An enterocele, also known as a small bowel prolapse, is a type of pelvic organ prolapse that occurs when the small intestine shifts from its normal position and pushes into the vaginal canal. This condition is essentially a hernia involving the weakening or damage of the supportive tissues and muscles of the pelvic floor. While it may sometimes occur without symptoms, an enterocele can lead to a noticeable bulge and feelings of discomfort.
Understanding the Anatomical Mechanism
The pelvic organs are normally held in place by a complex network of muscles, ligaments, and connective tissue called fascia, which together form the pelvic floor. An enterocele develops when this supportive structure becomes stretched or torn, creating a defect in the pelvic floor. This structural weakness allows the small intestine to drop down from the abdominal cavity.
The herniation typically occurs at the top of the vagina, along the posterior wall. The small bowel slips into the space between the rectum and the vagina, pressing against the vaginal wall and causing a noticeable protrusion. This means the small bowel is no longer fully contained within the abdomen but is instead bulging into the pathway of the vagina. The resulting bulge is often referred to as a herniation sac.
Factors That Increase Risk
The development of an enterocele is directly related to conditions that stretch or damage the pelvic support tissues or repeatedly increase pressure within the abdomen. Childbirth is a major factor, especially multiple or difficult vaginal deliveries, as the process of labor significantly strains the muscles and ligaments of the pelvis. However, not every woman who has had birth will develop an enterocele.
Prior pelvic surgery, such as a hysterectomy, can disrupt the pelvic support structures, allowing the small bowel to prolapse into the space where the uterus once was. Aging and hormonal changes, particularly the decline in estrogen during menopause, contribute to the loss of muscle tone and elasticity in the pelvic floor tissues. Other risk factors involve chronic straining, including persistent coughing from conditions like bronchitis or smoking, or prolonged pushing due to chronic constipation. Genetic predisposition, linked to weaker connective tissues, also increases the likelihood of developing an enterocele.
Recognizing the Physical Signs
Symptoms of an enterocele vary widely; some individuals may not experience any physical signs, while others have significant discomfort. The most common complaint is a sensation of pelvic pressure or a feeling of heaviness in the lower abdomen. This feeling often worsens late in the day or after prolonged periods of standing or physical activity, as gravity increases the downward pull on the small intestine.
Patients often report a sensation of a soft bulge or a mass inside the vagina, which may feel like something is falling out. This bulge is the small bowel pressing against the vaginal wall and is sometimes noticeable during self-examination. Specific bowel symptoms can occur, such as difficulty completing a bowel movement or the need to press on the vaginal area to fully empty the rectum. A persistent backache or a pulling sensation in the pelvis that is relieved when lying down may also be experienced. Urinary issues, like increased frequency or incontinence, may be present if other organs like the bladder are also affected by pelvic organ prolapse.
Medical Confirmation and Treatment
Diagnosis typically begins with a thorough pelvic examination performed by a healthcare provider. During the exam, the provider may ask the patient to perform a Valsalva maneuver, which involves bearing down or coughing. These actions increase abdominal pressure, making the prolapsed small bowel bulge downward and become more apparent for visual confirmation.
In some instances, imaging tests are used, such as a pelvic floor MRI or a specialized X-ray called defecography, to precisely determine the extent of the prolapse and rule out other pelvic floor conditions. Treatment options are tailored to the severity of symptoms and the patient’s overall health. For mild cases, conservative management is often recommended, which includes lifestyle adjustments like weight loss, avoiding heavy lifting, and managing chronic constipation or coughing.
A non-surgical option involves the use of a vaginal pessary, a removable silicone device inserted into the vagina to provide mechanical support to the weakened pelvic tissues. For more advanced cases or when symptoms significantly affect quality of life, surgical repair may be necessary. The goal of surgery is to move the small intestine back into its correct anatomical position and repair the stretched or torn connective tissues of the pelvic floor. This procedure can be performed through the vagina or the abdomen, often utilizing minimally invasive techniques like laparoscopy or robotic assistance, and sometimes involves using a synthetic mesh for reinforcement.