the first report of vaginal evisceration was described by hyernaux in 1864 , as disruption of the anterior wall of the proximal vagina , resulting in prolapse of the abdominal contents ( 1 ) . since then , there have been just over 120 reports in the literature , although in reality some cases may go unreported ( 1 ) .
vaginal evisceration is a rare postoperative complication of hysterectomy ( regardless of the surgical approach ) in women of this age group that carries a high risk of morbidity and mortality and requires rapid surgical intervention .
there are different aetiologies depending on the age group  pre - menopausal vs postmenopausal ( 2 ) . in post - menopausal women
interestingly , in pre - menopausal women there have been reports of vaginal evisceration following transvaginal ultrasonography ( 3 ) .
the use of each approach depends on the viability of the bowel , whether the defect in the vaginal wall is sufficiently large to replace the bowel back into the peritoneal cavity and on any evidence of foreign bodies in the abdominal cavity .
a 66 year old woman presented to a&e with per vagina bleeding , abdominal pain and a mass protruding from the vagina .
prior to this presentation , the patient had suffered for the past decade with cystocoele and retrocoeles .
three decades ago the patient had received an abdominal hysterectomy in order to relieve her symptoms of menorrhagia .
other than arthritis , the patient does not suffer from any other medical condition and was in good health . on examination the patient seemed well , but her abdomen was distended and tender in the suprapubic , left and right iliac fossa regions .
there was evidence of vaginal prolapse with a 20 - 30 cm evisceration of small bowel via a vaginal vault defect .
prior to the emergency operation which aimed to salvage the small bowel , the patient was given antibiotics .
the aim of the surgery was to reduce the prolapsed small bowel and re - suture the vaginal wall defect .
on inspection by the consultant gynaecologist , the small bowel appeared slightly dusky and an opinion was sought from a consultant general surgeon ( who deemed the bowel healthy ) .
the small bowel was replaced through the vaginal wall defect and vaginal wall biopsies taken .
the patient recovered well in the first few days after the operation , though she did have some trouble maintaining the catheter in situ , due to the still uncorrected vaginal prolapse .
the catheter was removed on day 5 post - operatively , but the patient had developed a urinary tract infection while catheterised and had to be on i.v .
the patient was discharged on day 8 , but was to come back 6 - 8 weeks later for an elective sacrocolpopexy to correct the vaginal wall prolapse .
initially exploratory laparoscopy was performed , the pelvis appeared normal and the consultant decided to perform an abdominal sacrocolpopexy .
a pfannenstial incision was made , small bowel adhesions to right pelvic side wall were noted and divided .
the peritoneum between sacrum and posterior vaginal wall was exposed , allowing prolene mesh to be attached to the vaginal wall with prolene and vinyl sutures .
the rectus sheath was sutured using vinyl and the skin closed with staples ( with a drain in situ ) .
cystoscopy was used to verify the function of the ureters , which revealed both were working well .
the patient recovered quickly , there were no post - operative complications and was discharged on day 2 post - operatively .
this patient had had a hysterctomy many years ago and it is unlikely her vaginal evisceration was a consequence of this surgery directly , but hysterectomy can lead , for example to changes in the vaginal axis . the vagina may come to lie in a more descended position , as it has lost part of its more proximal attachments .
this new position combined with factors such as cystocoeles and retrocoeles and their management ( for example the insertion of pessaries ) may predispose the vagina walls to more  wear and tear  damage .
these are risk factors that are likely to have contributed to this lady s transvaginal evisceration , together with her increasing age susceptibility .
vaginal evisceration if not recognised quickly can lead to peritonitis and bowel ischaemia . in this lady
however , it is important to make emergency doctors aware of these complications and encourage their proper management .
when the patient is received by an emergency department and the problem is determined , the emergency doctors must not delay the administration of broad spectrum antibiotics in preparation for taking the patient to theatre and ensure the prolapsed bowel is covered in saline - soaked gauze , as this improves the bowel chances of viability ( 4 ) .
this case illustrates the need for rapid recognition of vaginal evisceration and its appropriate management in order to avoid morbidity and mortality to the patient .
 a 66 year old woman presented to a&e with per vagina bleeding and a mass protruding from the vagina . 
 the patient was examined under anaesthesia , which revealed vaginal prolapse with evisceration of approximately 20 - 30 cm of bowel . 
 the patient had received an abdominal hysterectomy 30 years ago for menorrhagia . in the last decade , 
 the patient had experienced other recurrent episodes of prolapse ( cystocoele and retrocoele ) . 
 vaginal vault evisceration is a recognised rare complication of hysterectomy and is a gynaecological emergency . 
 this patient s condition was rapidly recognised and surgically managed . 
 the repair was achieved in two surgeries . 
 initially , the small bowel was re - inserted into the peritoneal cavity through the vaginal wall defect and the vaginal defect repaired . after sufficient time for healing 
 , a sacrocolpopexy was performed to repair the prolapse . 