Small Bowel prolapse (enterocele)

Small bowel prolapse (enterocele)

Small bowel prolapse, also called enterocele (EN-tur-o-seel), occurs when the small intestine (small bowel) descends into the lower pelvic cavity and pushes at the top part of the vagina, creating a bulge. The word “prolapse” means to slip or fall out of place.
Childbirth, aging and other processes that put pressure on your pelvic floor may weaken the muscles and ligaments that support pelvic organs, making small bowel prolapse more likely to occur.
To manage small bowel prolapse, self-care measures and other nonsurgical options are often effective. In severe cases, you may need surgical repair.

Symptoms

Causes

Increased pressure on the pelvic floor is the main reason for any form of pelvic organ prolapse. Conditions and activities that can cause or contribute to small bowel prolapse or other types of prolapse include:

Pregnancy and childbirth
Chronic constipation or straining with bowel movements
Chronic cough or bronchitis
Repeated heavy lifting
Being overweight or obese

Pregnancy and childbirth

Pregnancy and childbirth are the most common causes of pelvic organ prolapse. The muscles, ligaments and fascia that hold and support your vagina stretch and weaken during pregnancy, labor and delivery.
Not everyone who has had a baby develops pelvic organ prolapse. Some women have very strong supporting muscles, ligaments and fascia in the pelvis and never have a problem. It’s also possible for a woman who’s never had a baby to develop pelvic organ prolapse.

Risk factors

Factors that increase your risk of developing small bowel prolapse 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 prolapse. The more pregnancies you have, the greater your risk of developing any type of pelvic organ prolapse. Women who have only cesarean deliveries are less likely to develop prolapse.
Age. Small bowel prolapse 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 other muscles.
Pelvic surgery. Removal of your uterus (hysterectomy) or surgical procedures to treat incontinence may increase your risk of developing small bowel prolapse.
Increased abdominal pressure. Being overweight increases pressure inside your abdomen, which increases your risk of developing small bowel prolapse. Other factors that increase pressure include ongoing (chronic) cough and straining during bowel movements.
Smoking. Smoking is associated with developing prolapse because smokers frequently cough, increasing abdominal pressure.
Race. . For unknown reasons, Hispanic and white women are at higher risk of developing pelvic organ prolapse.
Connective tissue disorders. You may be genetically prone to prolapse due to weaker connective tissues in your pelvic area, making you naturally more susceptible to small bowel prolapse and other types of pelvic organ prolapse.

Prevention

You may be able to lower your chances of small bowel prolapse with these strategies:

Maintain a healthy weight. If you’re overweight, losing some weight can decrease the pressure inside your abdomen.
Prevent constipation. Eat high-fiber foods, drink plenty of fluids and exercise regularly to help prevent having to strain during bowel movements.
Treat a chronic cough. Constant coughing increases abdominal pressure. See your doctor to ask about treatment if you have an ongoing (chronic) cough.
Quit smoking. Smoking contributes to chronic coughing.
Avoid heavy lifting. Lifting heavy objects increases abdominal pressure.

Diagnosis

To confirm a diagnosis of small bowel prolapse, your doctor performs a pelvic exam. During the exam, your doctor may ask you to take a deep breath and hold it while bearing down like you’re having a bowel movement (Valsalva maneuver), which is likely to cause the prolapsed small bowel to bulge downward. If your doctor can’t verify that you have a prolapse while you’re lying on the exam table, he or she may repeat the exam while you’re standing.

Treatment

Small bowel prolapse typically doesn’t need treatment if the symptoms don’t trouble you. Surgery may be effective if you have advanced prolapse with bothersome symptoms. Nonsurgical approaches are available if you wish to avoid surgery, if surgery would be too risky or if you want to become pregnant in the future.
Treatment options for small bowel prolapse include:

Observation. . If your prolapse causes few or no obvious symptoms, you don’t need treatment. Simple self-care measures, such as performing exercises called Kegel exercises to strengthen your pelvic muscles, may provide symptom relief. Avoiding heavy lifting and constipation may reduce the likelihood of worsening your prolapse.
Pessary.A silicone, plastic or rubber device inserted into your vagina supports the bulging tissue. Pessaries come in a variety of styles and sizes. Finding the right one involves some trial and error. Your doctor measures and fits you for the device, and you learn how to insert, remove and clean it.
Surgery. A surgeon can perform surgery to repair the prolapse through the vagina or abdomen, with or without robotic assistance. During the procedure, your surgeon moves the prolapsed small bowel back into place and tightens the connective tissue of your pelvic floor. Sometimes, small portions of synthetic mesh may be used to help support weakened tissues.

A small bowel prolapse usually doesn’t recur. However, further injury to the pelvic floor can happen with increased pelvic pressure, for instance with constipation, coughing, obesity or heavy lifting.

When surgery is necessary

If you have noticeable and bothersome symptoms, it is possible that the previous prolapse requires surgery.

How it is performed. Often, surgery is done through the vagina and involves elevating the prolapsed bladder back into place, removing excess tissue, as well as tensing the muscles and ligaments of the pelvic floor. The doctor may use a special type of tissue graft to strengthen the vaginal tissues and increase support if the vaginal tissues are very thin.
If you have uterine prolapse. In case of previous prolapse associated with uterine prolapse, the doctor may recommend the removal of the uterus (hysterectomy) in addition to the repair of damaged muscles of the pelvic floor, ligaments and other tissues.

Si piensas quedar embarazada, es posible que el médico te recomiende postergar la cirugía hasta el momento en que decidas no tener más bebés. Mientras tanto, el uso de un pesario puede aliviar tus síntomas. Los beneficios de la cirugía pueden durar muchos años, pero existe cierto riesgo de reaparición, lo que puede suponer que debas someterte a otra cirugía en algún momento.

Manejo de la incontinencia

Si el prolapso anterior está acompañado por incontinencia de esfuerzo —pérdida involuntaria de orina durante actividades extenuantes— el médico puede recomendarte uno de varios procedimientos para sostener la uretra (suspensión uretral) y para aliviar los síntomas de incontinencia.

Kegel exercises

Kegel exercises strengthen your pelvic floor muscles, which, in part, support the uterus, bladder and bowel. A strong pelvic floor provides better support for your pelvic organs, prevents prolapse from worsening and relieves symptoms associated with pelvic organ prolapse.
To perform Kegel exercises, follow these steps:

Tighten (contract) your pelvic floor muscles — the muscles you use to stop urinating.
Hold the contraction for five seconds, then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds.)
Work up to holding the contraction for 10 seconds at a time.
Aim for at least three sets of 10 repetitions each day.

Ask your doctor for feedback on whether you’re using the right muscles. Kegel exercises may be most successful when they’re taught by a physical therapist and reinforced with biofeedback. Biofeedback involves using monitoring devices that help ensure you’re tightening the proper muscles, with optimal intensity and length of time.
Once you’ve learned the proper method, you can do Kegel exercises discreetly just about anytime, whether you’re sitting at your desk or relaxing on the couch.