The incidence of vaginal rupture after any type of pelvic surgery is 0.03 percent with the reported incidence of cuff dehiscence after a hysterectomy being higher after laparoscopic hysterectomy compared with abdominal or vaginal hysterectomies [5, 6]. Among the 7286 hysterectomies collection by Hur, an incidence of 0.14% was reported (total and subtotal), with a peak rate of 4.93% after laparoscopic hysterectomy [6] Another single institution case study (Loco on 3593 hysterectomies) reports a rate of 0.28%, without the evidence of statistical difference between different routes of access (trans-abdominal, trans-vaginal, or laparoscopic) or the presence of a closed or unclosed cuff [7].

Vaginal evisceration after trans-abdominal hysterectomy is rare in occurrence [2]. Review of literature over the years has been associated with vaginal rather than abdominal surgery [8]. Vaginal vault rupture with prolapse of small bowel during sexual intercourse after abdominal hysterectomy in pre-menopausal women is an extremely rare complication [3].

The risk groups for trans-vaginal bowel evisceration include the elderly, postmenopausal women and female patients after vaginal or laparoscopic hysterectomy [4]. Ramirez, on a review of the literature on 59 eviscerations, highlighted as risk factors: a postmenopausal state, trans-vaginal hysterectomy, and an increase in abdominal pressure [9].

Etiology of vaginal evisceration can be generally separated according to premenopausal or postmenopausal states. In postmenopausal women, evisceration can occur either spontaneously or more frequently in connection with an increase in intra abdominal pressure, induced by coughing, defecating or falling. In premenopausal patients, evisceration is usually preceded by vaginal trauma caused by rape, coitus, obstetric instrumentation or the insertion of the foreign bodies. Additional risk factors for vaginal evisceration include previous vaginal surgeries and enteroceles [4]. In young patients, sexual intercourse before the complete healing of the vaginal cuff is considered as the main trigger event, while in elderly patients, evisceration is a spontaneous event [7].

Establishing a diagnosis of coital vaginal trauma is often difficult as patients tend to give a misleading history. Coital trauma of vagina has been associated with multiparity. Nevertheless, the vaginal wall is designed to be extremely extended and the insertion of a penis alone should be unlikely to cause vaginal rupture [10].

There are several factors that may contribute to weakness at the vaginal apex. These are poor surgical technique, post operative wound or cuff infection, wound hematoma, resumption of sexual activity before complete healing, advanced age, previous radiotherapy, chronic steroid administration, trauma, previous vaginal surgery, a vulslava maneuver or straining during bowel movement [8]. Hysterectomy may enhance the risk of rupture as a complication of vaginal trauma, as the vagina is not supported by uterus [10].

Croak locates different sites of rupture between abdominal and vaginal hysterectomies, the former having lesions predominantly in the cuff, and the latter through a posterior wall enterocele, as might happen after radical pelvic operations for cancer [5]. Most of injuries reported occurred in posterior fornix because this is the most common direction of thrust during coitus and the upper vagina is unsupported except by bundles of connective tissue [10]. Evisceration can occur even after subtotal hysterectomy through the posterior fornix [1].

Bowel evisceration can lead to serious sequele, including peritonitis, bowel injury, necrosis and sepsis. The terminal ileum is most commonly protruding viscus, although other organs, such as omentum, salpinx, and epiploic appendices have also been described. Prompt surgical and medical intervention is required to prevent complications [8, 10].

In our patient, there was no bleeding or free air in peritoneal cavity, supposedly because of the ruptured area of the vagina being immediately packed by the prolapsed intestine, which remained in the vagina from when the accident occurred. In the course of time, further prolapse might have developed when intra abdominal pressure grew high at evacuation.

The primary intervention for vaginal evisceration consists of stabilization, fluid therapy, wrapping the bowel with moist saline sponges, early antibiotic therapy, radiograph to exclude foreign bodies and prompt surgical intervention [8].

All the authors agree on the need for emergency reduction and repair. The operation can be accomplished either by a trans-abdominal (open or laparoscopic) technique, by a trans-vaginal route or by a combination of the two depending on the patient's condition and bowel viability at the time of treatment [8, 11].

If the evisceration is associated with viable easily reducible bowel, lack of evidence of instrumentation historically and radiographically, the trans-vaginal approach consisting of a 2 layer closure of peritoneum and vagina should be considered [8]. To date, all the reported cases that have required bowel resection have been managed with exploratory laparotomy followed by repair of vaginal defect [12].

In our patient, there were signs of peritonitis, so we did exploratory laparotomy followed by reduction and repair.

The associated mortality rate of vaginal evisceration is 5.6%. However the incidence of morbidity is higher, when the bowel has become strangulated through vaginal defect [12].