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Journal of Gynecology Obstetrics and... Mar 2023When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life...
When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.
Topics: Female; Humans; Aged; Pelvic Organ Prolapse; Rectocele; Vagina; Gynecologic Surgical Procedures; Genital Diseases, Female; Pelvic Floor
PubMed: 36657614
DOI: 10.1016/j.jogoh.2023.102535 -
Neurourology and Urodynamics Aug 2022The mid-vagina (MV) represents Level II of the vagina. The surgical anatomy of the MV has not been recently subject to a comprehensive examination and description. MV... (Review)
Review
AIM
The mid-vagina (MV) represents Level II of the vagina. The surgical anatomy of the MV has not been recently subject to a comprehensive examination and description. MV surgery involving anterior and posterior colporrhaphy represents a key part of surgery for a majority of pelvic organ prolapse (POP).
METHODS
Literature review and surgical observations of many aspects of the MV were performed including MV length and width; MV shape; immediate relationships; histological analysis; anterior and posterior MV prolapse assessment and anterior MV surgical aspects. Unpublished pre- and postoperative quantitative data on 300 women undergoing posterior vaginal compartment repairs are presented.
RESULTS
The MV runs from the lower limit of the vaginal vault (VV) to the hymen. Its length is a mean of 5 cm. Its shape in section overall is a compressed rectangle. Its longitudinal shape is created by its anterior and posterior walls being inverse trapezoid in shape. Histology comprises three layers: (i) mucosa; (ii) muscularis; (iii) adventitia. MV prolapse staging uses pelvic organ prolapse quantification (POP-Q). Anterior MV prolapse can be quantitatively assessed using POP-Q while posterior MV prolapse can be assessed with POP-Q or PR-Q. Around 50% of both cystocele and rectocele are due to VV defects. POP will increase anterior MV width and length. Native tissue anterior colporrhaphy is the current conventional repair with mesh disadvantages outweighing advantages. Posteriorly, Level II (MV) defects are far smaller (mean 1.3 cm) than Level I (mean 6.0 cm) and Level III (mean 2.9 cm).
CONCLUSION
An understanding of the surgical anatomy of the MV can assist anterior and posterior colporrhaphy. In particular, if VV support is employed, the Level II component of a posterior repair should be relatively small.
Topics: Cystocele; Female; Humans; Pelvic Organ Prolapse; Postoperative Period; Surgical Mesh; Treatment Outcome; Vagina
PubMed: 35731184
DOI: 10.1002/nau.24994 -
Radiography (London, England : 1995) Aug 2022To provide an illustrative description of the technique and spectrum of findings in defecating proctography. (Review)
Review
OBJECTIVES
To provide an illustrative description of the technique and spectrum of findings in defecating proctography.
KEY FINDINGS
Important findings on defecating proctography include rectocoele, enterocoele, sigmoidocoele, cystocoele, intussusception, rectal prolapse, descending perineum, incomplete emptying, anismus, and faecal incontinence. This review article illustrates these key findings with examples.
CONCLUSION
Defecating proctography is a well-established and cost-effective method of assessing disordered defecation. In conjunction with clinical information and other diagnostic tests, findings on defecating proctography can guide appropriate multidisciplinary management and may lead to improvement in embarrassing and debilitating symptoms in many patients.
IMPLICATIONS FOR PRACTICE
This review article provides a suggested technique and covers the spectrum of findings on defecating proctography.
Topics: Defecation; Defecography; Humans; Intussusception
PubMed: 35569315
DOI: 10.1016/j.radi.2022.04.012 -
Journal of Clinical Gastroenterology Aug 2020Anorectal disorders encompass structural, neuromuscular, and functional disorders. They are common, often distressing, and in some cases debilitating, and significantly... (Review)
Review
Anorectal disorders encompass structural, neuromuscular, and functional disorders. They are common, often distressing, and in some cases debilitating, and significantly add to the health care burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathology and can pose significant diagnostic and management dilemmas. A meticulous history and comprehensive digital rectal examination can provide clarity on the diagnosis, appropriate testing, and management of these conditions. Today, with the development of sophisticated diagnostic tools such as high-resolution and high-definition (3-D) anorectal manometry, 3-D anal ultrasonography, magnetic resonance defecography and imaging, and neurophysiological tests such as translumbosacral anorectal magnetic stimulation, it is possible to more accurately define and characterize the underlying structural and functional abnormalities. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of anal fissure, hemorrhoids, rectal prolapse, intussusception, rectocele, solitary rectal ulcer syndrome, levator ani syndrome, dyssynergic defecation and fecal incontinence.
Topics: Anal Canal; Anus Diseases; Constipation; Defecation; Defecography; Fecal Incontinence; Humans; Manometry; Rectal Diseases; Rectum
PubMed: 32692116
DOI: 10.1097/MCG.0000000000001348 -
Gastroenterology Clinics of North... Mar 2022Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the... (Review)
Review
Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.
Topics: Ataxia; Biofeedback, Psychology; Constipation; Defecation; Humans; Laxatives
PubMed: 35135665
DOI: 10.1016/j.gtc.2021.10.004