Pelvic Organ Prolapse complicated by Small Bowel Extrusion through a Posterior Vaginal Defect: A Case Report

Abstract

Introduction: We report a case of transvaginal evisceration due to severe pelvic organ prolapse with vaginitis. Additionally, we describe the course of events following the development of an urethrovaginal fistula during urinary catheterization.

Case: A 77-year-old woman with untreated advanced POP was referred due to chronic residual urine exceeding 500 ml. At the initial examination, the vaginal wall was highly inflamed and there was a vaginal laceration over the Douglas fossa, and the small intestine had slipped into the vagina through this opening. While arranging for emergency surgery, we found her severe anemia (Hb 4.9 g/dl) due to gastrointestinal bleeding from an unknown site. Due to poor systemic and local conditions, we decided not to do POP repair immediately. After a blood transfusion, the gastroenterology and gynecology departments jointly performed laparoscopic and transvaginal procedures to repair the laceration. The wound healed well, but after discharge, an urethrovaginal fistula developed over the indwelling catheter. Until the source of gastrointestinal bleeding was identified and anemia was cured, we utilized a cystostomy and bilateral ureteral stents to manage chronic urinary stasis. 12 months later, we realized POP repair consisting of sacrospinous ligament fixation and mesh sling insertion, and urethroplasty, completing the treatment for POP.

Discussion: Conservative management of advanced POP often requires urological intervention and lifestyle education. In this case, emergency surgery was limited to closing the laceration, and POP repair was postponed until the patient’s overall condition improved. The stepwise treatment approach led to a stable course and favorable outcomes.