Transvaginal Evisceration in a Case With Iatrogenic Cushing's Syndrome and no Previous Gynecologic Surgery

Abstract

Transvaginal evisceration (rupture of the vagina vault and small bowel evisceration through the defect) was first reported in 1907 and is a rare event [1]. During the last century, approximately 100 cases of transvaginal evisceration were reported in English language literature. Most reported cases had histories of gynecologic surgical procedures, such as repair of vaginal prolapse or various hysterectomies (abdominal, vaginal, laparoscopy-assisted or radical) [2–4]. Spontaneous vaginal evisceration without previous gynecologic surgery is extremely rare. In this report, we describe a postmenopausal female with iatrogenic Cushing’s syndrome with spontaneous vaginal evisceration. We review the relevant literature and discuss the possible etiologies. A 78-year-old, gravida 6, para 6, woman presented at our emergency department with sudden onset lower abdominal pain that had started the previous night. A review of her medical history revealed no prior pelvic surgery, and no Papanicolaou examination had ever been performed. All previous births had been by vaginal delivery. The patient denied vaginal trauma and recent sexual intercourse. The patient had taken steroid medication from an unlicensed doctor for approximately 1 year to relieve back pain. Prior to admission, she had suffered from intermittent low-grade fever, and had experienced two episodes of ambiguous vaginal bleeding during the previous month. She had complained of poor appetite, diarrhea, abdominal fullness, and a pelvic bearing-down sensation for several days prior to admission. Her vital signs were: temperature, 37.6°C; pulse, 106 beats/minute; and blood pressure, 140/75 mmHg. Her general appearance was significant for Cushingoid face, truncal obesity, buffalo hump, and paper-thin skin with bruising. Physical examination revealed generalized abdominal rebound pain. Laboratory results were: white blood count, 14,900/μL; segmented neutrophils, 74.8%; albumin, 2.4 g/dL; blood sugar, 153 mg/dL. Other laboratory data were within reference ranges. Clinical evaluation included an abdominal X-ray series, which indicated possible small bowel obstruction. Abdominal computed tomography revealed severe small bowel dilatation with air–fluid level formation. A gynecologist was consulted because of the complaint of vaginal bleeding and pelvic pressure. Before a gynecologic evaluation could be performed, she experienced sudden evisceration of about 50 cm of small bowel with ischemic changes from the vaginal introitus during urination (Figure 1). The eviscerated small bowel was immediately placed on warm, moist saline-soaked pads, and the patient was then transferred to the operating theatre.