Enterocele: Symptoms, Types, Causes and Treatment

Enterocele is a specific form of pelvic organ prolapse that can significantly affect quality of life. Although sometimes overlooked, understanding enterocele is crucial for patients and healthcare professionals involved in pelvic health. This article provides a comprehensive look at the symptoms, types, causes, and treatments of enterocele, based on current research and clinical evidence.

Symptoms of Enterocele

Enterocele often presents with subtle, non-specific symptoms that can overlap with other pelvic floor disorders. Recognizing these symptoms is the first step toward timely diagnosis and effective management.

Symptom	Description	Typical Patient Impact	Sources
Difficulty Emptying	Trouble fully evacuating bowel	Sensation of incomplete evacuation, straining	2, 4
Pelvic Pain	Aching or heaviness in pelvis	Discomfort, pain, or pressure	2, 4
Prolapse Sensation	Feeling of bulge or descent	Sensation of tissue protrusion	4, 1
Postevacuation Discomfort	Pain/heaviness after bowel movement	Persistent pelvic discomfort	2, 4

Table 1: Key Symptoms

Understanding Symptom Patterns

Enterocele symptoms often mimic those of other pelvic disorders, making diagnosis challenging. While some patients experience obvious prolapse, others report vague sensations of heaviness or fullness in the pelvis which may worsen over the course of the day or with physical activity 1, 2, 4.

Difficulty with Bowel Movements

A common complaint is difficulty emptying the bowels, even with straining or manual assistance. However, research indicates that not all patients with enterocele experience bowel dysfunction; in fact, bowel symptoms may not differ significantly between those with and without enterocele when controlled for prolapse severity 1. Still, difficulty emptying and a sensation of incomplete evacuation are hallmark symptoms for many 2, 4.

Pelvic Pain and Discomfort

Pelvic pain, pressure, or a feeling of heaviness is frequently reported by patients with symptomatic enterocele 2, 4. This discomfort may be persistent or occur particularly after bowel movements (postevacuation discomfort). Some patients also describe a false urge to defecate, which can be distressing 4.

Prolapse Sensation

A noticeable bulge or a sense of tissue descending into or through the vaginal opening is another classic symptom, particularly in more advanced cases 1, 4. This sensation may be more pronounced after standing, lifting, or during physical activities.

Variability and Overlap

It’s important to note that symptoms can be highly variable. Some women may be entirely asymptomatic, while others experience significant impairment. Additionally, enterocele often coexists with other prolapse types, complicating the symptom picture 2, 4.

Types of Enterocele

Enterocele is not a one-size-fits-all diagnosis. Several anatomical and clinical subtypes exist, each with its own implications for treatment and prognosis.

Type	Defining Feature	Common Association	Sources
Primary	Develops without prior surgery	Congenital or age-related weakness	7, 11
Secondary	Occurs after pelvic surgery	Often follows hysterectomy	7, 11, 6
Anterior	Protrusion toward anterior vagina	Post-radical cystectomy	6
Posterior	Toward posterior vaginal wall	Most common; with apical prolapse	1, 11

Table 2: Types of Enterocele

Primary vs. Secondary Enterocele

Primary enteroceles arise spontaneously, usually due to congenital weaknesses, tissue atrophy, or age-related loss of pelvic support. Secondary enteroceles are more common and develop following pelvic surgeries, particularly hysterectomy or repairs for other forms of prolapse 7, 11.

Anterior and Posterior Enterocele

• Posterior enterocele: The most prevalent type, where the herniation occurs between the rectum and vagina, often accompanying apical (vault) prolapse 1, 11.
• Anterior enterocele: Less common, seen in situations such as after radical cystectomy, where the anterior vaginal wall becomes the site of herniation 6.

Isolated vs. Combined Defects

Most enteroceles do not occur in isolation. Studies show that the majority are accompanied by other pelvic floor defects, such as rectocele, perineal descent, or rectal intussusception 2. Isolated enteroceles are relatively rare.

Clinical Implications of Types

Understanding the enterocele type is crucial for treatment planning. For example, an anterior enterocele after radical cystectomy may require a different surgical approach than a typical posterior enterocele 6. Similarly, secondary enteroceles often necessitate repair of the underlying surgical defect 7, 11.

Causes of Enterocele

The development of enterocele is multifactorial, involving both acquired and inherent risk factors. Recognizing these helps in prevention and early intervention.

