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. 2009 Aug 13;2009:bcr05.2009.1860. doi: 10.1136/bcr.05.2009.1860

Vaginal rupture caused by transvaginal ultrasonography in follow-up for ovarian cancer

Lene Lundvall 1, Flemming Jensen 2, Henrik Roed 3, Christian Ottosen 1, Caroline Ewertsen 2, Birthe Merete Henriksen 2
PMCID: PMC3027710  PMID: 21841949

Abstract

Vaginal rupture is a rare complication of hysterectomy. It is, among others, related to age and the incidence is higher in postmenopausal women. The rupture can occur spontaneously or in relation to clinical follow-up. In ovarian cancer the follow-up after surgery includes clinical examination, cancer antigen (CA)-125, and transabdominal and transvaginal ultrasonography. We experienced vaginal rupture in three patients with ovarian cancer. All patients had undergone surgery for ovarian cancer and were receiving chemotherapy. The rupture occurred shortly after transvaginal ultrasonography, performed by separate radiologists specialised in ultrasonography. All patients had acute surgery without any complications. Caution should be taken when performing transvaginal ultrasonography in hysterectomised patients and the complication of vaginal rupture should always be borne in mind.

BACKGROUND

Ovarian cancer (OC) is the sixth most commonly diagnosed cancer among women worldwide and has a high incidence in the Scandinavian countries.1 It is difficult to diagnose initially and at relapse because of the lack of symptoms and of valid screening methods. More than two thirds of the patients have advanced disease at diagnosis. The prognosis at relapse is poor with a median survival of <2 years, and a 5 year survival of <10%.2–4

In our institution, the follow-up of patients having had surgery for OC is in accordance with international and national guidelines,5,6 and includes a medical history, clinical examination, cancer antigen (CA)-125, and transabdominal and transvaginal ultrasonography.

Vaginal rupture with bowel loops in the vagina is a rare complication of hysterectomy and has an incidence of 0.28%.7 However, in 2 years we experienced four cases of vaginal rupture after transvaginal ultrasonography in three patients treated for OC.

CASE PRESENTATION

Patient 1: 65-year-old woman with OC stage III, vaginal rupture 6 months postoperatively after nine series of chemotherapy. The patient had surgery at the main hospital of the Faroe Islands by a specialist in gynaecology. The patient had a medical history of hypothyreosis and steatosis of the liver.

Patient 2: 67-year-old woman with OC stage III, vaginal rupture 3 and 6 months postoperatively after six and nine series of chemotherapy. The patient had surgery at Copenhagen University Hospital by a specialist in gynaecological oncology. This patient had no other medical diseases.

Patient 3: 78-year-old woman with OC stage IV, vaginal rupture 3 months postoperatively after three series of chemotherapy. The patient had surgery at Copenhagen University Hospital by a specialist in gynaecological oncology. The patient had a medical history of cardiac disease, hypertension and chronic obstructive pulmonary disease.

All patients had open surgery for the OC according to guidelines,8,9 which included hysterectomy, bilateral salpingo-oophorectomia, omentectomia and appendectomia. The vaginal vault was closed by interrupted sutures in patient 1 and by running sutures in patient 2 and 3. Surgery was followed by a combination chemotherapy with docetaxel and carboplatin.4

Transvaginal postoperative ultrasonography was carried out at our institution by three different radiologists specialised in the technique. All patients had been examined with ultrasound without complications before the rupture. A LOGiQ9 system (GE Healthcare, Chalfont St Giles, UK) with a transvaginal probe (E8C) with a frequency of 8 MHz was used (fig 1). The tip of the probe was curved with a radius of 12 mm. The examination was carried out with a slight pressure against the top of the vagina, which was subsequently estimated to be 500 g/cm2 in an experimental set-up.

Figure 1.

Figure 1

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Probe for transvaginal ultrasonography. Insert shows enlarged probe tip.

All cases of vaginal rupture occurred within 30–60 min after abdominal and transvaginal ultrasonography with small bowel loops in the vagina, discovered by the patient. All patients had acute surgery—in three cases by a vaginal procedure and in one case by laparotomy.

OUTCOME AND FOLLOW-UP

One patient has since died from ovarian cancer and two are alive. None of the patients had further complications related to their vaginal rupture.

DISCUSSION

Vaginal rupture is a rare complication of hysterectomy. We searched Pubmed using the keywords “vaginal rupture”, “vaginal vault rupture”, and “vaginal evisceration” in June 2009. The search revealed 11 references from the last 10 years.7,10–19 In young patients the complication is usually related to sexual intercourse.7,20 In postmenopausal patients the complication is more frequent and is, among others, related to age, radiation therapy, postoperative infection.12,17 In this age group a rupture can be either spontaneous or occur in relation to clinical follow-up. Some authors state that the incidence is higher after total laparoscopic hysterectomy14,18; however, none of the patients in this case report had total laparoscopic hysterectomy. It has also been hypothesised that intraperitoneal chemotherapy increased the risk.11 To our knowledge, the incidence in relation to chemotherapy in general has not been studied.

The treatment of transvaginal evisceration is immediate surgery in order to avoid damage to the intestine.

The interval between hysterectomy and evisceration is very variable with an average time of 6 months, though a 30 year period has been reported.14

In our institution, the follow-up of OC follows international guidelines, which include transvaginal ultrasonography. However, there does not seem to be evidence based agreement about the intervals for follow-up.5,21 As between 25–50% of recurrent OC occurs in the pelvic area, abdominal and transvaginal ultrasonography seem relevant in the follow-up. However, positron emission tomography/computed tomography (PET/CT) is gaining use in patients with a rise in CA-125 where other imaging modalities are unable to reveal the recurrent OC.3

The experience of four cases of vaginal rupture in three patients within 2 years made us question the relevance of transvaginal ultrasound as a routine examination in the follow-up of patients with OC. However, we have not been able to find evidence for a higher incidence in patients undergoing treatment with chemotherapy. Caution should be taken when performing transvaginal ultrasonography in hysterectomised patients and the complication of vaginal rupture should always be borne in mind in hysterectomised patients.

LEARNING POINTS

  • Vaginal rupture after hysterectomy is a rare complication.

  • Vaginal rupture with small bowel loops in the vagina is potentially life threatening and needs immediate surgery.

  • Caution should be taken in transvaginal ultrasonography in hysterectomised patients.

Footnotes

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

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