Transvaginal evisceration progressing to peritonitis in the emergency department: a case report

A 63-year-old female presented ambulatory to the emergency department with abdominal pain and foreign body sensation in her vagina after coughing. Physical exam demonstrated evisceration of her small bowel through her vagina. During her clinical course, she rapidly deteriorated from appearing well without abdominal tenderness to hypotensive with frank peritonitis.This case demonstrates the need to perform a thorough physical exam on all patients with abdominal pain and details the management of vaginal evisceration. This case also highlights the difficulty of appropriate triage for patients with complaints not easily assessed in triage. In an era of emergency department crowding, emergency physicians should reevaluate nursing education on triaging abdominal pain to prevent delays in caring for well-appearing patients who have underlying life-threatening illnesses.Abdominal pain is the most common presentation to US emergency departments (ED) and accounts for 6.8% of all visits [1]. Identifying those patients with abdominal pain who are at risk for acute decompensation is essential. Evisceration of bowel through the vagina is a rarely reported complication of a hysterectomy. It is more commonly associated with trauma and conditions that increase intra-abdominal pressure, including heavy lifting, coughing or straining [2]. Much of the literature on this topic is available in obstetrics and gynecology journals [2-4]. We report this rare finding in a patient presenting to the emergency department with the common chief complaint of abdominal pain.A 63-year-old G2P2 female presented ambulatory to the ED with the chief complaint of abdominal pain, described further to the triage nurse as abdominal cramping and a mass in her vagina. The patient described that she had had a "bulge" in her vagina for the past 2 years and was currently being treated by her gynecologist for an enterocele with estrogen cream. Elective surgical repair of an enterocele was planned. She complained