Enterocele Presenting as Anterior Rectal Prolapse: Resolutio
An enterocele is a pelvic hernia formed from the separation of endopelvic fascia, associated with the posterior or anterior vaginal fornix, and most commonly located in the posterior superior vaginal segment. Rectal prolapse is a debilitating condition in which the mucosa of the rectum protrudes circumferentially from the anus. Surgical repair is the recommended treatment for rectal prolapse, and though there are many different surgical options, there is no consensus on which approach is best.

An 84-year-old postmenopausal white female was referred for evaluation and treatment of a persistent rectal bulge. She had noticed this bulge for over 10 years and initially thought that it was a hemorrhoid. She described a bulge at the anus with the size of a lemon which worsened with physical activity and reported accidental leakage of bowel contents consisting of pellet-formed stool. She was sometimes unable to differentiate between the bulge and stool. Additionally, she reported anal laxity, constipation, and occasional bright red blood per rectum. She denied any urinary symptoms or vaginal prolapse.

Pelvic exam revealed an atrophic vagina with no significant anterior or posterior vaginal wall prolapse. Her cervix was absent surgically, and her pelvic organ prolapse quantification was as follows: GH 2, PB 2, Aa -3, Ba -3, Ap -3, Bp -3, C -7, D n/a, and TVL 7. Rectal exam showed normal perianal skin and sphincter tone. With Valsalva, she demonstrated significant anterior rectal wall prolapse with palpable contents consistent with small bowel enterocele in the rectovaginal space. Prolapse was approximately 6 cm in size with the anterior rectal wall extending outside the anal verge and no evidence of posterior or circumferential rectal prolapse. Endoanal ultrasound showed normal levators, intact external anal sphincter circumferentially, and attenuation of the internal anal sphincter. There were no discernible masses, but the patient was unable to produce her rectal prolapse with the ultrasound transducer in place.

Transperineal ultrasound was used to dynamically evaluate the perineal and rectal anatomy and demonstrated a large enterocele prolapsing between the vagina and the rectum with apparent fat or small bowel contents. Prolapse at the anterior rectal wall was directly associated with this enterocele. Defecography and dynamic MRI were not available at our facility.

The patient was admitted to the hospital and anesthetized for surgery. A vertical posterior vaginal incision was made, extending into the perineal body. The vaginal epithelium was separated from the underlying endopelvic fascia, and dissection was performed superiorly and laterally to the level of the ischial spines and levator ani. A large enterocele was identified, opened, ligated with two purse-string sutures of delayed absorbable monofilament suture, and then excised . A suture capturing device was used to pass a polypropylene suture through the levator tendon immediately distal to the ischial spine bilaterally, following which these sutures were attached superiorly and laterally to the rectovaginal septum completing the iliococcygeus suspension in a tension-free manner . Small site-specific rectovaginal septal defects were repaired. The vaginal epithelium was then closed, and the perineal body was reconstructed.

Postoperatively, the patient recovered well and was discharged home on the first postoperative day with complete resolution of her rectal prolapse symptoms. She was seen at 1 month and 3 months postoperatively and by 3 months had resumed her normal activities of daily living with complete symptom resolution and normal defecation without incontinence.

In Conclusion enterocele presenting as anterior rectal prolapse appears to be a rare condition, but one that may be amenable to a vaginal approach to treatment rather than traditional rectal prolapse repair. Careful physical examination is crucial. As a key physical exam finding, absence of circumferential mucosal folds and isolated anterior prolapse may herald the presence of an enterocele and should prompt an appropriate evaluation.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961605/