Cause	Mechanism	Risk Factors	Sources
Pelvic Surgery	Disruption of pelvic support	Hysterectomy, cystectomy	1, 6, 7, 8, 11
Aging & Menopause	Tissue atrophy & weakening	Advanced age, menopause	1, 7, 11
Childbirth	Stretching of pelvic tissues	Multiparity	7, 11
Chronic Pressure	Increased abdominal pressure	Obesity, constipation	7, 4, 11

Table 3: Main Causes

Surgical Factors

A significant percentage of enteroceles develop after pelvic surgeries, especially hysterectomy (removal of the uterus) 1, 7, 8, 11. The risk is higher if the support structures at the vaginal apex are not adequately reconstructed at the time of surgery, allowing the small bowel to descend into the pelvic cavity. Radical cystectomy (bladder removal) can similarly predispose to enterocele, especially in women 6.

Age and Hormonal Changes

Aging and postmenopausal status lead to loss of connective tissue elasticity and muscle strength. These changes weaken pelvic support structures, making older women particularly vulnerable 1, 7, 11.

Obstetric History

Multiparity (having had multiple vaginal deliveries) stretches and sometimes damages the pelvic floor, increasing the risk of enterocele later in life 7, 11.

Chronic Increased Intra-abdominal Pressure

Conditions that chronically raise intra-abdominal pressure—such as obesity, chronic constipation, or frequent heavy lifting—can contribute to the gradual development of enterocele 7, 4, 11. Repeated straining during defecation, in particular, is a recognized risk.

Other Contributing Factors

• Genetic predisposition: Some women may have inherently weaker connective tissue.
• Lack of tissue elasticity: Generalized connective tissue disorders may also play a role 7.
• Previous pelvic organ prolapse repairs: Recurrent or previous repairs may leave residual weaknesses, leading to secondary enterocele 1, 7.

Treatment of Enterocele

Treatment for enterocele is highly individualized, depending on the severity of symptoms, the type of enterocele, and patient preferences. Both conservative and surgical options are available, each with its pros and cons.

Treatment	Approach/Method	Outcome/Efficacy	Sources
Conservative	Observation, pelvic floor therapy	For mild/asymptomatic cases	11
Vaginal Repair	Fascial repair, mesh, colpocleisis	High success, minimal recurrence	7, 9, 10, 11
Abdominal Repair	Obliteration of pelvic inlet	Effective, especially for large/recurrent cases	3, 4, 6
Prophylactic Repair	Culdeplasty at hysterectomy	Reduces later enterocele risk	8, 11

Table 4: Treatment Approaches

Conservative Management

For women with mild or no symptoms, conservative management is appropriate. This may include:

• Watchful waiting
• Pelvic floor physical therapy to strengthen support structures 11

Surgical Options

Vaginal Approaches

• Site-Specific Fascial Repair: Identifies and repairs defects in the vaginal fascia, often combined with vault suspension and posterior colporrhaphy. Short-term results show high success with low recurrence rates 9.
• Colpocleisis: Obliteration of the vaginal canal, suitable for women who no longer desire vaginal intercourse 6, 11.
• Use of Mesh: Nonabsorbable mesh may be used for reinforcement, especially in recurrent cases 4.

Abdominal Approaches

• Obliteration of the Pelvic Inlet: Abdominal insertion of mesh to close the pelvic inlet is effective for large or recurrent enteroceles, with significant relief of pelvic discomfort 3, 4.
• Douglas’ Pouch Repair: Surgical repair of the peritoneal sac, particularly in cases with significant pelvic pain 2.

Prophylactic Repairs

Performing a culdeplasty or other support-restoring procedures at the time of vaginal hysterectomy dramatically reduces the risk of developing enterocele later 8, 11. The McCall-type culdeplasty is noted to be the most effective among common techniques 8.

Symptom Relief and Outcomes

• Most surgical repairs offer high rates of symptom resolution, especially for pelvic heaviness and discomfort 4, 9.
• Symptoms like difficulty emptying may persist if caused by other pelvic floor disorders 2, 4.
• Complications are rare but can include infection, mesh erosion, or recurrence 11.

Individualized Treatment Planning

Treatment must be tailored to the patient’s anatomy, comorbidities, lifestyle, and preferences. A multidisciplinary approach often yields the best results.

Conclusion

Enterocele, while sometimes underdiagnosed, is a significant cause of pelvic discomfort and prolapse symptoms, particularly in women with a history of pelvic surgery or multiple childbirths. Understanding its symptoms, types, causes, and treatment options is key to effective management and improved quality of life.

Key points covered:

• Enterocele presents with symptoms such as difficulty emptying, pelvic pain, and a prolapse sensation, but symptoms are often variable.
• Types include primary, secondary, anterior, and posterior enteroceles, with most cases being secondary to surgery and posterior in location.
• Major causes include surgical disruption, aging, childbirth, and chronic increased intra-abdominal pressure.
• Treatment ranges from conservative management to surgical repair, with tailored approaches yielding high success rates.
• Prophylactic surgical techniques during hysterectomy can greatly reduce future risk.

Awareness and individualized care are essential for optimal outcomes in patients with enterocele.