An enterocele is a hernia in which the small bowel, wrapped in its lining, pushes down into the top of the vagina, usually between the vagina and the rectum. It often follows hysterectomy or earlier prolapse surgery. Cul-de-sac closure, which shrinks or seals the space where the hernia forms, is a key step in repairing an enterocele and in preventing one.
The cul-de-sac: where an enterocele begins
Inside the pelvis, the lining of the abdomen (peritoneum) dips down into a pocket between the back of the uterus or vagina and the front of the rectum. This pocket is called the cul-de-sac or pouch of Douglas. It is the lowest point of the abdominal cavity when you stand.
Normally the top of the vagina is held firmly by the uterosacral and cardinal ligaments, and the connective tissue between vagina and rectum keeps the cul-de-sac shallow. If those supports weaken, the pouch can deepen and push down, and loops of small bowel, or sometimes the sigmoid colon, slide into it. The result is a hernia sac that bulges into the vagina from above.
How an enterocele differs from other prolapse
Pelvic organ prolapse is named by what lies behind the bulging vaginal wall:
- Cystocele: the bladder bulges into the front wall
- Rectocele: the rectum bulges into the lower back wall
- Uterine or vault prolapse: the uterus, or the top of the vagina after hysterectomy, descends
- Enterocele: small bowel and peritoneum bulge into the upper back wall or the vault
These types often coexist. An enterocele is easily mistaken for a high rectocele, but the two need different repairs. A rectocele repair alone will not fix an enterocele, which is one reason prolapse can seem to come back soon after surgery.
Causes and risk factors
The most important risk factor is a previous hysterectomy, especially if the top of the vagina was not well suspended or the cul-de-sac was left deep. Other contributors include:
- Vaginal childbirth and stretching of the apical supports
- Previous prolapse surgery that changed the vaginal axis, such as some bladder suspension operations
- Menopause and reduced tissue strength
- Chronic straining, coughing and heavy lifting
- Obesity
- Inherited connective tissue weakness
Symptoms of an enterocele
Small enteroceles may cause no symptoms. Larger ones commonly produce:
- A bulge or pressure in the vagina, often worse after standing for a long time
- A dragging or pulling ache in the lower abdomen or back, easing when lying down
- A sense of fullness in the pelvis
- Difficulty or incomplete emptying of the bowel
- Discomfort during intercourse
Because the hernia contains bowel, any sudden severe pain, vomiting, inability to pass wind or a bulge that becomes firm and tender needs urgent medical care, although incarceration is uncommon.
How doctors diagnose an enterocele
Diagnosis begins with an examination while the patient strains, sometimes standing. Doctors look for a bulge at the vault or upper back wall that is separate from the rectum. A combined vaginal and rectal examination can help: the examiner may feel small bowel slide between two fingers. When the picture is unclear, dynamic imaging such as MRI defecography or fluoroscopic defecography can show bowel entering the cul-de-sac during straining. A POP-Q examination documents the extent of prolapse in every compartment.
What cul-de-sac closure means
Cul-de-sac closure, also called culdoplasty or obliteration of the cul-de-sac, is a group of techniques that reduce or eliminate the hernia space. The aim is to bring the supporting tissues together so there is no deep pocket for bowel to fall into, and to restore strong support at the top of the vagina.
McCall culdoplasty
Performed through the vagina, usually during vaginal hysterectomy, this technique uses stitches to draw the uterosacral ligaments together across the midline and attach them to the top of the vagina. It closes the cul-de-sac and suspends the vault in one step. Many gynecologic surgeons use it routinely to help prevent later enterocele and vault prolapse.
Moschcowitz and Halban procedures
These abdominal techniques close the cul-de-sac with concentric purse-string sutures or with vertical sutures running between the vagina and rectum. They are sometimes added during abdominal or laparoscopic operations such as sacrocolpopexy.
Enterocele repair steps
When an enterocele is already present, a typical vaginal repair follows these steps:
- Open the vaginal wall over the bulge and identify the hernia sac.
- Separate the sac from the vagina and rectum, taking care not to injure the bowel.
- Open or reduce the sac and return the bowel to the abdomen.
- Close the neck of the sac high up with stitches, effectively closing the cul-de-sac.
- Suspend the top of the vagina to strong ligaments, such as the uterosacral or sacrospinous ligaments.
- Repair any coexisting rectocele or cystocele and close the vaginal wall.
Why cul-de-sac closure matters
Experts on pelvic support, building on the anatomical work of DeLancey, emphasize that the top of the vagina must be well supported for any prolapse repair to last. Leaving a deep cul-de-sac and an unsupported vault can allow bowel to push down again even when the front and back walls have been repaired. Closing the space and suspending the apex together address the cause rather than just the bulge. However, culdoplasty is not risk-free: stitches near the uterosacral ligaments can occasionally kink or injure a ureter, so surgeons usually check ureteric function during the operation. Other possible risks include bleeding, infection, bowel injury, pain with intercourse and recurrence, and these should be discussed openly before consent.
Frequently asked questions
Can an enterocele be treated without surgery?
Yes. A pessary can support the vault and relieve symptoms for many women, and pelvic floor training plus avoiding straining may help milder cases. Surgery is reserved for bothersome symptoms when these measures are not enough or not wanted.
Is an enterocele dangerous?
Usually it is not, but it is a true hernia containing bowel. Rarely, bowel may become trapped. Seek urgent care for severe pain, vomiting or a firm, tender bulge.
Does every hysterectomy need cul-de-sac closure?
Many surgeons support the vault and close or reduce the cul-de-sac routinely during vaginal hysterectomy, especially in women with prolapse. The approach depends on the type of hysterectomy, the anatomy and the surgeon's judgment. Ask how the vault will be supported before surgery.
Can an enterocele come back after repair?
Recurrence is possible, as with any prolapse repair. Addressing apical support well, managing constipation and avoiding heavy lifting reduce the risk. Regular follow-up allows early detection.
How long is recovery after enterocele repair?
Most women stay in hospital for one or two nights and return to light activity within two weeks. Heavy lifting, straining and intercourse are usually avoided for about six weeks while the tissues heal. Recovery may take longer if the repair is combined with other procedures.
References
- American College of Obstetricians and Gynecologists and American Urogynecologic Society. Practice Bulletin No. 214: Pelvic Organ Prolapse. Obstet Gynecol. 2019.
- DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992.
- Haylen BT, Maher CF, Barber MD, et al. An IUGA/ICS joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016.
- Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016.
This article is for general education and does not replace an examination by a qualified gynecologist. Individual results vary, and every procedure carries risks.
