On the day of the surgery, which was 2 months later, she presented with a 2-cm prolapse of the anterior rectal wall with no fecal incontinence (Fig. 3). Colorectal surgery was consulted on the phone, but were unavailable for surgical assessment and recommended outpatient follow-up after POP repair. This was discussed with the patient who wished to proceed with her planned surgery. It was felt that correcting the anterior rectocele and enterocele, thereby eliminating the descent of the bowel on the anterior rectal wall, might cause resolution of the rectal prolapse. She then underwent bilateral sacrospinous ligament fixation with mesh through an anterior vaginal approach, enterocele repair, Moschcowitz culdoplasty, and posterior colporrhaphy.
First the anterior sacrospinous ligament fixation and mesh augmented anterior repair were completed with the Uphold Lite (Boston Scientific, Natick, Mass). A standard posterior repair was then started after infiltrating the vaginal epithelium with lidocaine mixed with epinephrine. The rectovaginal muscularis was then dissected off the vaginal epithelium. The enterocele sac was identified and entered. A Moschcowitz culdoplasty was then performed where the neck of the sac was then isolated, and a series of sutures were placed, thereby closing off the cul-de-sac. The first row of 2–0 polypropylene (Prolene) was followed by a row of 0 polydioxanone sutures, effectively closing the enterocele sac. Then, the muscularis was plicated in the midline and also in a site-specific fashion by identifying the defects using 2–0 polyglactin 910 sutures, attaching it to the levators bilaterally. The vagina was then closed with 2–0 polyglactin 910. The patient was discharged home the same day.
At her 2 week postoperative visit, she reported improvement of vaginal prolapse along with resolution of the rectal prolapse. At her last follow-up at 54 weeks she continued to have great improvement since her surgery. She did not experience any symptoms of rectal prolapse, vault prolapse, fecal incontinence, or urinary incontinence. Her POP-Q examination revealed gh = 4, pb = 3.5, tvl = 7, Aa = −1.5, Ba = −1.5, C = −6.5, Ap = −3, and Bp = −3. Her pelvic and rectal examinations revealed no evidence of vaginal or rectal prolapse.
Rectal prolapse is a disabling condition with significant impact on quality of life and sexual dysfunction.1 Associated symptoms include abdominal discomfort, incomplete evacuation, prolapsing mass, and mucous discharge or stool seepage and staining.4 Several studies have linked rectal prolapse with concomitant POP.5,6 A case series by Peters et al5 reported that simultaneous POP and rectal prolapse is associated with parity and injury to the pudendal nerve and levator ani muscle, resulting in denervation of the pelvic floor, causing weakness and prolapse. Prior hysterectomy has also been linked to the development of rectal prolapse.7 The mechanism of rectal prolapse is poorly understood and can be variable in nature. In this case, the compressive enterocele seen on dynamic MRI may have caused the rectal prolapse. As the enterocele begins compressing the anterior wall of the rectum, it causes the wall to push down into the anal canal and pass outward through the anus. It is quite possible that this may have been missed on physical examination because of the intermittent nature of the prolapse or the lack of force generated by the patient on Valsalva. It is also possible that the rectal prolapse worsened over the 2 months leading up to the surgery.
We believe our case supports the theory of rectal prolapse proposed by Sir Moschcowitz himself. In 1912, Sir Alexis Moschcowitz had demonstrated that rectal prolapse was a result of a deep pouch of Douglas, which permitted intra-abdominal pressure to force the anterior rectal wall to bulge into the anal canal. Based on this theory, he developed the Moschcowitz culdoplasty procedure.8 This procedure involves a series of purse string sutures in the cul-de-sac, incorporating the posterior vaginal wall, pelvic sidewalls, serosa of the sigmoid colon, and anterior and posterior peritoneum reducing the small bowel back into the abdominal cavity.8–10 Later on in 1916, Daniel Fiske Jones demonstrated how this procedure could be adapted to treat uterine prolapse and rectoceles.11 Despite its wide use for enterocele prevention during vaginal reconstructive surgery, there are no reports of rectal prolapse treated with this traditional repair.
