Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

ABSTRACT A 31-year old female with a history of laparoscopic assisted vaginal hysterectomy presented by ambulance to the emergency department with acute onset of abdominal pain and a vaginal protrusion which occurred while straining to pass a bowel movement.  Physical examination was notable for a flat but slightly tender abdomen, normal bowel sounds, scant vaginal bleeding, and a 15cm long, blood-tinged mass protruding from the vagina.  A brief and unsuccessful attempt at reduction was made by the emergency physician.  Obstetrics and Gynecology was consulted, and the patient was taken to the operating DIAGNOSIS Omental prolapse through vaginal cuff dehiscence .  Following vaginal hysterectomy, the vaginal cuff is closed surgically1.  Occasionally, this site can dehisce, allowing abdominal contents to enter the vagina or protrude through the vaginal canal. Vaginal cuff dehiscence is estimated to have a rate of 0.39%. It is more commonly seen after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy, (0.28%)2. Risk factors include trauma from sexual intercourse, repetitive Valsalva maneuvers, smoking, malnutrition, anemia, diabetes, immunosuppression, and corticosteroid use2.  Cases typically present as vaginal spotting or post-coital bleeding, and occasionally pelvic pressure or protrusion2.  Most cases occur within weeks to months after the procedure, but some can present years later. Patients are at risk for infection due to exposure of peritoneal contents to vaginal and skin flora.  Management includes administration of broad-spectrum antibiotics.  Partial dehiscence can be managed with rest, but large dehiscence is usually managed surgically. This case highlights the importance of the pelvic exam in patients with vaginal bleeding and abdominal pain, and care should be taken to not mistake protruding omental tissue for prolapsed vaginal mucosa.   REFERENCES 1.     Binz NM, et al. Complications of Gynecologic Procedures. Emergency Medicine: A Comprehensive Study Guide , 9e. McGraw Hill; 2020. 2.     Clarke-Pearson D, & Geller E. Complications of Hysterectomy.  Obstetrics & Gynecology, 121 (3), 654-673; 2013.