# A Rare Case of Severe Pelvic Organ Prolapse with Massive Perineal Hernia in a Nulliparous Woman: A Case Report and Literature Review

## TL;DR

A rare case of severe pelvic organ prolapse with a massive perineal hernia in a nulliparous woman is reported, highlighting the challenges in its management and recurrence.

## Contribution

This case report presents an unusual instance of severe pelvic organ prolapse in a nulliparous woman with no known risk factors.

## Key findings

- The patient had a severe grade IV pelvic organ prolapse with a perineal hernia containing the uterus, bladder, and small bowel.
- Despite successful initial surgery, the patient experienced a recurrence of prolapse within two months.
- Multiple complications, including chronic kidney disease and infections, delayed further gynaecological intervention.

## Abstract

Background and Clinical Significance: Advanced pelvic organ prolapse (POP) associated with perineal herniation of pelvic and abdominal organs is a sporadic occurrence in gynaecological practice. Generally, POP affects up to 50% of multiparous women at some point during their lives. Advanced forms (grade III or IV) represent less than 10% of all cases, with severe grade IV prolapse occurring in fewer than 2% of patients. Case Presentation: We report the case of a 48-year-old nulliparous woman with no prior surgical history and no known medical conditions at presentation. The patient presented with severe grade IV POP (Baden–Walker Classification), characterised by abdominal pain, vaginal bleeding and significant urinary incontinence. A computed tomography scan was performed, revealing an extremely large perineal hernia, containing the uterus, urinary bladder, and small bowel loops—a rare finding with only isolated cases reported in the medical literature. Surgical treatment involved a total intracapsular hysterectomy with right-sided adnexectomy and colpoperineorrhaphy. After the surgery, the overall status of the patient was good. However, less than two months later, she returned, complaining of a recurrence of the initial pathology, and was diagnosed with grade II/III POP recurrence despite having no connective tissue disorders or other classical predisposing factors such as pregnancies, pelvic surgery history or obstetric trauma. The case was further complicated by a femoral neck fracture, stage V chronic kidney disease, COVID-19 pneumonia, and a Clostridium difficile infection. All these complications led to the postponement of the gynaecological reintervention procedure. Conclusions: We emphasise the significant challenges in managing this kind of perineal hernia, under unusual conditions and without common risk factors. A personalised, multidisciplinary approach is required, including careful follow-up to prevent early recurrence.