Carcinoma of the vagina presenting as a ruptured procidentia with an entero-vaginal fistula and prolapse of the small bowel.

The 74-year-old widow was admitted as an emergency with a 4-day history of faecal incontinence and loose stools. Whilst on the lavatory she had felt something 'give way' and this prompted her referral to Casualty. She had had one normal pregnancy and delivery 50 years previously. The menopause had occurred 24 years previously and she denied any postmenopausal bleeding or discharge. She admitted that she had had a uterine prolapse for 1 year but had not noticed any change in this. On examination she had a complete procidentia and 15-20 cm of ruptured and everted small bowel hanging from the perineum. She was transferred to the operating theatre once blood had been cross matched and her blood count and electrolytes shown to be normal. Further examination was carried out under anaesthetic. There was a 10 cm diameter malignant-looking ulcer on the posterior wall of the procidentia stretching from the cervix to the fourchette. Small bowel, which had been adherent to the tumour in the pouch of Douglas, had perforated resulting in an enterovaginal fistula. The bowel had prolapsed through the ulcer at two separate points and had become everted (Fig. 1). A combined abdomino-vaginal approach was employed to reduce the prolapsed bowel and uterus. Fifteen centimetres of small bowel were resected and continuity restored with an end-to-end anastomosis. A total hysterectomy and bilateral salpingooophorectomy was also performed but removal of the vaginal tumour was impossible so several biopsies were taken. Closure of the vault also closed the ulcer in the vaginal tumour.