A cul-de-sac hernia (also termed a peritoneocele) is a

hernia A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal Devel ...

tion of

peritoneal The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...

folds into the

rectovaginal septum The rectovaginal fascia (often called rectovaginal septum or sometimes fascia of Otto) is a thin structure separating the vagina and the rectum. This corresponds to the rectoprostatic fascia in the male. Clinical significance Perforations in i ...

(in females), or the rectovesical septum (in males). The herniated structure is the

recto-uterine pouch The rectouterine pouch (rectovaginal pouch, pouch of Douglas or cul-de-sac) is the extension of the peritoneum into the space between the posterior wall of the uterus and the rectum in the human female. Structure In women, the rectouterine pouch ...

(pouch of Douglas) in females, or the

rectovesical pouch The rectovesical pouch is the pocket that lies between the rectum and the bladder in males in humans and other mammals. It is lined by peritoneum. Structure The rectovesical pouch is a space between the rectum and the bladder in men. It lies ab ...

in males. The hernia descends below the proximal (upper) third of the vagina in females, or, according to another definition, below the pubococcygeal line (PCL).The "pubococcygeal line" (PCL) is a reference line which may be drawn on defecography. It extends from the inferior (lower) border of the

pubic symphysis The pubic symphysis (: symphyses) is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attache ...

to the last coccygeal joint. See Bordeianou ''et al.'' 2018. According to a consensus statement by the USA, Australia and the UK,Consensus statement by the

American Society of Colon and Rectal Surgeons The American Society of Colon and Rectal Surgeons (ASCRS), formerly the American Proctologic Society, is a professional society for surgeons specializing in colorectal surgery. It is one of the oldest surgical societies, having been established in ...

(ASCRS), the Colorectal Surgical Society of Australia, and the Association of Coloproctology of Great Britain and Ireland. First published in 2001, revised statement in 2018. See Bordeianou ''et al.'' 2018. a cul-de-sac hernia / peritoneocele is defined as "a protrusion of the peritoneum between the rectum and vagina that does not contain any abdominal viscera" (organs). An enterocele is defined as "a protrusion of the peritoneum between the rectum and vagina containing the small intestine." A sigmoidocele is defined as "a protrusion of the peritoneum between the rectum and vagina that contains the sigmoid colon." An omentocele is defined as "a protrusion of the omentum between the rectum and the vagina." As such, peritoneocele, enterocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia.

Anatomy

This hernia is so named because it is a herniation of the recto-uterine pouch (pouch of Douglas), which is also sometimes called the "cul-de-sac". This is the pocket formed by the reflection of the peritoneum from the rectum and the posterior wall of the uterus. The equivalent structure in males is the rectovesical pouch, which is the pocket formed by the reflections of the peritoneum from the rectum to the male bladder. In terms of pelvic organ prolapse, a cul-de-sac hernia is located in the posterior compartment of the pelvis. A true cul-de-sac hernia contains only omental fat, and often intraperitoneal liquid. If the hernia contains omentum, sometimes the term "omentocele" is used. If the cul-de-sac hernia contains loops of small bowel, the term

enterocele An enterocele is a herniation of a peritoneum-lined sac containing small intestine through the pelvic floor, between the rectum and the vagina (in females). Enterocele is significantly more common in females, especially after hysterectomy. It has ...

is used. If it contains sigmoid colon, the term

sigmoidocele Sigmoidocele (also known as pouch of Douglas descent) is a medical condition in which a herniation of peritoneum containing loops of redundant sigmoid colon descends (prolapses) into the rectouterine pouch (in females), between the rectum and the v ...

is used. It has been suggested that the terms enterocele and sigmoidocele are inaccurate, since hernias are usually named according to location and not according to contents. However, the terms are in widespread use. As such, peritoneocele, enterocele, sigmoidocele, and omentocele could be considered as types of cul-de-sac hernia.

