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Annals of Coloproctology Oct 2022Rectocele can be associated with both obstructed defecation and fecal incontinence. There exists a great variety of operative techniques to treat patients with...
PURPOSE
Rectocele can be associated with both obstructed defecation and fecal incontinence. There exists a great variety of operative techniques to treat patients with rectocele. The purpose of this study was to evaluate the clinical outcome in a consecutive series of patients who underwent transperineal repair of rectocele when presenting with fecal incontinence as the predominant symptom.
METHODS
Twenty-three consecutive patients from April 2000 to July 2015 with symptomatic rectocele underwent transperineal repair by a single surgeon.
RESULTS
All patients had a history of vaginal delivery, with or without evidence of associated anal sphincter injury at the time. The median age of the cohort was 53 years (range, 21-90 years). None were fully continent preoperatively. However, continence improved to just rare mucus soiling or loss of flatus in all patients 6 months after their surgery. There was no operative mortality. Postoperative complications including urinary retention and wound dehiscence occurred in 3 patients.
CONCLUSION
Fecal incontinence associated with rectocele is multifactorial and may be caused by preexisting anal sphincteric damage and attenuation. Our experience suggests that transperineal repair provides excellent anatomic and physiologic results with minimal morbidity in selected patients presenting with combined rectocele and anal sphincter defect.
PubMed: 34663063
DOI: 10.3393/ac.2021.00157.0022 -
Neurogastroenterology and Motility Nov 2022More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation.... (Review)
Review
BACKGROUND
More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful.
PURPOSE
We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.
Topics: Aged; Colorectal Neoplasms; Constipation; Defecography; Female; Humans; Prospective Studies; Rectocele; Retrospective Studies
PubMed: 36102693
DOI: 10.1111/nmo.14453 -
Female Pelvic Medicine & Reconstructive... Jan 2021Our primary objective was to determine the association between rectocele size on defecography and physical examination in symptomatic patients. Our secondary objective...
OBJECTIVES
Our primary objective was to determine the association between rectocele size on defecography and physical examination in symptomatic patients. Our secondary objective was to describe the associations between both defecography and physical examination findings with defecatory symptoms and progression to surgical repair of rectocele.
METHODS
We performed a retrospective review of all patients referred to a female pelvic medicine and reconstructive surgery clinic with a diagnosis of rectocele based on defecography and/or physical examination at a single institution from 2003 to 2017. Patients who did not have defecatory symptoms, did not undergo defecography imaging, or did not have a physical examination in a female pelvic medicine and reconstructive surgery clinic within 12 months of defecography imaging were excluded.
RESULTS
Of 200 patients, 181 (90.5%) had a rectocele diagnosed on defecography and 170 (85%) had a rectocele diagnosed on physical examination. Pearson and Spearman tests of correlation both showed a positive relationship between the rectocele size on defecography and rectocele stage on physical examination; however, one was not reliable to predict the results of the other (Pearson correlation = 0.25; Spearman ρ = 0.29). The strongest predictor of surgery was rectocele stage on physical examination (P < 0.001). Size of rectocele on defecography was not a strong independent predictor for surgery (P = 0.01), although its significance improved with the addition of splinting (P = 0.004).
CONCLUSIONS
Our results suggest that rectocele on defecography does not necessarily equate to rectocele on physical examination in patients with defecatory symptoms. Rectocele on physical examination was more predictive for surgery than rectocele on defecography.
Topics: Defecography; Disease Progression; Female; Humans; Middle Aged; Physical Examination; Rectocele; Retrospective Studies; Symptom Assessment
PubMed: 31390332
DOI: 10.1097/SPV.0000000000000719 -
Journal of the Anus, Rectum and Colon 2022Pelvic organ prolapse (POP) is a condition wherein one or more of the organs in the pelvis slip down from their original position and protrude into the vagina. Pelvic... (Review)
Review
Pelvic organ prolapse (POP) is a condition wherein one or more of the organs in the pelvis slip down from their original position and protrude into the vagina. Pelvic organ prolapse surgery has increased in the urogynecological field due to higher aging society. POP patients often suffer from bowel dysfunction, such as difficulty of bowel movements and the need to strain or push on the vagina to have a bowel movement. Rectocele is often treated with the same method used for POP, but sometimes it is treated transanally. In the transabdominal approach, the vagina is divided from the rectum, and the mesh is fixed between the vagina and rectum. On the other hand, rectal prolapse is a condition wherein the rectum slips down from its original position and protrudes from the anus. Like POP surgery, rectal prolapse has been treated laparoscopically. Even though the protruding position is different, both are pelvic conditions, and the concept of treatment is similar. Recently, POP and rectal prolapse have been diagnosed at the same time, and sometimes these diseases have been treated together. In the higher aging society, incidences of POP and rectal prolapse will increase, and both will have greater chance to be treated. Although POP is a urogynecological disease, coloproctologists need to know the bowel dysfunction in order to treat POP.
