Douglas fossa herniation syndrome

Specialty: Gynecology and breast.

• Symptomatic enterocele
• Prolapse of the Douglas cul-de-sac
• posterior vaginal hernia of intestinal contents

Why it occurs

• Herniation of the peritoneal sac of the pouch of Douglas towards the rectovaginal space, containing loops of small intestine or sigmoid colon, secondary to laxity of the uterosacral ligaments and the rectovaginal fascia, common after previous hysterectomy

Initial workup

Bimanual gynecological examination combined with rectal examination (while the patient performs a Valsalva maneuver while standing) to palpate the intestinal loops sliding in the rectovaginal septum. Defeco-MRI of the pelvis (dynamic study of choice to visualize herniation of the peritoneum and accurately differentiate a rectocele from an enterocele/sigmoidocele).

Standard management

• There are no drugs to correct the fascial and anatomical defect of peritoneal herniation. Stool softeners such as polyethylene glycol 10-17 g per day orally are prescribed to avoid straining. The use of pelvic support pessaries (Gellhorn or ring type) is the conservative management of choice if surgery is contraindicated. The definitive treatment of choice for moderate or severe symptomatic enterocele is surgical correction (enterocectomy with closure of the cul-de-sac using the McCall or Halban technique laparoscopically or vaginally) (note: misdiagnosis of rectocele instead of enterocele may lead to immediate surgical failure if the herniated peritoneal sac is not repaired).