Peritoneocoele, enterocoele and anismus
Obstructed defaecation, feeling of fullness in vagina and tenderness on posterior wall. Previous vaginal hysterectomy for fibroid disease.
MRI defaecating proctogram
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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.
Measurements obtained using the PCL system at maximal straining are as follows:
Bladder neck: 13 mm below line (mild cystocoele)
Vaginal apex: 10 mm above line
Anorectal junction: 63 mm below line (moderate to severe anorectal junction descent)
Rectocoele: 26 mm in depth (small anterior rectocoele)
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/peritoneocoele seen in the rectovaginal space, extending to the perineum, effectively displacing the vagina from the rectum. A small anterior rectocoele is also noted. No evidence of mucosal thickening or intussusception.
The vaginal symptoms were thought to be due to a larger rectocoele than is apparent on the study, because the bulging was caused predominantly by the mesenteric and peritoneal fat descending into the rectovaginal space.