Intestinal Prolapse Through the Vagina is Uncommon in Pelvic Floor Prolapse
Intestines do not typically "fall out" from pelvic floor prolapse—instead, small bowel or sigmoid colon can herniate into the rectovaginal space (enterocele or sigmoidocele), which presents as a posterior vaginal bulge rather than external protrusion. 1
What Actually Happens in Pelvic Organ Prolapse
Pelvic organ prolapse involves excessive descent of organs through the pelvic floor hiatus, typically affecting three compartments 1:
- Anterior compartment: Bladder and/or urethra (cystocele/urethrocele) 1
- Apical compartment: Uterus/cervix or vaginal vault 1
- Posterior compartment: Rectum (rectocele) or herniation of pelvic contents into the rectovaginal space 1
When intestines are involved, they herniate into the cul-de-sac (the space between the rectum and vagina), not externally through the vaginal opening. 1 This can contain peritoneal fat (peritoneocele), small bowel (enterocele), or sigmoid colon (sigmoidocele). 1
Clinical Presentation
Patients with pelvic organ prolapse typically present with 1:
- Pelvic pressure or sensation of a bulge 1
- Vaginal protrusion visible at the introitus (vaginal opening) 2
- Associated urinary or bowel dysfunction 3
The key distinction: what patients see or feel is the vaginal wall bulging, not intestines protruding externally. 2 Even when small bowel is present in an enterocele, it remains contained within the vaginal wall tissue. 1
Epidemiology and Risk Context
Pelvic organ prolapse is extremely common, affecting 25-33% of postmenopausal women 1, with approximately 13% undergoing surgery in their lifetime. 3 Risk factors include 4:
- Advanced age and menopause 4
- Vaginal multiparity (multiple vaginal deliveries) 4
- Obesity 4
- Chronic straining from constipation or other causes 4
- Conditions causing chronic increases in intra-abdominal pressure 4
Critical Clinical Pitfall
Do not confuse enterocele (small bowel in the rectovaginal space) with external bowel prolapse—these are entirely different conditions. 1 External rectal prolapse (complete rectal prolapse extending beyond the anal verge) is a separate entity from vaginal prolapse and occurs through the anus, not the vagina. 1 This condition has an incidence of only 2.5 per 100,000 inhabitants with a 9:1 female-to-male ratio. 4
Diagnostic Approach
When enterocele is suspected clinically 1:
- Physical examination is the initial evaluation method 1
- Imaging (fluoroscopic cystocolpoproctography or MR defecography) is reserved for cases where clinical evaluation is inadequate, symptoms persist after treatment, or differentiation between cul-de-sac hernias and rectoceles is needed 1
- Fluoroscopic cystocolpoproctography has 35% sensitivity for detecting enteroceles compared to physical examination, indicating these are often occult 1
The goal of imaging is to determine the contents of cul-de-sac hernias and evaluate for occult pelvic floor disorders in compartments not apparent on physical examination. 1