Presentation
Obstructed defecation, feeling of fullness in vagina and tenderness on posterior wall. Previous vaginal hysterectomy for fibroid disease.
Patient Data
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 (within normal limits)
Anorectal junction: 63 mm below line (moderate anorectal junction descent)
Rectocele: 26 mm in depth (moderate sized 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 are not typical for anismus and are likely to reflect a degree of situational anxiety.
There is a large enterocele/peritoneocele seen in the rectovaginal space, extending to the perineum, effectively displacing the vagina from the rectum. A moderate sized anterior rectocele is also noted. No evidence of mucosal thickening or intussusception.
In summary:
Hysterectomy.
Global pelvic floor descent during evacuation with moderate sized anterior rectocele.
Large enterocele/peritoneocele in the rectovaginal space.
No 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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