How to Ask Your Doctor About Enterocele: A Definitive Guide

Experiencing discomfort or unusual symptoms in your pelvic region can be unsettling, and for many, the term “enterocele” might be entirely new, yet incredibly relevant to their health. An enterocele is a type of pelvic organ prolapse where the small intestine bulges into the vagina, often causing a range of uncomfortable and sometimes debilitating symptoms. It’s a condition that, while common, is frequently misunderstood or misdiagnosed. Navigating a conversation with your doctor about something as personal and potentially complex as an enterocele requires preparation, clear communication, and a proactive approach.

This comprehensive guide is designed to empower you with the knowledge and confidence to effectively discuss enterocele with your healthcare provider. We’ll delve into understanding the condition, recognizing its symptoms, preparing for your appointment, asking the right questions, and understanding your treatment options. By the end of this article, you’ll be equipped to have a productive, insightful, and ultimately reassuring conversation about your pelvic health.

Understanding Enterocele: What It Is and Why It Matters

Before you can effectively discuss enterocele with your doctor, it’s crucial to have a foundational understanding of what it is. Imagine your pelvic floor as a hammock of muscles, tissues, and ligaments that support your pelvic organs – your bladder, uterus, vagina, and rectum. When these supportive structures weaken or stretch, one or more organs can descend or “prolapse” from their normal position.

An enterocele specifically involves the small intestine (small bowel) pushing against the top of the vagina, creating a bulge. This can happen if the connective tissues between the vagina and the rectum weaken, allowing the small bowel to drop into the space.

Why Does It Happen? Risk Factors and Causes

Several factors can contribute to the weakening of pelvic floor support, increasing the risk of enterocele:

• Childbirth: This is a primary risk factor, especially difficult or multiple vaginal deliveries. The pushing and stretching during labor can strain pelvic floor muscles and ligaments.

• Chronic Strain: Persistent activities that increase intra-abdominal pressure can contribute. This includes chronic coughing (e.g., from asthma or smoking), chronic constipation and straining during bowel movements, and heavy lifting.

• Aging and Menopause: As women age, particularly after menopause, estrogen levels decrease. Estrogen plays a vital role in maintaining the strength and elasticity of connective tissues. Lower estrogen can lead to weakening of the pelvic floor.

• Obesity: Excess body weight puts additional strain on the pelvic floor.

• Previous Pelvic Surgery: Hysterectomy (removal of the uterus) can sometimes contribute to enterocele formation, as the uterus provides some support to the top of the vagina.

• Genetics: Some individuals may have a genetic predisposition to weaker connective tissues.

Understanding these risk factors can help you contextualize your own situation when speaking with your doctor.

Differentiating Enterocele from Other Prolapses

It’s important to note that enterocele is one type of pelvic organ prolapse. Others include:

• Cystocele (bladder prolapse): The bladder bulges into the front wall of the vagina.

• Rectocele (rectal prolapse): The rectum bulges into the back wall of the vagina.

• Uterine prolapse: The uterus descends into the vagina.

• Vaginal vault prolapse: After a hysterectomy, the top of the vagina descends.

While symptoms can overlap, the specific location and nature of the bulge help distinguish an enterocele. Your doctor will be able to perform an examination to identify the type of prolapse.

Recognizing the Signs: When to Suspect an Enterocele

The symptoms of an enterocele can vary widely in severity and can often be intermittent. Some women may experience no symptoms at all, especially with mild prolapse, while others find their daily lives significantly impacted. Being aware of these signs is the first step toward a productive conversation with your doctor.

Common Symptoms to Look For:

• Pelvic Pressure or Heaviness: This is one of the most common complaints. You might feel a sensation of something “falling out” or a general dragging sensation in your pelvis, especially towards the end of the day or after prolonged standing.

• A Bulge or Lump in the Vagina: You might feel a soft, often reducible, bulge in your vagina, especially when coughing, sneezing, or straining. Some women can even see it. This bulge might be more noticeable when standing and disappear when lying down.

• Discomfort During Intercourse (Dyspareunia): The presence of the prolapse can make sexual activity uncomfortable or painful.

