Peritoneocele, enterocele and anismus

Case contributed by Dr Vikas Shah

Presentation

Obstructed defaecation, feeling of fullness in vagina and tenderness on posterior wall. Previous vaginal hysterectomy for fibroid disease.

Patient Data

Age: 40 years
Gender: Female
MRI

MRI defecating proctogram

Structural findings:

Hysterectomy noted.  There is a 25 mm left ovarian cyst. Fat is noted within the rectovaginal space, with a small bowel loop lying quite low at rest.

Dynamic findings:

Measurements obtained using the PCL system at maximal straining are as follows:

Bladder neck: 13 mm below line (mild cystocele)

Vaginal apex: 10 mm above line

Anorectal junction: 63 mm below line (moderate to severe anorectal junction descent)

Rectocele: 26 mm in depth (small anterior rectocele)

At the onset of evacuation, there is global pelvic floor descent.  Very little gel is expelled during straining, but there is some opening of the anal canal after multiple attempts. The appearances may reflect anismus.

There is a large enterocoele/peritoneocele seen in the rectovaginal space, extending to the perineum, effectively displacing the vagina from the rectum. A small anterior rectocele is also noted.  No evidence of mucosal thickening or intussusception.

Case Discussion

The vaginal symptoms were thought to be due to a larger rectocele than is apparent on the study, because the bulging was caused predominantly by the mesenteric and peritoneal fat descending into the rectovaginal space.

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Case information

rID: 46858
Published: 21st Jul 2016
Last edited: 5th Jan 2019
Inclusion in quiz mode: Included

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