Classification

Cul-de-sac hernias may be classified as rectal, septal, or vaginal depending on the structure they herniate into. Rectal cul-de-sac hernias herniate into an

internal rectal prolapse Internal rectal prolapse (IRP) is medical condition involving a telescopic, funnel-shaped infolding of the wall of the rectum that occurs during defecation. The term IRP is used when the prolapsed section of rectal wall remains inside the body and ...

or external rectal prolapse. Septal cul-de-sac hernias herniate into the recto-vaginal septum (rectovesical septum in males). Vaginal cul-de-sac hernias bulge into the vagina itself. Combinations of these types are also possible. Severity of the hernia may be classed as first degree if it is above the pubococcygeal line, second degree if it is below the pubococcygeal line but above the ischiococcygeal line,The "ischiococcygeal line" is a reference line which may be drawn on defecography. It extends from the inferior (lower) border of the

ischium The ischium (; : is ...

to the last coccygeal joint. See Bordeianou ''et al.'' 2018. or third degree if it is below the ischiococcygeal line. Severity may also be graded according the distance between the pubococcygeal line and the lowest point of the sac as follows: small (less than 3 cm), moderate (3–6 cm) or large (more than 6 cm). Cul-de-sac hernias may also be classified as primary and secondary. Primary cul-de-sac hernias are associated with factors such as multiparity, old age, lack of elasticity,

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The Human feces, stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the ...

, and increased abdominal pressure are present. Secondary cul-de-sac hernias are those which develop after gynecologic procedures, especially after vaginal hysterectomy. Another classification of cul-de-sac hernias is internal, meaning those that are only visible on defecography, or external, which are associated with a clinically visible rectocele or rectal prolapse.

Signs and symptoms

Symptoms are variable, and depend on the exact location and severity of the hernia. Possible symptoms include: * Bulge in the posterior (back) wall of the vagina. * Bulge in perineum, (A cul-de-sac hernia can eventually extend as far as the

perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...

). * Incomplete evacuation of rectal contents during defecation. * "Heavy" sensation in pelvis. * Constipation.

Diagnosis

Cul-de-sac hernias are the most difficult to diagnose during physical examination, and to distinguish from anterior

rectocele In gynecology, a rectocele ( ) or posterior vaginal wall prolapse results when the rectum bulges ( herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of ...

or enterocele. Furthermore, rectocele and cul-de-sac hernia may occur together. Combined vaginal and rectal digital palpation may be used (examiner's thumb in vagina, index finger in anal canal). The peritoneal sac containing omentum may be palpable between the thumb and index finger. The prolapse may be detectable at the upper posterior vaginal wall during Valsalva's maneuver. Imaging which may be used to detect cul-de-sac hernia includes standard

defecography Defecography (also known as proctography, defecating/defecation proctography, evacuating/evacuation proctography or dynamic rectal examination) is a type of medical radiological imaging in which the mechanics of a patient's defecation are visuali ...

, magnetic resonance defecography and dynamic transperineal ultrasound. Cul-de-sac hernias usually only appear on such imagining at the end of the simulated defecation, and require complete or near complete evacuation of the rectum before they are visible. This feature may distinguish cul-de-sac hernia from rectocele. However, a large rectocele that retains contrast medium may hide a cul-de-sac hernia. Cul-de-sac hernia (peritoneocele / omentocele) may appear on fluoroscopic defecography as an un-opacified mass which deforms the anterior border of the rectum and the posterior border of the vagina, with widening of the recto-vaginal space in between. On magnetic resonance defecography, the vagina and rectum may appear clearly "splayed" apart.

Causes

Risk factors include prior

hysterectomy Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes ( salpi ...

and

urethropexy A urethropexy is a surgical procedure where support is provided to the urethra. One form is the " Burch urethropexy". It is sometimes performed in the treatment of incontinence (particularly stress incontinence Stress incontinence, also known a ...

because of the damage caused to the

rectovaginal fascia The rectovaginal fascia (often called rectovaginal septum or sometimes fascia of Otto) is a thin structure separating the vagina and the rectum. This corresponds to the rectoprostatic fascia in the male. Clinical significance Perforations in ...

. Hysterectomy also increases the size of the pouch of Douglas.

Notes

References

{{Digestive system diseases Colorectal surgery Rectal diseases Noninflammatory disorders of female genital tract