• Bowel Dysfunction: While enterocele primarily involves the small intestine, it can affect bowel movements. You might experience:

  • Difficulty with Bowel Movements: A feeling of incomplete evacuation, or needing to press on the perineum (the area between the vagina and anus) or inside the vagina to facilitate a bowel movement (splinting).

  • Constipation: Due to the altered anatomy, stool may become trapped.

• Lower Back Ache: A dull, aching pain in the lower back is sometimes associated with pelvic organ prolapse.

• Urinary Symptoms (Less Common, but Possible): While less common than with cystocele, some women with enterocele may experience mild urinary symptoms like increased frequency or a feeling of incomplete emptying if the prolapse puts pressure on the bladder.

Understanding Symptom Fluctuation

It’s crucial to understand that enterocele symptoms can fluctuate. They might be worse:

• After prolonged standing.

• During physical activity.

• After straining (e.g., coughing, sneezing, lifting, bowel movements).

• Towards the end of the day.

Conversely, symptoms often improve or disappear when lying down, especially after a night’s rest. This fluctuation is an important detail to share with your doctor.

Preparing for Your Appointment: Maximizing Your Time with the Doctor

A well-prepared patient is an empowered patient. Taking some time before your appointment to gather information and organize your thoughts can significantly improve the quality of your consultation and ensure you get the most out of your time with the doctor.

1. Document Your Symptoms Thoroughly

This is perhaps the most critical step. Doctors rely on detailed accounts of your symptoms to make an accurate diagnosis. Don’t rely on memory alone. Keep a symptom diary for a few days or weeks leading up to your appointment. Note:

• When did the symptoms start?

• What exactly do you feel? Describe the sensations in your own words (e.g., “heavy,” “dragging,” “bulge,” “pressure”).

• How often do they occur? Are they constant, intermittent, or worse at certain times?

• What makes them better or worse? (e.g., lying down, standing, lifting, straining, time of day).

• How do these symptoms impact your daily life? (e.g., affecting exercise, work, social activities, sexual intimacy, sleep).

• Have you tried any self-care measures? (e.g., rest, changing activities, dietary changes) and did they help?

• Any associated symptoms? (e.g., back pain, urinary issues, bowel issues).

Example: “For the past three months, I’ve felt a constant heavy pressure in my lower pelvis, especially after standing for an hour or more. It feels like something is falling out of my vagina. It’s much worse by evening, and sometimes I feel a definite soft bulge when I wipe after urinating. Lying down for 15-20 minutes usually makes the pressure ease. I’ve also noticed I have to strain more for bowel movements, and sometimes it feels like I need to push on my perineum to help pass stool.”

2. Compile Your Medical History

Your medical history provides crucial context. Be ready to discuss:

• Past Pregnancies and Deliveries: Number of pregnancies, type of delivery (vaginal, C-section), complications during delivery (e.g., forceps, episiotomy, large baby).

• Past Surgeries: Especially any pelvic or abdominal surgeries (e.g., hysterectomy, appendectomy).

• Current Medications: List all prescription medications, over-the-counter drugs, supplements, and herbal remedies you are taking.

• Chronic Medical Conditions: (e.g., asthma, chronic cough, diabetes, autoimmune diseases).

• Family History: Does anyone in your family have a history of prolapse or connective tissue disorders?

• Lifestyle Factors: Your typical activity level, exercise habits, diet (especially fiber intake), smoking status, and alcohol consumption.

3. Prepare a List of Questions

Having your questions written down ensures you don’t forget anything important during the appointment, especially if you feel nervous or rushed. Organize them from most to least important.

Example Questions to Add to Your List:

• “Could my symptoms be caused by an enterocele or another type of prolapse?”

• “What diagnostic tests will you perform to confirm this?”

• “What are my treatment options if it is an enterocele?”

• “What are the pros and cons of each treatment option?”

• “Are there non-surgical options I should consider first?”

• “If surgery is recommended, what type of surgery would it be, and what is the recovery like?”

• “What are the potential risks and complications of surgery?”

• “What can I do to prevent the enterocele from worsening?”

• “Are there any lifestyle changes I should make?”

• “Will this condition impact my ability to exercise or engage in sexual activity?”

