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). One resulting condition is an enterocele.

An enterocele occurs when your small intestine (small bowel) drops into the lower pelvic cavity and protrudes into your vagina, creating a bulge. An enterocele is a vaginal hernia.

For a mild or moderate enterocele, nonsurgical treatments — particularly, exercises to strengthen your pelvic floor muscles — may help relieve symptoms. More severe cases of enterocele may require surgical repair.

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 discharge and bleeding
• 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

Click to Enlarge

Enterocele

There are four categories of enterocele. The cause determines the type.

• Traction enterocele. Pregnancy, childbirth and loss of estrogen cause traction enterocele, the most common type of enterocele. Also, other prolapsed organs may exert pressure within your pelvic cavity, contributing to formation of an enterocele.
• Congenital enterocele. An enterocele is present in a very small number of females at birth.
• Iatrogenic enterocele. This type of enterocele may follow surgical removal of the uterus (hysterectomy) or certain types of surgery for urinary incontinence.
• Pulsion enterocele. Conditions that continually cause pressure inside your abdomen, such as chronic cough or extreme physical exertion, may result in this type of enterocele.

Factors that increase your risk of developing an enterocele include:

• Pregnancy and childbirth. Vaginal deliveries of one or more children contribute 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 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 pelvic organ prolapses.

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
• Vaginal bleeding
• Painful intercourse

You'll need a pelvic exam to confirm a diagnosis of an enterocele. 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.

Mild cases of enterocele may require no treatment. Surgical repair may be most effective in more severe cases, particularly when enterocele is accompanied by other types of pelvic organ prolapse. Nonsurgical approaches are also available if surgery would be risky for you or if you want to bear more children.

Nonsurgical treatments
These approaches 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 usually involves 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. Estrogen therapy corrects thinning of the vaginal lining that occurs after menopause and helps keep a pessary from irritating dry vaginal walls.

Surgery
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.

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.

Kegel exercises, which are designed to strengthen your pelvic floor muscles, can help prevent an enterocele. They won't, however, cure one. You can do these exercises almost anytime — while driving, watching television 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.