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Enterocele Symptoms Causes Risk factors Complications Preparing for your appointment Tests and diagnosis Treatments and drugs Lifestyle and home remedies Coping and support Prevention

 Filed under: Women's Health 
An enterocele (EN-tur-o-seel) is a vaginal hernia, which occurs when your small intestine (small bowel) descends into the lower pelvic cavity and pushes at the top part of your vagina, creating a bulge. Enteroceles most commonly occur in women who have had surgery to remove the uterus (hysterectomy).

Childbirth and aging may weaken the muscles and ligaments (pelvic floor) that support your bladder, uterus, colon and small intestine. The weakening may cause one or more of these organs to drop (prolapse). Enterocele is one condition that can result from weakening pelvic floor structures.

For a mild or moderate enterocele, nonsurgical treatments — particularly, exercises to strengthen your pelvic floor muscles — may help relieve symptoms, if symptoms are present. More severe cases of enterocele may require surgery to fix the condition.

A mild enterocele may produce no signs or symptoms. However, if you have a severe enterocele, you may experience the following:

A pulling sensation in your pelvis that eases when you lie down
A feeling of pelvic fullness, pressure or pain
Low back pain that eases when you lie down
A soft bulge of tissue in your vagina
Vaginal discomfort and painful intercourse (dyspareunia)
Related conditions
When your pelvic floor muscles lose tone, organs other than your small bowel may descend as well. Related conditions that may occur with enterocele include:
Rectocele, in which your rectum bulges into your vagina
Cystocele, in which your bladder bulges into your vagina
Uterine prolapse, in which your uterus descends into your vagina
When to see a doctor
If you have a mild enterocele, you may have no signs or symptoms and require no medical attention. See your doctor if you develop:

A sense of pulling in your pelvis or low back pain that worsens with prolonged standing and eases when you lie down
A feeling of pelvic fullness, pressure or pain
A soft bulge of tissue in your vagina
Painful intercourse

Enterocele and prolapse of other pelvic organs often results from a combination of factors, including:

Pregnancy and childbirth. The physical stresses of pregnancy put strain on your pelvic support structures and can weaken them. Difficult vaginal births — especially if you have a prolonged second stage of labor, a very large baby or a forceps-assisted delivery — can damage pelvic floor muscles and connective tissues and lead to development of an enterocele.
Age. As you get older, your pelvic floor muscles and connective tissues are more likely to become stretched and weakened.
Pelvic surgery. In some instances, surgical removal of your uterus (hysterectomy) and some types of surgery to treat urinary incontinence may lead to development of an enterocele.
Increased abdominal pressure. Chronic coughing, frequent heavy lifting, or any other activity that increases pressure on your abdomen may also strain your pelvic floor muscles and contribute to the development of enterocele.
Connective tissue disorders. Some women are genetically predisposed to having weaker connective tissues and may be more likely to experience enterocele and prolapse of other pelvic organs.

Risk factors
Factors that increase your risk of developing an enterocele include:

Pregnancy and childbirth. Vaginal delivery of one or more children contributes to the weakening of your pelvic floor support structures, increasing your risk of enterocele.
Age. Enterocele and other types of pelvic organ prolapse occur more often with increasing age. As you get older, you tend to lose muscle mass and muscle strength — in your pelvic muscles as well as in muscles elsewhere in your body.
Pelvic surgery. Removal of your uterus (hysterectomy) or surgical procedures to treat incontinence may increase your risk of developing an enterocele.
Increased abdominal pressure. Being overweight increases pressure inside your abdomen, which increases your risk of developing an enterocele. Other factors that increase pressure include chronic cough, smoking (which increases coughing) and straining during bowel movements.
Genetics. You may be born with weaker connective tissues in your pelvic area, making you naturally more susceptible to enterocele and other types of pelvic organ prolapse.
Race. For unknown reasons, Hispanic and Asian women appear to be at greater risk of developing pelvic organ prolapse than are Caucasian women. Black women seem to have the lowest risk of any of these groups of women.
Family history. If your mother experienced an enterocele or prolapse of other pelvic organs, your chances of also experiencing prolapse are greater than a woman with no family history of prolapse.

Preparing for your appointment
To evaluate pelvic organ prolapse, your first appointment may be with your primary care provider. However, in some cases when you call to set up an appointment, you may be referred directly to a doctor who specializes in conditions affecting the female reproductive tract (gynecologist).

Here's some information to help you prepare for your appointment and what to expect from your doctor.