• “What is the likelihood of recurrence after treatment?”

• “Do you recommend a referral to a specialist, such as a urogynecologist or colorectal surgeon?”

4. Consider Bringing a Support Person

It can be helpful to have a trusted friend or family member with you. They can help listen, take notes, and remember details you might forget.

5. Dress Comfortably

You will likely need to undergo a physical examination, so wear clothing that is easy to remove.

The Doctor’s Visit: What to Expect and How to Communicate Effectively

Your appointment will typically involve a discussion of your symptoms and medical history, followed by a physical examination. This is your opportunity to clearly and concisely convey all the information you’ve gathered.

The Consultation: Be Open and Honest

When your doctor asks about your symptoms, use the detailed notes you’ve prepared. Be as specific as possible. Don’t be embarrassed to discuss symptoms related to bowel function, sexual activity, or the sensation of a bulge. These details are critical for an accurate diagnosis.

• Example Dialogue Snippet:
  • Doctor: “So, what brings you in today?”

  • You: “I’ve been experiencing a heavy, dragging sensation in my pelvis for the past few months, which gets much worse by the end of the day. I also feel a soft bulge inside my vagina, especially when I cough. It’s making me really uncomfortable and affecting my ability to exercise.”

  • Doctor: “Have you noticed any changes in your bowel habits?”

  • You: “Yes, I’ve been very constipated, and sometimes I have to press on the area between my vagina and anus to help pass stool. It feels like things aren’t moving properly.”

The Physical Examination: What to Expect

Your doctor will perform a thorough physical examination, which typically includes:

• Pelvic Exam: This is similar to a routine gynecological exam. You will lie on an exam table with your feet in stirrups.
  • Visual Inspection: The doctor will visually inspect the external genitalia and the vaginal opening for any signs of prolapse.

  • Speculum Exam: A speculum will be used to open the vaginal walls, allowing the doctor to visualize the inside of the vagina and cervix. They will look for any bulging or descent of organs.

  • Bimanual Exam: The doctor will insert two gloved fingers into your vagina while placing the other hand on your abdomen to feel your pelvic organs and assess their position and mobility.

  • Rectovaginal Exam: The doctor may insert one finger into your vagina and one into your rectum to assess the space between the two and feel for any enterocele. This is crucial for diagnosing enterocele.

  • Stress Test: You may be asked to cough, bear down (as if having a bowel movement), or stand up during parts of the exam. This helps the doctor assess the degree of prolapse when your pelvic floor is under strain.

• Abdominal Exam: To check for any general tenderness or masses.

The examination might feel a bit uncomfortable, but it’s essential for diagnosis. Try to relax as much as possible, and remember to breathe deeply. Don’t hesitate to voice any discomfort you experience.

Communicating During the Exam

• Point out sensations: If you feel a bulge or pressure during a specific part of the exam, tell your doctor. “Yes, I feel that pressure there, exactly what I feel at home.”

• Ask for clarification: If you don’t understand what the doctor is doing or saying, ask them to explain.

• Confirm observations: The doctor might say, “I see some bulging here.” You can confirm, “Yes, that’s what I feel.”

Diagnostic Tools: Beyond the Physical Exam

While a physical examination is the primary method for diagnosing enterocele, your doctor may recommend additional tests to confirm the diagnosis, rule out other conditions, or plan for treatment.

Common Diagnostic Tests:

• Pelvic Floor Ultrasound: This can provide images of the pelvic organs and help visualize the prolapse. It can be performed transvaginally (probe inserted into the vagina), transabdominally (probe on the abdomen), or transperineally (probe on the perineum).

• MRI (Magnetic Resonance Imaging) of the Pelvis: MRI provides detailed images of soft tissues and can be particularly useful in complex cases or when other pelvic floor disorders are suspected. A “dynamic MRI” (also called MR defecography) involves taking images while you perform maneuvers like straining, which can help visualize the movement of organs during prolapse.

• Defecography (X-ray or MRI): This specialized test involves filling the rectum and sometimes the small bowel with a contrast material and then taking X-rays or MRI images while you have a bowel movement on a special commode. This helps visualize how the rectum and small bowel function and if there is any prolapse during straining. It’s particularly useful for assessing bowel function issues associated with enterocele.

