Hypernaux et al. described the transvaginal prolapse of abdominal content for the first time in 1864 [
12]. Later in 1907, McGregor reported protrusion of small bowel through vaginal wall rupture [
13]. Since then, a few more than 100 cases with this pathology have been reported in the literature [
1‐
10,
14]. About 70% of the affected patients are postmenopausal women [
3,
6]. This increased incidence could be explained by vaginal wall atrophy, which coincided with the triad of hypoestrogenism, chronic tissue devascularization, and pelvic floor weakness [
10,
15]. Most patients with transvaginal evisceration have previous gynaecological surgery or concomitant pelvic organ prolapse [
10,
15,
16]. According to a review of all hysterectomies and pelvic repairs performed at Mayo Clinic from 1970 through 2001, Croak et al. reported a 0.032% incidence of vaginal evisceration after a pelvic operation [
10]. Somkuti et al. described ten risk factors for apical vaginal rupture after an abdominal or vaginal hysterectomy: (1) poor technique, (2) postoperative infection, (3) hematoma, (4) coitus before healing, (5) age, (6) radiotherapy, (7) corticosteroid therapy, (8) trauma or rape, (9) the previous vaginoplasty, and (10) use of the Valsalva manoeuvre [
17]. Many other factors can influence this condition, such as lifestyle, hypothyroidism, obesity, multiparous women, previous pelvic radiotherapy, and poor collagen structure [
1‐
10]. However, most case reports on the topic described a trigger moment for the evisceration as recent trauma or surgery, coughing, constipation or any other factor that would increase the intra-abdominal pressure suddenly in the context of pelvic floor weakness [
8,
16,
18,
19]. In premenopausal women, transvaginal intestinal evisceration is extremely rare and often associated with instrumentation, obstetric injury or coital trauma, which vaginal lacerations may accompany [
7,
10,
14,
20]. Our patient was a postmenopausal woman with concomitant uterine prolapse, which may have weakened the vaginal wall. However, the unique feature of the case is that there was no event provoking the vaginal rupture and intestinal evisceration through it.
Transvaginal small bowel evisceration is related to 6–8% mortality and a high morbidity rate (15–20%) [
1,
3,
4,
21]. Complications associated with this condition include intestinal ischaemia and gangrene, abdominal sepsis and deep vein thrombosis [
1,
2,
22]. Because of that, early recognition and surgical treatment are crucial. Due to the rarity of this condition, there is no unified consensus about the optimal surgical technique [
23]. So, the surgical approach should be individualized and performed by a multidisciplinary team. Guttman and Afilalo emphasized five key points that may aid in the acute management of rupture and evisceration: (1) stabilizing the patient; (2) managing the patient’s fluid status, especially in patients with shock; (3) preserving the bowel in a moist saline wrap; (4) administering broadspectrum antibiotics to cover gastrointestinal flora, and (5) initiating the immediate surgical repair [
10]. The transvaginal intestinal evisceration management must start with a detailed assessment of the herniated viscus. A reduction may be attempted if the eviscerated bowel is viable, has not been previously irradiated, and there are no signs of an acute abdomen. Subsequent transvaginal surgical repair may be feasible [
3,
4]. This, however, limits thorough inspection of the bowel length [
19]. So, in these cases, a combined laparoscopic and vaginal approach may be beneficial to enable appropriate inspection of the abdominopelvic viscera before repairing the vaginal defect [
8,
19]. However, in most cases such as ours, the intraperitoneal reposition of the eviscerated intestine was not possible (due to the status of the affected loops or the vaginal defect is located too high) [
19]. So, this required laparotomy combined with a transabdominal or transvaginal vault repair [
3,
4,
10,
19]. Ischaemic, non-viable bowel would require resection and anastomosis [
3‐
5,
7,
10]. In our case, after transabdominal reduction, eviscerated small intestine restored its vital colour and hysterectomy, partial resection of the vagina and vaginal closure was performed due to high-grade uterine prolapse. Additional cholecystectomy was necessary because of the visible pathologic changes of the gallbladder.