Postcoital vaginal rupture is a rare but well documented complication of hysterectomy. Evisceration of the small intestine, vaginal bleeding and pelvic pain are common presenting features. We report the unusual case of vaginal rupture presenting with generalised peritonitis without vaginal evisceration.Postcoital vaginal rupture is a rare but well documented complication of hysterectomy. Evisceration of the small intestine is a common presenting feature and may be accompanied by vaginal bleeding and pelvic pain. These symptoms usually occur during or soon after intercourse and the diagnosis is self evident. We report the unusual case of vaginal rupture presenting with generalised peritonitis without vaginal evisceration 4 days after intercourse and 10 months after a laparoscopic hysterectomy.
case historyA 35-year-old woman presented to the accident and emergency department with a 4-day history of abdominal pain. The pain was generalised, colicky and progressive in nature. It was associated with anorexia, vomiting and constipation for 48 hours. She admitted to being sexually active but denied any abnormal vaginal discharge or bleeding. At that time, neither was she asked directly whether the onset of pain coincided with sexual intercourse nor did she volunteer this information. Her past medical history consisted of a laparoscopic hysterectomy ten months earlier for dysfunctional uterine bleeding and pelvic pain, hypothyroidism and irritable bowel syndrome.On examination, the patient looked unwell with significant abdominal discomfort. Initial observations showed a temperature of 37.4ºC, a systolic blood pressure of 121mmHg and a tachycardia of 103 beats per minute. Her abdomen was distended with generalised tenderness and peritonism. Rectal and vaginal examinations were not performed in the emergency department. Inflammatory markers were raised with a white cell count of 15.9 x 103/µl and a C-reactive protein level of 180mg/l. Plain x-rays of the chest and abdomen showed dilated small bowel loops and free air under the diaphragm (Fig 1).She was referred to the on-call general surgeon with peritonitis secondary to a perforation of a hollow viscus. The on-call general surgeon confirmed the findings and diagnosis and proceeded to an emergency laparotomy. At surgery, pneumoperitoneum was found with minimal purulent contamination of the abdominal cavity. A thorough examination of the stomach, small bowel and colon failed to identify a perforation. A closer inspection of the pelvis revealed a perforated vaginal stump and localised adhesions. The vaginal stump defect was closed with nonabsorbable sutures and a washout of the peritoneal cavity was performed. A pelvic drain was left in situ. The patient's postoperative course was accompanied by pain and ongoing sepsis but there was a good response to intravenous antibiotics with no further complications. On direct questioning at this stage, she confirmed that her symptoms had started soon after sexual intercourse. She was discharged home on the seventh postoperat...
