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

<b>Background and Clinical Significance:</b> 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. <b>Case Presentation:</b> 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 <i>Clostridium difficile</i> infection. All these complications led to the postponement of the gynaecological reintervention procedure. <b>Conclusions:</b> 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.