Small bowel prolapse (enterocele)
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The small intestine (small bowel), also known as enterocele, descends into the lower pelvic cavity and pushes on the top part of the vagina, resulting in the bulging of the bowel. Prolapse refers to the act of slipping or falling.
The muscles and ligaments that support your pelvic organs may get weaker as a result of childbirth, aging, and other processes that increase pressure in the abdominal cavity. This increases the likelihood of small bowel prolapse.
Treatment for small bowel prolapse usually is conservative treatment such as pelvic support and pelvic floor exercise. If the prolapse is severe, surgery may be required.
Symptoms
The patient might not experience symptoms of mild small bowel prolapse. However, if your prolapse is severe, signs and symptoms may include the following:
- A sensation of fullness, pressure, or pain in the pelvis
- A soft tissue growth in your vagina
- Urinary incontinence
- Painful intercourse and vaginal discomfort (dyspareunia)
- A pelvic tugging sensation that subsides as you sleep down
- Having low back discomfort that goes away after lying down
Many women with small bowel prolapse also have prolapse of the bladder, uterus, or rectum. If you experience any prolapse signs or symptoms, consult your doctor.
Causes
Pelvic floor muscles and ligaments support the small bowel and other pelvic organs. Small bowel prolapse happens when the connective tissue is damaged or weakened. The pelvic muscles can deteriorate due to several reasons, such as:
- Having a weight problem (obese or overweight)
- Heavy lifting repeatedly
- Pregnancy and giving birth
- Frequent cough or bronchitis
- Prolonged constipation or difficult bowel motions
Pregnancy and childbirth
Pelvic organ prolapse is commonly caused by pregnancy and childbirth. During pregnancy, labor, and delivery, the muscles, ligaments, and tissue that hold and support your vagina stretch and deteriorate.
Pelvic organ prolapse does not always occur in postpartum women. Some women have incredibly robust pelvic supporting muscles, ligaments, and fascia and never experience any issues. A woman who has never given birth could also suffer pelvic organ prolapse.
Risk factors
Your risk of experiencing small bowel prolapse is affected by the following factors:
- Age. With advancing age, small bowel prolapses and other pelvic organ prolapse become more frequent. You typically lose muscle mass and strength as you age, including in your pelvic muscles as well as other muscles.
- Race. White and Hispanic women are more likely to get pelvic organ prolapse for unknown reasons.
- Smoking. Smokers regularly cough, which raises abdominal pressure, which increases the risk of prolapse.
- Pregnancy and childbirth. Your risk of prolapse rises as a result of the weakened pelvic floor support structures caused by one or more vaginal deliveries. You run a higher risk of getting any kind of pelvic organ prolapse the more pregnancies you have. Women who only give birth via cesarean section are less likely to get prolapse.
- Pelvic surgery. Surgery treatment to cure incontinence or removal of your uterus (hysterectomy) may increase your risk of developing small bowel prolapse.
- Increased abdominal pressure. Being overweight puts more pressure on your internal organs, which raises the possibility of small bowel prolapse. Continuous (chronic) coughing as well as straining while going to the bathroom, are additional variables that increase blood pressure.
- Connective tissue disorders. Due to weaker connective tissues in your pelvic region, you may be genetically predisposed to prolapse, making you more likely to experience small bowel prolapse and other pelvic organ prolapses.
Diagnosis
Your doctor will perform a pelvic exam to confirm the diagnosis of small bowel prolapse. To better visualize the prolapsed small bowel during the examination, your doctor could ask you to perform the Valsalva technique, which involves taking a deep breath, holding it, and bearing it down as if you had a bowel movement. The examination may be repeated while you are standing if your doctor cannot confirm that you have a prolapse while you are laying on the examination table.
You may also get one or more of these tests:
- Cystoscopy, examining and locating the bladder with a lit scope equipment (cystoscope).
- Imaging tests, such as a computed tomography (CT) scan, ultrasound, or pelvic floor magnetic resonance imaging (MRI), to evaluate for prolapsed organs and assess the pelvic floor muscles.
- Urodynamic testing to assess bladder capacity and investigate the root causes of urine incontinence.
Treatment
In most cases, small bowel prolapse does not require therapy if the symptoms do not bother you. If you have advanced prolapse and persistent symptoms, surgery might be helpful. If you want to avoid surgery, if surgery is too risky, or if you want to get pregnant, nonsurgical treatments are an option.
Small bowel prolapse can be treated in various ways, including:
- Observation. You do not need therapy if your prolapse produces few or no noticeable symptoms. Simple self-care techniques, including Kegel exercises to strengthen your pelvic muscles, may help relieve symptoms. Constipation and heavy lifting should be avoided to prevent your prolapse from worsening.
- Pessary. The protruding tissue is supported by a silicone, plastic, or rubber device that is inserted into your vagina. Pessaries are available in a range of designs and sizes. There will be some trial and error in selecting the best one. You are measured and fitted for the device by your doctor, and you are taught how to put it in, take it out, and clean it.
- Surgery. With or without robotic help, a surgeon can undertake surgery to repair the prolapse through the vagina or abdomen. Your surgeon will tighten the connective tissue in your pelvic floor and bring the prolapsed small bowel back into its proper position during the treatment. Small pieces of artificial mesh may occasionally be employed to bolster weaker tissues.
In most cases, a minor bowel prolapse is one-time only. However, increased pelvic pressure, such as that caused by constipation, coughing, obesity, or heavy lifting, can further damage the pelvic floor.
