PATIENT CHARACTERISTICS ASSOCIATED WITH VAGINAL RUPTURE AND EVISCERATION

A. Croak, DO, C. Klingele,MD, J. Gebhart, MD, K. Podratz, MD, PhD, and R.Lee, MD

   Objective: We examined our institutional experience with vaginal rupture and evisceration involving disruption of the vaginal apex with extrusion of intraperitoneal contents. Our goals were to identify clinical conditions or patient characteristics that may be associated with vaginal rupture and evisceration, and to compare our experience to other published reports.

   Methods: A medical records search was performed to identify cases at our institution while a MEDLINE search using the key words “vaginal evisceration” and “ruptured enterocele” was used to identify published reports. A chart review of identified cases was performed. Demographic variables extracted were age, menopausal status, and past medical and surgical history. Clinical variables extracted were, time interval from prior surgery to occurrence of rupture, presenting complaints, inciting event, physical exam findings (rupture site and eviscerated structure), surgical repair, pathology, management complications, and outcomes. Comparisons between groups were made using the Fisher’s exact test.

   Results: Twelve women with vaginal rupture and evisceration from our institution and 121 historical cases were identified. In both groups, this condition was associated most often with prior surgical history in menopausal women with prolapse (75% vs. 81% respectively). Coitus was predominantly associated with rupture and evisceration in the premenopausal review group (77%). Median time of postoperative occurrence was 23 months and 10.5 months respectively. Historically, time of evisceration until intervention did not statistically increase the rate of ileus, obstruction, or incarceration (p=0.42). Ileal evisceration involved a respective 42% and 68% of the cases. The most common presenting complaints were pain, vaginal bleeding, and a sensation of pressure. Those with a history of abdominal hysterectomy most often ruptured through the vaginal vault (institutional p 0.007 / historical p < 0.001). Those having had vaginal hysterectomies most often ruptured through an ape! x associated with an enterocele (institutional p 0.007 / historical p < 0.001). Postcoital ruptures occurred at the posterior fornix (historical p <0.001). Vaginal repair was accomplished in 58% of the institutional cases versus 32% of the reviewed cases. A combined abdominal-vaginal approach was frequently reserved for those cases requiring bowel inspection, bowel resection or concomitant repairs. All deaths occurred in the reviewed literature and were most often due to thromboembolic sequelae (n=6). Recurrent prolapse after evisceration repair was found to be insignificant in both the institutional and review populations.

   Conclusions: Our institution’s experience with rupture and evisceration was similar to that reported in the literature. Vaginal rupture with or without evisceration is rare following pelvic surgery or trauma. Postoperative evaluation was beneficial in identifying early vaginal rupture prior to evisceration, thus enabling vaginal repair. The high rate of vaginal rupture or evisceration, following vaginal hysterectomy presenting with an associated enterocele, argues for the importance of a proper initial repair. Prompt surgical intervention in cases of vaginal rupture may lessen the risk of bowel injury. Concomitant prolapse repairs are acceptable at the time of reparative surgery for vaginal rupture with or without evisceration.