Case notes

An 81-year-old woman was admitted to our emergency room with severe genital hemorrhage after falling at home. She weighed 150 lb (68 kg), and her medical history included cerebral ictus, arterial hypertension, venous insufficiency, and atrial fibrillation, which was treated with oral anticoagulant therapy. The patient had delivered vaginally 3 times, had never had pelvic surgery, and now had mild uterovaginal prolapse. Menopause occurred when she was 52 years old; she did not receive hormonal therapy.

A vaginal laceration, 1.6 in (4 cm) in length, was identified in the posterolateral left fornix during gynecologic examination. This was accompanied by herniation of the small intestine. Protruding bowel loops, measuring 15.7 in (40 cm), were edematous and congested but apparently undamaged and viable ( Figure ).

Small intestine was herniated through vaginal laceration.

Fedele. Traumatic vaginal evisceration. Am J Obstet Gynecol 2011.

Conclusions

The patient, in stable clinical condition, underwent an emergency surgical procedure with reduction of small bowel evisceration, typical vaginal hysterectomy with adnexal preservation, and cystocele-rectocele repair to reinforce the vaginal vault. After the prolapsed intestine was disinfected and preserved in a moist saline wrap, it was reduced vaginally through a circular colpotomy that started from the site of spontaneous laceration. Recanalization occurred on the sixth postsurgical day.

On that same day, the patient’s recovery was complicated by dyspnea and fever. A diffuse pulmonary thromboembolism was diagnosed with pulmonary perfusion scintigraphy. Initially, heparin was administered alone; combination therapy with an oral anticoagulant followed. She also received broad-spectrum antibiotics (metronidazole and a cephalosporin) and red blood cell transfusions. She was discharged on the 17th postsurgical day in stable condition. Histologic examination of a biopsy sample from the vaginal vault showed an edematous and ulcerative inflammatory process with hyperplastic squamous epithelium. No evidence of malignant transformation was present.

Vaginal rupture with evisceration was first described in 1864 by Hyernaux, and since then <100 cases have been reported in the scientific literature. Most commonly, patients are postmenopausal (68-75%), have recently had a hysterectomy or other pelvic surgery (73-83%), and have an enterocele (63-83%). Other risk factors are associated with the presence of weak, inflexible, or atrophic vaginal tissue: hypoestrogenism, chronic devascularization, pelvic floor weakness, collagen disease, multiparity, pelvic radiation, obstetric trauma, vault hematoma, or infections. In an estimated 32% of cases, vaginal evisceration occurs after an acute event that causes increased intraabdominal pressure–coitus, rape, vaginal instrumentation, trauma, defecation, or Valsalva maneuvers–but more often, it is spontaneous (67%); patients with multiple sexual partners have an increased risk of infection and weakness of the vaginal vault.

Patients usually present to the emergency room within 24 hours of symptom onset with reports of abdominopelvic pain (58%), hemorrhage, a feeling of vaginal fullness, visible intestinal incarceration, or shock. Rupture most often occurs in the posterior fornix of the vagina, with the intestine prolapsing through the pouch of Douglas (67%). Immediate emergency management is critical to preserve bowel viability. Guttman and Afilalo underscored several important treatment steps: stabilization of patients and their fluid status, positioning of a moist saline wrap around the bowel, administration of broad-spectrum antibiotics, and immediate surgical repair.

Surgical modality depends on the clinical situation. A vaginal approach is performed in about 58% of cases when bowel peristalsis is present and the patient is stable. If questions about organ viability, bowel incarceration, or mesenteric trauma exist, an abdominal approach with exploratory laparotomy is preferred because it permits adequate examination of the remaining intestine and resection. Laparoscopy is often used in cases of minor laceration so that pelvic content can be inspected after vaginal repair. Surgery includes intestinal reduction, vaginal repair, and pelvic reconstruction. Bowel resection is performed in one-third of cases for incarceration, trauma, or necrosis. A decision to postpone primary closure of the vaginal defect depends on vaginal tissue health since repairing nonviable tissue can increase the risk of recurrence. Timing of pelvic floor reinforcement depends on the patient’s general condition and the status of pelvic tissues. Histopathologic analysis always shows inflammation and hyperplasia of vaginal squamous epithelial tissues.

Patients with a history of pelvic surgery and additional risk factors for vaginal prolapse should be examined annually, although regular follow-up may not prevent vaginal evisceration. In conclusion, vaginal evisceration is rare and potentially life threatening. Adequate emergency management is crucial to preserve bowel function.