• Urodynamic Studies: If you also have significant urinary symptoms, your doctor might recommend these tests to assess bladder function. While not directly for enterocele, they can rule out other urinary issues.

Don’t hesitate to ask your doctor about the purpose of any recommended test, what to expect during the procedure, and how the results will inform your treatment plan.

Understanding Your Treatment Options: A Comprehensive Overview

Once an enterocele is diagnosed, your doctor will discuss a range of treatment options, from conservative management to surgical intervention. The best approach depends on the severity of your symptoms, the grade of the prolapse, your overall health, your lifestyle, and your personal preferences.

Conservative (Non-Surgical) Management

For mild enterocele or for those who prefer to avoid surgery, conservative options can be very effective in managing symptoms and preventing progression.

1. Pelvic Floor Physical Therapy (PFPT):
   • What it is: PFPT is a specialized form of physical therapy that focuses on strengthening and rehabilitating the muscles of the pelvic floor. A trained pelvic floor physical therapist can teach you exercises to improve muscle tone, coordination, and support.

   • How it helps: Stronger pelvic floor muscles can provide better support to the prolapsed organs, reducing symptoms like heaviness and bulging. PFPT also helps with proper bowel emptying techniques, reducing straining.

   • Example: Learning how to properly engage your “Kegel” muscles (pelvic floor muscle contractions) and relaxation techniques, as well as core strengthening exercises.

2. Pessaries:

   • What it is: A pessary is a removable device, usually made of silicone, that is inserted into the vagina to provide support for the prolapsed organs. Pessaries come in various shapes and sizes (e.g., ring, cube, donut).

   • How it helps: It acts as a scaffold, holding the prolapsed small bowel and other organs in place. This can significantly reduce or eliminate symptoms of pressure and bulging.

   • Considerations: Pessaries need to be properly fitted by a healthcare professional. They require regular cleaning and follow-up appointments to ensure proper fit and prevent complications like irritation or infection. Many women find pessaries to be a highly effective and non-invasive solution.

3. Lifestyle Modifications:

   • Weight Management: If you are overweight or obese, losing even a small amount of weight can significantly reduce pressure on your pelvic floor.

   • Managing Chronic Constipation:

     • Dietary Changes: Increase your fiber intake (fruits, vegetables, whole grains).

     • Hydration: Drink plenty of water throughout the day.

     • Bowel Habits: Avoid straining during bowel movements. Elevating your feet on a stool while on the toilet can help (e.g., using a Squatty Potty).

     • Laxatives/Stool Softeners: Your doctor may recommend these if dietary changes aren’t enough.

   • Avoiding Heavy Lifting: Learn proper lifting techniques and avoid lifting objects that put excessive strain on your core and pelvic floor.

   • Managing Chronic Cough: If you have a chronic cough due to allergies, asthma, or smoking, addressing the underlying cause is crucial.

   • Smoking Cessation: Smoking contributes to chronic cough and can weaken connective tissues.

4. Estrogen Therapy (for postmenopausal women):

   • What it is: Topical (vaginal) estrogen creams, rings, or tablets can help improve the health, elasticity, and thickness of vaginal tissues, which can be beneficial for pelvic floor support.

   • How it helps: While not a cure for prolapse, it can improve tissue quality and make other treatments (like pessary use) more comfortable and effective.

Surgical Management

Surgery is typically considered when conservative measures have failed, symptoms are severe, or the prolapse significantly impacts quality of life. The goal of enterocele repair surgery is to restore the small bowel to its proper position and reinforce the weakened vaginal wall.

Key Surgical Approaches:

1. Vaginal Repair (Anterior/Posterior Colporrhaphy with Enterocele Repair):
   • Procedure: This involves making an incision in the vaginal wall, pushing the small bowel back into place, and then strengthening the weakened tissue (fascia) with sutures. Often, the cul-de-sac (the pouch between the rectum and uterus/vagina where the enterocele forms) is closed or reduced.

   • Approach: Performed through the vagina, so no abdominal incision.

   • Pros: Less invasive than abdominal surgery, quicker recovery time.