What you can do

Write down any symptoms you've had, and for how long.
Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking.
Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
For enterocele, some basic questions to ask your doctor include:

What is the most likely cause of my symptoms?
Are there any other possible causes?
Do I need any tests to confirm the diagnosis?
What are the goals of treatment in my case?
What treatment approach do you recommend?
Am I at risk of complications from this condition?
What is the risk that this problem will recur in the future?
Do I need to follow any restrictions?
Are there any self-care steps I can take?
Should I see a specialist?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:

What symptoms are you experiencing?
When did you first notice these symptoms?
Have your symptoms gotten worse over time?
Do your symptoms include pain? If yes, how severe is the pain?
Does anything in particular trigger your symptoms, such as coughing or heavy lifting?
Do your signs and symptoms include urine leakage (urinary incontinence)?
Have you had a chronic or severe cough?
Does your work or daily activities involve heavy lifting?
Do you strain during bowel movements?
Are you currently being treated or have you recently been treated for any other medical conditions?
What medications are you taking, including over-the-counter and prescription drugs as well as vitamins and supplements?
Do any of your first-degree relatives — such as a parent or sibling — have a history of enterocele or any other pelvic problems?
How many children have you delivered? Were your deliveries vaginal or cesarean?
Do you plan to have children in the future?
Do you have any other concerns?

Tests and diagnosis
You'll need a pelvic exam to confirm a diagnosis of an enterocele. With a speculum in the vagina, your doctor may ask you to take a deep breath and hold it while bearing down (Valsalva maneuver), which is likely to cause the prolapsed small bowel to bulge downward. If your doctor can't verify that you have an enterocele while you're lying on the examining table, he or she may repeat the exam while you're standing.

Treatments and drugs
Mild cases of enterocele may require no treatment. Surgical repair may be most effective in more severe cases, particularly when an enterocele is accompanied by other types of pelvic organ prolapse. Nonsurgical approaches are also available if you're not interested in surgery, if surgery would be too risky for you or if you want to bear more children.

Nonsurgical treatments
Nonsurgical treatment options include:

Vaginal pessary. A silicone, plastic or rubber ring or device inserted into your vagina supports the bulging tissue. Pessaries come in a variety of styles and sizes, and finding the right one for you may involve trial and error. Your doctor will measure and fit you for the device and teach you how to insert and remove it. You'll need to remove the pessary regularly and clean it. Or, if you leave the pessary in place, your doctor may have you come in periodically to remove and clean the pessary and examine your vagina.
Estrogen therapy. If you're postmenopausal, your doctor may recommend estrogen therapy, such as a vaginal cream, gel or tablet, in combination with a vaginal pessary. Estrogen therapy corrects thinning of the vaginal lining that occurs after menopause and helps keep a pessary from irritating dry vaginal walls.
A severe or extremely uncomfortable enterocele may require surgery. The surgery is designed to repair the hernia and relieve signs and symptoms of the enterocele.

In most cases, the surgical approach is through your vagina. In this procedure, your surgeon puts the prolapsed small bowel back into place and tightens the muscles and ligaments of your pelvic floor.

Surgical repair of an enterocele is more common when other prolapsed organs, such as the uterus, bladder or rectum, are involved. In those cases, hysterectomy and repairs of the cystocele and rectocele can be done at the same time as the enterocele repair.

With proper technique during surgical repair, an enterocele usually doesn't recur.

Lifestyle and home remedies
Kegel exercises can help improve the overall strength of your pelvic floor muscles and may help alleviate some of the symptoms of pelvic organ prolapse, such as pelvic pressure, urinary incontinence or fecal incontinence.

You can do these exercises almost anytime — while watching television, talking on the telephone or sitting at your desk.

To perform Kegel exercises:

Pull in your pelvic floor muscles, which are the muscles you use to stop urinating.
Hold for a count of five, and then relax for a count of five.
Work up to 10 to 15 repetitions, and eventually 30 repetitions, if possible.
Repeat at least three times a day.
If you have trouble with Kegel exercises, consider asking your doctor for help. Many women find it difficult to isolate the pelvic floor muscles. Your doctor can show you the right muscles and proper technique for Kegel exercises. You might also benefit from the help of a physical therapist, who uses special training devices to help you identify and isolate your pelvic floor muscles for strengthening.

You may be able to prevent an enterocele by doing the following:

Lose weight. If you're overweight, losing weight can decrease the pressure inside your abdomen.
Prevent constipation. Eat high-fiber foods, drink fluids and exercise regularly to help prevent having to strain during bowel movements.
Treat a chronic cough. Because constant coughing can increase abdominal pressure, see your doctor if you have a chronic cough.
Quit smoking. Smoking is likely to increase coughing.
Avoid heavy lifting. Lifting heavy objects can increase abdominal pressure.

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