When is her pelvic pressure
and bulge due to
Pouch of Douglas hernia?

Your patient reports symptoms similar to pelvic organ prolapse, but prolapse is not the problem. These authors offer how to make an accurate diagnosis.

Dr. Kim-Fine is Fellow, Female Pelvic Medicine and Reconstructive Surgery, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota.

Dr. Gebhart is Associate Professor and Fellowship Director, Female Pelvic Medicine and Reconstructive Surgery, Mayo Clinic.

The authors report no financial relationships relevant to this article.

CASE: Pelvic organ prolapse or Pouch of Douglas hernia?

A 42-year-old G3P2 woman is referred to you by her primary care provider for pelvic organ prolapse. Her medical history reveals that she has been bothered by a sense of pelvic pressure and bulge progressing over several years, and she has noticed that her symptoms are particularly worse during and after bowel movements. She reports some improved bowel evacuation with external splinting of her perineum. Upon closer questioning, the patient reports a history of chronic constipation since childhood associated with straining and a sense of incomplete emptying. She reports spending up to 30 minutes three to four times per day on the commode to completely empty her bowels.

Physical examination reveals an overweight woman with a soft, nontender abdomen remarkable for laparoscopic incision scars from a previous tubal ligation. Inspection of the external genitalia at rest is normal. Cough stress test is negative. At maximum Valsalva, however, there is significant perineal ballooning present.

Speculum examination demonstrates grade 1 uterine prolapse, grade 1 cystocele, and grade 2 rectocele. There is no evidence of pelvic floor tension myalgia. She has weak pelvic muscle strength. Visualization of the anus at maximum Valsalva reveals there is some asymmetric rectal prolapse of the anterior rectal wall. Digital rectal exam is unremarkable.

Are these patient’s symptoms due to pelvic organ prolapse or Pouch of Douglas hernia?