   • Cons: Higher risk of recurrence compared to some abdominal approaches in certain cases.

2. Abdominal Sacrocolpopexy:

   • Procedure: This is considered the “gold standard” for apical (top of the vagina) prolapse, including enterocele and vaginal vault prolapse after hysterectomy. It involves attaching a synthetic mesh to the top of the vagina and then securing the mesh to the sacrum (a bone at the base of the spine). This suspends the vagina and provides strong, long-lasting support. The enterocele itself is often repaired at the same time by closing the cul-de-sac.

   • Approach: Can be performed open (through a large abdominal incision), laparoscopically (minimally invasive with small incisions and a camera), or robotically (using robotic arms for enhanced precision).

   • Pros: Very durable repair with low recurrence rates.

   • Cons: More invasive than vaginal repair, longer recovery for open approach, potential for mesh-related complications (though rare).

3. Laparoscopic/Robotic Sacrocolpopexy: These minimally invasive versions of sacrocolpopexy offer similar durability with smaller incisions, less pain, and quicker recovery compared to open abdominal surgery.

Important Considerations for Surgery:

• Risk vs. Benefit: Discuss the potential risks (infection, bleeding, pain, mesh erosion, recurrence) versus the expected benefits (symptom relief, improved quality of life).

• Mesh Use: Understand if mesh will be used and why. Discuss the risks and benefits of synthetic mesh. For enterocele, mesh is commonly used in sacrocolpopexy to provide long-term support.

• Concomitant Procedures: Your doctor may recommend repairing other types of prolapse (e.g., cystocele, rectocele) at the same time if they are also present.

• Surgeon’s Expertise: Inquire about your surgeon’s experience with the specific type of enterocele repair they recommend. Urogynecologists (specialists in female pelvic medicine and reconstructive surgery) are highly trained in these procedures.

• Recovery: Understand the typical recovery period, activity restrictions, and potential pain management.

• Long-Term Outlook: Discuss the likelihood of recurrence and what follow-up care will be needed.

Post-Diagnosis and Beyond: Living with and Managing Enterocele

Receiving a diagnosis of enterocele is the first step toward regaining control of your pelvic health. Whether you choose conservative management or surgical repair, ongoing self-care and communication with your healthcare team are vital.

Lifestyle for Pelvic Health:

• Maintain a Healthy Weight: Continued weight management helps reduce pressure on the pelvic floor.

• Prevent Constipation: Keep fiber intake high, stay hydrated, and practice good bowel habits.

• Avoid Heavy Lifting: When lifting, use your legs, not your back, and avoid straining. If possible, get help with heavy objects.

• Manage Chronic Cough: Address conditions that cause chronic coughing.

• Pelvic Floor Exercises: Continue with pelvic floor exercises (as taught by a physical therapist) even after treatment to maintain muscle strength and support.

• Regular Follow-Ups: Adhere to your doctor’s recommended follow-up schedule to monitor your condition and ensure the effectiveness of your treatment.

Addressing Emotional and Psychological Impact

Living with pelvic organ prolapse can have an emotional toll. The discomfort, embarrassment, and impact on daily activities and intimacy can lead to anxiety or depression.

• Communicate Openly: Don’t shy away from discussing the emotional aspects with your doctor. They can offer support or refer you to mental health professionals if needed.

• Seek Support Groups: Connecting with others who share similar experiences can be incredibly validating and provide valuable coping strategies.

• Educate Yourself: The more you understand your condition, the less intimidating it becomes.

Conclusion: Empowering Your Pelvic Health Journey

Discussing an enterocele with your doctor requires preparation, clarity, and an open mind. By understanding what an enterocele is, recognizing its symptoms, meticulously preparing for your appointment, and asking informed questions, you transform from a passive patient into an active participant in your healthcare journey.

Remember, you are not alone in this. Enterocele is a common condition, and effective treatments are available. Your doctor is your partner in this process, and a strong, communicative relationship is the foundation for successful management. Be persistent in seeking answers, advocating for your needs, and pursuing the treatment path that aligns best with your health goals and quality of life. Empower yourself with knowledge, and take charge of your pelvic health, because your well-being matters.