Vaginal evisceration is an evisceration of the

small intestine The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the p ...

that occurs through the

vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...

, typically subsequent to

vaginal hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...

, and following

sexual intercourse Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal penetrat ...

after the surgery. It is a

surgical emergency Surgical emergency is a medical emergency for which immediate surgical intervention is the only way to solve the problem successfully. The following conditions are surgical emergencies: * Acute trauma Cardiothoracic * Cardiac tamponade * Acute ...

Presentation

Vaginal evisceration is typically obvious upon presentation, as intestine (typically

ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine ma ...

) can be seen protruding from the

introitus An introitus is an entrance into a canal or hollow organ. The vaginal introitus In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal open ...

. Other symptoms include a sense of pressure in the pelvis and

vaginal bleeding Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductiv ...

Complications

Complications of surgery can include injury to the

bladder The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine enters ...

rectum The rectum is the final straight portion of the large intestine in humans and some other mammals, and the Gastrointestinal tract, gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the s ...

, or

ureter The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually long and around in diameter. The ureter is lined by urothelial cells, a type of transitional epit ...

, especially in cases where there has been tissue

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...

. Surgeons typically perform intraoperative

cystoscopy Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope. The urethra is the tube that carries urine from the bladder to the outside of the body. The cystoscope has lenses like a telescope or microscope ...

with dye to assess potential bladder or ureter injuries.

Causes

Vaginal evisceration is a serious complication of dehiscence (where a surgical wound reopens after the procedure), which can be due to trauma. 63% of reported cases of vaginal evisceration follow a

(where the uterus removal surgery is performed entirely through the vaginal canal). Most instances of vaginal evisceration following a laparoscopic hysterectomy result from sexual intercourse among women approaching

menopause Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often d ...

, and from the combination of heightened pressure within the abdomen and weakened vaginal muscles among those who have experienced menopause. Other risk factors include regular

Valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can ...

, advanced age,

obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...

smoking Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...

immunosuppressive therapy Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse react ...

vaginoplasty Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplas ...

anemia Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...

, poor surgical technique,

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues a ...

, and postoperative/perioperative infection. One case has been reported as of 2015 where placement of a

pessary A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat Stress incontinence, stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to ...

caused an evisceration. Dehiscence is more common in laparoscopic hysterectomy than in open hysterectomy.

Prevention

When performing a vaginal hysterectomy, surgeons should aim to avoid damaging surrounding tissue or drying the vaginal cuff. Surgeons should take extra care to align the tissues, and include sufficient undamaged tissue. Instead of single-layer figure-of-eight sutures, two-layer sutures can aid in preventing vaginal evisceration.

Treatment

Emergently, vaginal eviscerations are treated by keeping the exposed intestines moist and wrapped, while waiting for definitive surgical treatment. Vaginal evisceration is usually treated by removing damaged tissue along the edges of the

vaginal cuff The vaginal cuff is the upper portion of the vagina that opens up into the peritoneum and is sutured shut after the removal of the cervix and uterus during a hysterectomy. The vaginal cuff is created by suturing together the edges of the surgi ...

, re-suturing the opening, and giving the patient broad-spectrum

antibiotic prophylaxis An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...

. Surgery can be conducted via a

laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ane ...

, though research from the 2010s shows that a transvaginal or laparoscopic approach can also be used safely and successfully if an infection has not developed. If left untreated, it can cause

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or ...

or injury to the exposed bowel, including

strangulation Strangling is compression of the neck that may lead to unconsciousness or death by causing an increasingly hypoxic state in the brain. Fatal strangling typically occurs in cases of violence, accidents, and is one of two main ways that hanging ...

or mesenteric tears.

Cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of t ...

abscesses An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...

hematomas A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is b ...

, and other complications can appear at the same time as an evisceration. Abscesses and hematomas can be resolved after surgery with a

surgical drain A surgical drain is a tube used to remove pus, blood or other fluids from a wound, body cavity, or organ. They are commonly placed by surgeons or interventional radiologists after procedures or some types of injuries, but they can also be used ...

. Post-surgical treatment includes continuation of antibiotics and, in some

postmenopausal Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often d ...

people, vaginal estrogen to speed recovery. After surgery, people with vaginal evisceration are advised to avoid intercourse until the surgical site is fully healed.

Epidemiology

Though it is a rare complication, as the popularity of laparoscopic hysterectomy has risen, the rate of vaginal evisceration has also risen. Vaginal cuff dehiscence occurs in 0.24–0.39% of cases; of these, vaginal evisceration occurs in 35%–67%. When all surgical procedures are considered, the rate of vaginal evisceration is 0.032–1.2%.

History

The first report of vaginal evisceration in the medical literature was published in 1864 by Belgian obstetrician Léon Hyernaux; it occurred secondary to traumatic rupture of the vagina during an unsuccessful attempt at

forceps delivery Obstetrical forceps are a medical instrument used in childbirth. Their use can serve as an alternative to the ventouse (vacuum extraction) method. Medical uses Forceps births, like all assisted births, should only be undertaken to help prom ...

. The patient, a 42-year-old woman, survived and made a complete recovery.

References

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External links

Massive Vaginal Eversion: Background, Problem, Epidemiology
Injuries of abdomen, lower back, lumbar spine and pelvis Medical emergencies Gynecological surgery Vagina