Mrs. B. O. is a 40-year-old petty trader. She is para 1+0 with one living male child. She achieved menarche at 14 years of age. She has a regular 28 days menstrual cycle with 4 days menstrual flow, and her last menstrual period was on January 15, 2014. She presented at the gynecology clinic of University of Nigeria Teaching Hospital on January 22, 2014 with complaints of masses protruding from her vagina and anus of 24 months duration. The protrusions started 5 months after a spontaneous unsupervised delivery at home of a live male baby. The concomitant protrusions occurred spontaneously. They were usually noticed while straining, sneezing, coughing or in standing position, but often receded spontaneously while in a recumbent position. There was associated low back pain, urinary frequency, and constipation. There was no chronic cough, weight lifting, dysuria, abdominal swelling, or similar family history. About 6 months prior to the presentation, the condition became associated with weight loss and difficulty in holding her stool. The vaginal protrusion no longer receded spontaneously in recumbent position and then required manual reduction. On examination, she appeared generally well. There were no abnormal findings on the examination of the chest, abdomen, central nervous system, and the musculoskeletal system. Pelvic examination showed a protrusion of the entire uterus from the vagina. The protrusion was reducible with associated mild cystocele []. There was no demonstrable stress incontinence. The cervix was healthy looking and the os was parous. The uterus was normal sized, retroverted, and mobile. The adnexa were free. Rectal examination showed a concomitant mass (rectum) protruding from the anus []. There was associated fecal incontinence, but the rectal mucosa was normal. A diagnosis of concomitant occurrence of uterovaginal prolapse (procidentia) and rectal prolapse was made. The hemoglobin concentration, white cell count, urinalysis, culture of her midstream urine, stool analysis and culture, and abdominopelvic ultrasound showed no abnormality. In view of her parity and desire to retain her reproductive function, she and her husband were counseled for open abdominal sacrohysteropexy with synthetic mesh and rectopexy, which they consented to. Following the above investigation results which were available within 2 weeks from her first clinic visit, she was admitted into the ward for the above surgery. While in the ward, she was reviewed by the general surgeons who commenced her on a 1-day mechanical bowel preparation alongside with antibiotics bowel preparation, using the oral neomycin and metronidazole for antibiotics bowel preparation. She had an overnight fasting prior to the day of surgery and was placed on intravenous fluid (normal saline) to ensure adequate rehydration. She received intravenous ceftriaxone and metronidazole as preoperative antibiotics medication. She subsequently had a successful surgery done by a combined team of gynecologists and general surgeons. The surgical procedure briefly involved a general anesthesia/endotracheal intubation; peritoneal cavity entered via a midline sub-umbilical incision; synthetic mesh sutured to the back of the cervix with the other end sutured to a prominent part of sacral promontory (sacrohysteropexy); rectum lifted and sutures taken to secure the sides to the sacrum with a synthetic mesh that provided added reinforcement (rectopexy).\nThe postoperative period was uneventful and she is being follow-up in the gynecologic clinic. Her last clinic visit, before this report was on June 30, 2014; she had no complaint and was happy with the procedure.
We present the case of an 81-year-old woman without interesting medical precedents excepting a moderated cognitive deterioration (with partial dependence for activities of daily living). She was taken to the hospital by her relatives after they found her in the bathroom presenting with intestinal loops exiting through her anus. The presence of a rectal prolapse was not among her precedents ().\nOn the first exploration, we recognized an abdominal excavation, which was painless on palpation, and we observed many small intestine loops with a congestive aspect exiting through the anus. When the patient arrived, she was hypotensive and tachycardic. After the first resuscitation attempt, an urgent blood test was requested, and the results showed albumin, 3; C-reactive protein, 47.3 mg/dL; and 19,700 leukocytes with neutrophilia, indicating an urgent need for surgery. The patient was taken to the operating room less than two hours after the beginning of the symptoms, and during the surgery, her hemodynamic condition remained the same.\nFor the surgery, the patient was placed in a modified lithotomy position, and two areas (abdominal and perineal) were prepared. After checking the difficulty of reducing the intestine exclusively through the anus, we performed an exploratory laparotomy, which revealed the absence of small intestine loops in the cavity; these had been moved to the pelvis and this was causing an important traction of the mesentery root. As a result, a manual reduction of the loops to the cavity through intraperitoneal traction was done; this was controlled from the perineal field. After the reduction had been completed, a 3 to 4 cm lineal craniocaudal perforation in the antimesenteric portion of the upper rectum was objectified (RIS II/AAC III). An important flaccidity of the entire pelvic musculature which contained a large rectovaginal pouch was observed, which resulted in both the superior rectum and the peritoneal reflection leaning on the pelvic floor (). The peritoneal cavity was abundantly washed with hot saline, and after some minutes, the loops initiated a visible peristalsis and took on a normal coloration. Later, the superior rectum and the sigmoid colon were dissected until the promontory, and an anterior resection of the rectum and a terminal colostomy in the left iliac region (Hartmann's procedure) were performed ().\nLater, the patient's relatives told us that she had difficulties defecating and had frequently manipulate herself to extract her feces. The patient was admitted to the intensive care unit for 3 days where she remained hemodynamically stable and her ventilatory support was ceased without incidence. She had a slow recovery, and on the 6th day tolerated oral intake well. She was discharged after 13 days, and two months later remained asymptomatic.