suggested that delayed evaluation of the pelvic support followed by appropriate repair is preferable to immediate repair.[10] There is also a mention in one of the literature where it was advised to leave the defect open for secondary suturing transvaginally if the edges are not healthy enough to support healing.[8] However, we recommend early management as it shows better results. In recent literature the use of omental patch has also been illustrated with Narducci et al. describing a successful laparoscopic and vaginal approach with the use of omental patch.[19]

The principles involved in prevention of such a dreaded condition include:

(a) Restoration of normal vaginal axis; (b) anastomosis of the stumps of the supporting ligaments of the pelvis to the angles of the vagina; (c) preservation of vaginal length and (d) maintenance of vaginal integrity with application of estrogen if necessary.[2]

Spontaneous transvaginal bowel evisceration, although uncommon, can occur following abdominal surgical procedures, radical cystectomy as in this case, and simultaneous vault fixation and reinforcement of pelvic support at the time of surgery may prevent its occurrence in future.