PubMed: 35572489
DOI: 10.23922/jarc.2020-007 -
International Urogynecology Journal Jun 2021The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their...
INTRODUCTION AND HYPOTHESIS
The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements.
METHODS
We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size.
RESULTS
We identified three primary factors with large effect sizes of 2 or greater: two attachment factors-posterior paravaginal descent and perineal height; and one hiatal factor-genital hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60-76% of cases; and highly correlated with one another (r = 0.72-0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani hiatus had smaller effect sizes and were less likely to fall outside the norm (20-24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size.
CONCLUSIONS
Lower perineal and lateral posterior vaginal location and enlarged genital hiatus size were strong predictors of rectocele occurrence and size and correlated highly.
Topics: Female; Humans; Magnetic Resonance Imaging; Pelvic Floor; Rectocele; Uterine Prolapse; Vagina
PubMed: 33704534
DOI: 10.1007/s00192-021-04685-2 -
Ultrasound in Obstetrics & Gynecology :... May 2023It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI),...
OBJECTIVE
It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.
METHODS
This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.
RESULTS
Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).
CONCLUSION
In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Pregnancy; Humans; Female; Middle Aged; Male; Rectocele; Intussusception; Retrospective Studies; Body Mass Index; Prolapse; Anal Canal; Fecal Incontinence; Ultrasonography
PubMed: 36565432
DOI: 10.1002/uog.26145 -
International Urogynecology Journal Dec 2022Women with a symptomatic rectocele may undergo different trajectories depending on the specialty consulted. This survey aims to evaluate potential differences between...
INTRODUCTION AND HYPOTHESIS
Women with a symptomatic rectocele may undergo different trajectories depending on the specialty consulted. This survey aims to evaluate potential differences between colorectal surgeons and gynecologists concerning the management of a rectocele.
METHODS
A web-based survey was sent to abdominal surgeons (CS group) and gynecologists (G group) asking about their perceived definition, diagnostic workup, multidisciplinary discussion (MDT) and surgical treatment of rectoceles. The answers of both groups were analyzed with the chi-square test or Fisher's exact test at p < 0.050.
RESULTS
A rectocele was defined as a prolapse of the posterior vaginal wall by 78% of the G and 41% of the CS group. All gynecologists and 49% of the CS group evaluated a rectocele clinically in dorsal decubitus, with 91% of gynecologists using a speculum and 65% using the Pelvic Organ Prolapse-Quantification (POP-Q) scoring system, compared to < 1/3 of colorectal surgeons. A digital rectal examination was performed by 90% of the CS group and 57% of the G group. A transvaginal ultrasound was only used by the G group, while anal manometry was opted for by the CS group (65%) and minimally by the G group (14%). In the G group, a posterior repair was the preferred surgical technique (78%), whereas 63% of the CS group preferred a rectopexy. Multidisciplinary discussions (MDT) were mostly organized ad hoc.
CONCLUSIONS
An availability bias is seen in different aspects of rectocele evaluation and treatment. Colorectal surgeons and gynecologists are acting based on their training and experience. Motivation for pelvic floor MDT starts with creating awareness of the availability bias.
Topics: Female; Humans; Rectocele; Belgium; Surgical Mesh; Surgeons; Colorectal Neoplasms
PubMed: 35201369
DOI: 10.1007/s00192-022-05118-4 -
BMC Women's Health Apr 2021The aim of this study is to examine the relationship between rectal-vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP).
OBJECTIVE
The aim of this study is to examine the relationship between rectal-vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP).
