EP344 - Symptomatic Enterocele In Adolescent Male: Successful Robotic Repair

Purpose/Background: Enterocele, the herniation of the small intestine into the pelvic cul-de-sac, is predominantly diagnosed in post-menopausal women or women with prior hysterectomy. It is rarely observed in males and is exceptionally uncommon in adolescents. Symptoms often include abdominal pain, difficulty with bowel movements, and post-evacuation discomfort. Physical examination may not detect enterocele, making advanced imaging like defecography or dynamic MRI essential for diagnosis. Current literature primarily focuses on cases in female patients, leaving a gap in understanding optimal treatment for young males. We present a case of a 16-year-old male with a large, symptomatic enterocele requiring surgical intervention.

Methods/Interventions: A 16-year-old male with a history of anxiety presented with five months of abdominal pain, frequent small liquid stools with urgency and leakage, tenesmus, rectal pain, feelings of incomplete evacuation, and a mass-like sensation during straining that resolved spontaneously. An abdominal X-ray by his pediatrician showed a large stool burden that was incompletely resolved with laxatives. Persistent symptoms led to a referral to a pediatric gastroenterologist with a subsequent unremarkable colonoscopy. Physical examination was notable only for rectal tenderness. Pelvic floor physical therapy was initiated for suspected dysfunction but yielded no improvement. Defecography revealed a large enterocele (see figure), rectorectal intussusception, and a small anterior rectocele, with subsequent dynamic pelvic MRI demonstrating no structural abnormalities of the pelvic floor. After discussion with the patient and his family, he subsequently underwent a robotic-assisted rectopexy with layered purse-string suture obliteration of the anterior cul-de-sac.

Results/Outcomes: The patient recovered uneventfully in the postoperative period, tolerating the procedure well. By three months postoperatively, they had experienced a complete resolution of symptoms and remain symptom-free after 22 months.

Conclusion/Discussion: This case underscores the rarity and diagnostic challenges of enterocele in young males, a condition predominantly observed in post-menopausal women. The patient's nonspecific gastrointestinal symptoms and absence of typical risk factors contributed to a delayed diagnosis, highlighting the importance of considering a broad differential in young males with persistent defecatory dysfunction. Advanced imaging techniques, particularly defecography, were crucial in identifying the anatomical abnormalities. The successful use of robotic-assisted rectopexy with obliteration of the anterior cul-de-sac demonstrates that robotic-assisted minimally invasive surgical approaches can be effective for treating this rare condition in males. This case adds valuable insight to the limited literature on male enterocele, suggesting that early recognition and tailored surgical intervention can lead to excellent outcomes. Clinicians should be aware of enterocele as a potential diagnosis in male patients with chronic pelvic symptoms unresponsive to conventional therapies and consider advanced imaging for timely diagnosis and management.

Defecography Study
Defecography showing the presence of an enterocele (circled in red) during evacuation. The descending loops of small bowel can be seen prolapsing into the cul-de-sac