Culdoplasties are traditional procedures to treat and prevent enteroceles at the time of hysterectomy.12 McCall culdoplasty involves plicating the uterosacral ligaments in the midline, suturing it to the posterior peritoneum and to the vaginal cuff.13 Halban culdoplasty involves placing a series of sagittal sutures between the uterosacral ligaments, into the deep cul-de-sac, posterior vaginal walls, and sigmoid serosa to prevent enterocele formation.13 A randomized controlled trial by Cruikshank and Kovac14 compared McCall culdoplasty (n = 32), Moschcowitz culdoplasty (n = 33), and simple peritoneal closure (n = 33) at the time of vaginal hysterectomy and found that McCall culdoplasty was superior to the other 3 techniques in preventing enterocele formation at 3 years (P = 0.004). To this day, there are no clear indications for either culdoplasty. Although McCall culdoplasty is the popular procedure to close the posterior vaginal cuff at the time of hysterectomy, the Moschcowitz procedure was preferred in this case as the rectal prolapse was believed to be the result of an open peritoneal window, which when closed would cause reduction of the enterocele. As CRS was unavailable and recommended outpatient follow-up after surgery, the choice of surgical management was directed at restoring the support to the apex of the vagina and reduction of the small bowel through approximation of the peritoneum and closure of the cul-de-sac.
An enterocele results from the herniation of abdominal contents that displace the vagina. They can be apical, posterior and anterior based on the anatomic location.15 Nichols and Randall16 described 4 categories of enteroceles: congenital, iatrogenic, traction, and pulsion. Our patient’s defect is a traction type of enterocele, as vaginal vault prolapse and rectocele were also present. Risk factors for enteroceles are similar to rectal prolapse.10 In a series by Hawksworth and Roux,17 the incidence of enterocele occurring after hysterectomy is 6.3% at 1 year. In this case, prior hysterectomy was a risk factor. The MRI defecogram demonstrated the small bowel prolapsing between the rectum and the vagina forming an enterocele. Surgical therapy was directed at reducing the small bowel prolapse, thereby eliminating the compressive enterocele and rectal prolapse. We acknowledge that multiple concurrent vaginal reconstructive procedures addressing the prolapse of specific compartments were performed in our patient. Although it is unclear exactly which component contributed to the resolution of the rectal prolapse, we believe that the Moschcowitz culdoplasty was the most likely reason, because of reduction of the enterocele, therefore alleviating pressure on the anterior rectal wall.
Typically, when extensive rectal prolapse and vaginal vault prolapse coexist, vault suspension through a vaginal approach is matched with a perineal route for rectal prolapse, and if a rectopexy is performed, then a sacrocolpopexy is often the method of choice.6,10,11 Because of her prior medical history complicated by appendiceal carcinoma, a vaginal approach was preferred to an abdominal approach. This would also allow access to the enterocele. Nichols and Randall16 proposed 4 principles of enterocele repair once identified, which include (1) identify the enterocele and etiology, (2) mobilize and obliterate the enterocele sac, (3) occlude the sac with suture ligation as high as possible, and (4) restore the normal anatomy of the vaginal axis and provide support below the hernia to close the hernia sac. In our case, this was achieved through performing Moschcowitz culdoplasty after sacrospinous ligament fixation with mesh alone. Because this approach is based on theory, further studies are required to determine efficacy.
Usually, the choice of surgical approach is tailored to each individual based on anatomy, age, comorbidity, and patient factors. Correcting both vaginal and rectal prolapse at the same time with a minimally invasive approach is an advantage to the patient. Restoring the apical, anterior, and posterior vaginal wall anatomy along with treating the enterocele through the vaginal route caused resolution of the rectal prolapse. Further research is required as to whether rectal prolapse caused by anterior rectal compression needs an additional procedure or repair of the vaginal prolapse and enterocele alone will suffice.
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
compressive enterocele; Moschcowitz culdoplasty; rectal prolapse