Small Bowel in Vagina: A Case for Pelvic Exams

Vaginal cuff dehiscence with small bowel evisceration is a serious but uncommon postoperative complication of total laparoscopic hysterectomies. The severity of surgical site dehiscence can range from small, partial to full-thickness wound dehiscence, manifesting with acute abdominal pain, vaginal bleeding, or discharge, and is often precipitated by sexual intercourse. While imaging, including a pelvic ultrasound and computed tomography (CT), may help in undifferentiated acute abdominal pain, vaginal cuff dehiscence remains a clinical diagnosis found on physical exam. Because vaginal cuff dehiscence is a clinical diagnosis, sparse data exist regarding radiographic sensitivities and specificities in the identification of vaginal cuff dehiscence. Despite the increasing literature suggesting that pelvic exams are invasive with often limited utility, the authors argue that pelvic exams remain essential in identifying complications of hysterectomies. The authors present a case of a 40-year-old woman with acute abdominal pain found to have loops of small bowel in the vaginal vault, discovered only on physical exam after negative CT and ultrasound imaging.