Small bowel evisceration in a perforated uterine prolapse

Abstract

The evisceration of the bowel through the vaginal vault is an extremely rare condition and a surgical emergency with a high-reported mortality rate. Vaginal evisceration most commonly affects menopausal women with a hysterectomy or those with previous vaginal surgery. The most common risk factors include the triad of post-menopausal atrophy, previous vaginal surgery and enterocele. Estrogen deficiency in post-menopausal women leads to weaker pelvic support structures and a thin, atrophic vagina, making it more prone to rupture. Previous vaginal surgery leaves scar tissue with diminished vascularity in the vaginal wall and apex, predisposing it to dehiscence. Post hysterectomy, the axis of the vagina may be changed, making it more vertical or shortened and resulting in the vagina losing its valve-like mechanism. We present a 70-year-old female brought to the emergency department with a vaginal prolapse complicated by bowel evisceration, without any history of vaginal surgery, hysterectomy or trauma. The bowel was inspected and irrigated copiously, then reduced into the abdominal cavity as it was still viable. A total vaginal hysterectomy with an anterior and posterior colporrhaphy was done. The patient had a successful recovery with no complication. We present this case due to its rarity, the absence of previous vaginal surgery, trauma, or hysterectomy and the successful multidisciplinary surgical approach with total recovery.