METHOD
Patients with posterior vaginal prolapse staged III or IV in accordance with the POP Quantitation classification method who were scheduled for pelvic floor reconstructive surgery in the years 2016-2019 were included in the study. Rectocele was diagnosed using translabial ultrasound, and obstructed defecation (OD) was diagnosed in accordance with the Roma IV diagnostic criteria. Both rectal and vaginal pressure were measured using peritron manometers at maximum Vasalva. To ensure stability, the test was performed three times with each patient.
RESULTS
A total of 217 patients were enrolled in this study. True rectocele was diagnosed in 68 patients at a main rectal ampulla depth of 19 mm. Furthermore, 36 patients were diagnosed with OD. Symptomatic rectocele was significantly associated with older age (p < 0.01), a higher OD symptom score (p < 0.001), and a lower grade of apical prolapse (p < 0.001). The rectal-vaginal pressure gradient was higher in patients with symptomatic rectocele (37.4 ± 11.7 cm HO) compared with patients with asymptomatic rectocele (16.9 ± 8.4 cm HO, p < 0.001), and patients without rectocele (17.1 ± 9.2 cm HO, p < 0.001).
CONCLUSION
The rectal-vaginal pressure gradient was found to be a risk factor for symptomatic rectocele in patients with POP. A rectal-vaginal pressure gradient of > 27.5 cm HO was suggested as the cut-off point of the elevated pressure gradient.
Topics: Aged; Female; Humans; Pelvic Organ Prolapse; Rectocele; Rectum; Ultrasonography; Vagina
PubMed: 33879140
DOI: 10.1186/s12905-021-01304-6 -
Biomedical Papers of the Medical... Dec 2023The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and...
AIMS
The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders.
METHODS
44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T.
RESULTS
MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases.
CONCLUSION
As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.
Topics: Humans; Female; Middle Aged; Defecation; Rectocele; Defecography; Retrospective Studies; Constipation; Magnetic Resonance Imaging
PubMed: 35582728
DOI: 10.5507/bp.2022.023 -
The American Journal of Gastroenterology Dec 2023Obesity is a global epidemic. Its clinical impact on symptoms of fecal incontinence (FI) and/or constipation and underlying anorectal pathophysiology remains uncertain.
INTRODUCTION
Obesity is a global epidemic. Its clinical impact on symptoms of fecal incontinence (FI) and/or constipation and underlying anorectal pathophysiology remains uncertain.
METHODS
This is a cross-sectional study of consecutive patients meeting Rome IV criteria for FI and/or functional constipation, with data on body mass index (BMI), attending a tertiary center for investigation between 2017 and 2021. Clinical history, symptoms, and anorectal physiologic test results were analyzed according to BMI categories.
RESULTS
A total of 1,155 patients (84% female) were included in the analysis (33.5% normal BMI; 34.8% overweight; and 31.7% obese). Obese patients had higher odds of FI to liquid stools (69.9 vs 47.8%, odds ratio [OR] 1.96 [confidence interval: 1.43-2.70]), use of containment products (54.6% vs 32.6%, OR 1.81 [1.31-2.51]), fecal urgency (74.6% vs 60.7%, OR 1.54 [1.11-2.14]), urge FI (63.4% vs 47.3%, OR 1.68 [1.23-2.29]), and vaginal digitation (18.0% vs 9.7%, OR 2.18 [1.26-3.86]). A higher proportion of obese patients had Rome criteria-based FI or coexistent FI and functional constipation (37.3%, 50.3%) compared with overweight patients (33.8%, 44.8%) and patients with normal BMI (28.9%, 41.1%). There was a positive linear association between BMI and anal resting pressure (β 0.45, R 2 0.25, P = 0.0003), although the odds of anal hypertension were not significantly higher after Benjamini-Hochberg correction. Obese patients more often had a large clinically significant rectocele (34.4% vs 20.6%, OR 2.62 [1.51-4.55]) compared with patients with normal BMI.
DISCUSSION
Obesity affects specific defecatory (mainly FI) and prolapse symptoms and pathophysiologic findings (higher anal resting pressure and significant rectocele). Prospective studies are required to determine whether obesity is a modifiable risk factor of FI and constipation.
Topics: Humans; Female; Male; Defecation; Rectocele; Cross-Sectional Studies; Overweight; Manometry; Constipation; Fecal Incontinence; Anal Canal; Obesity
PubMed: 37417793
DOI: 10.14309/ajg.0000000000002400