A 60-year old vaginally multiparous woman presents with symptoms of a bothersome vaginal bulge. She first noted the bulge 5 years ago after undergoing a vaginal hysterectomy for abnormal uterine bleeding and states that it has progressively grown in size. The bulge is particularly bothersome when she exercises or takes long walks. She needs to reduce the bulge to completely empty her bladder, but does not report stress or urgency urinary incontinence. She does not report difficulty with defecation, splinting or fecal incontinence. Standing evaluation reveals that her anterior vaginal wall prolapses to the hymen, but her vaginal cuff and posterior vaginal wall prolapse 2 cm beyond the hymen. On standing bimanual exam, with one finger in the rectum and one in the vagina, small bowel is palpated as it descends into the rectovaginal space between the vagina and rectum. Standing full bladder cough stress test with the prolapse reduced is negative.

This patient has stage III pelvic organ prolapse of her vaginal cuff, consistent with an enterocele. An enterocele is a herniation of the pelvic peritoneum and/or small bowel beyond the normal boundaries of the cul-de-sac. Endopelvic fascia supporting the anterior, apical or posterior vagina is deficient, allowing the vagina to prolapse and small bowel to fill the hernia sac. An enterocele classically causes apical and/or posterior vaginal wall prolapse as the small bowel dissects into the rectovaginal space. Less commonly, an enterocele may occur anterior to the vagina resulting in anterior vaginal wall prolapse. As with most pelvic organ support defects, enteroceles are rarely isolated and typically present in conjunction with apical prolapse.

Clinical evaluation of pelvic organ prolapse relies on the patient’s history and physical exam findings. An enterocele may be suspected when a patient with apical and/or posterior prolapse reports a dragging sensation in the pelvis, especially when standing or bearing down. Stretching of the small bowel mesentery is also thought to cause colicky lower abdominal pain.

Because vaginal topography does not reliably predict the location of the associated pelvic viscera [1], current terminology describes prolapse in terms of the anterior, apical and posterior vaginal walls rather than as cystocele, enterocele or rectocele [2]. While standardized systems for the clinical assessment of pelvic organ prolapse, such as the Pelvic Organ Prolapse Quantification System (POP-Q) [2], enable clinicians to reliably and reproducibly describe the extent of prolapse in each vaginal compartment [3], the underlying defects that contribute to the symptomatology of prolapse often escape visual inspection in the office. The pelvic organ behind each prolapsed vaginal segment varies [1, 4] and important defects in the levator ani musculature cannot be visualized on physical exam [5]. Fortunately, in the majority of cases, the vaginal apex is addressed during surgery and thus, a definitive diagnosis of enterocele is less important.

On physical exam, enterocele is most often mistaken for rectocele when the posterior vaginal wall is the leading edge of the prolapse. In cases of posterior vaginal wall prolapse near the apex, an enterocele may be differentiated from a distal rectocele on rectovaginal exam. Alternatively, a transverse groove separating an enterocele from a rectocele may be seen on split speculum exam. In some cases, enterocele can be difficult to differentiate from rectocele or sigmoidocele and defecography or dynamic MRI may aid in diagnosis and surgical planning. In one study of 62 women planning surgical repair for prolapse, Defecography identified an enterocele not previously detected by physical exam in nearly half of women [6]. Enterocele is diagnosed by visualizing small bowel within the rectovaginal space; however, an enlarged rectovaginal space (>2 cm) on imaging also suggests that there is a potential space for enterocele development.

Anterior and/or posterior vaginal wall prolapse without concomitant apical prolapse is uncommon [7]. Therefore, apical prolapse repair should be included in the majority of enterocele repairs. Historically, reconstructive pelvic surgeons focused on separating the vagina into distinct compartments and identifying the underlying pelvic viscera prior to surgical repair. More recent data indicate that suspension of the vaginal apex alone adequately addresses prolapse in the majority of cases [8, 9]. Outcome studies also show that restoration of the apex corrects nearly half of anterior vaginal wall defects and one-third of posterior defects [10].

Most women will not be symptomatic until the leading edge of their prolapse extends beyond the hymen [11]. Similarly, half of women presenting for routine gynecologic care with no pelvic floor symptoms have prolapse that extends to the hymen [12]. Therefore, isolated pelvic symptoms such as pressure or splinting with defecation should not be attributed to enterocele or other anatomic support defects unless the most prolapsed vaginal segment extends beyond the hymen. Women with a symptomatic enterocele should be offered the full range of options for treating prolapse, including observation, pessary and surgery.

Satisfaction after surgery for pelvic floor disorders strongly correlates with achievement of patient-selected preoperative goals, but is not associated with objective outcome measures, such as POP-Q or prolapse stage [13, 14]. Therefore, it is important to assess the level of bother and impact on quality of life caused by the patient’s prolapse. The surgeon should assist the patient in setting realistic treatment goals and should take these factors into account when guiding the patient to the most appropriate treatment option.

Initial surgical counseling should include a directed conversation to identify the patient’s bothersome pelvic symptoms. The patient should be encouraged to express which symptoms she hopes will be addressed with surgery. This will ensure that her expectations are aligned with the selected treatment. In addition to the common risks of pelvic surgery, the patient should be counseled regarding the risk of prolapse recurrence, recovery time associated with various routes of surgery and the impact of enterocele repair on sexual function including the risk of dyspareunia. She should also be informed of the likely need for concomitant procedures, particularly to address apical support. Because enterocele repair will often include apical prolapse repair, surgeons should thoroughly explain the alternatives, risks, benefits, complications and perioperative course associated with abdominal (open, laparoscopic, and robotic) and vaginal apical prolapse repairs, with and without mesh. Nearly all of these procedures address the endopelvic fascial defect between the anterior and posterior vaginal walls and may correct a symptomatic enterocele. Native tissue apical repairs reattach the anterior and posterior endopelvic fascia to the uterosacral ligaments or sacrospinous ligament. In both procedures, it is important to incorporate the anterior and posterior vagina to obliterate the enterocele defect. Similarly, sacrocolpopexy involves attaching synthetic mesh to the anterior and posterior vagina and suspending both walls to the anterior longitudinal ligament, thereby eliminating the anterior and posterior enterocele. Most enterocele repairs require entry into the peritoneal cavity thus, patients should be counseled regarding elective or risk-reducing bilateral salpingo-oophorectomy and/or prophylactic salpingectomy for ovarian cancer risk reduction [15, 16].

Finally, the impact of enterocele repair on urinary symptoms and continence must be addressed. In incontinent patients, surgeons should determine the incontinence subtype (stress or urgency) and need for additional treatments (surgical or non-surgical). Likewise, continent women should be advised of their risk of developing de novo stress incontinence after prolapse repair [17, 18].