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Arquivos de Gastroenterologia 2021Few studies have investigated the constipation or obstructed defecation symptoms identified by using imaging, as dynamic three-dimensional ultrasound and correlate...
BACKGROUND
Few studies have investigated the constipation or obstructed defecation symptoms identified by using imaging, as dynamic three-dimensional ultrasound and correlate vaginal delivery, parity, and age.
OBJECTIVE
The aim of this study was to assess the prevalence of pelvic floor dysfunctions in female patients with obstructed defection symptoms and to determine whether specific pelvic floor dysfunctions identified by dynamic three-dimensional ultrasonography (echodefecography) are correlated with vaginal delivery, parity, and age. The secondary goal is to report the prevalence of coexisting pelvic floor dysfunctions.
METHODS
This is a retrospective cohort study including patients with obstructed defecation symptoms underwent echodefecographyto evaluate pelvic floor dysfunctions in the posterior compartment and correlate with vaginal delivery, parity, and age.
RESULTS
Of 889 female: 552 (62%) had had vaginal delivery and 337 (38%) were nulliparous. The prevalence of dysfunctions identified by echodefecography (rectocele, intussusception, enterocele/sigmoidocele, and dyssynergia) was similar between the two groups and was not associated with number of deliveriesor age. However, the prevalence of sphincter defects showed higher rates in women with vaginal delivery and increased with the parity. Up to 33% of patients had coexisting dysfunctions.
CONCLUSION
The prevalence of dysfunctions such as rectocele, intussusception, dyssynergia, and enterocele/sigmoidocele assessed by echodefecography in patients with obstructed defecation symptoms are found similar regardless of vaginal delivery, number of deliveries or stratified-age. In vaginal delivery, number of deliveries does impact on detection of sphincter defects and liability to fecal incontinence.
Topics: Constipation; Defecation; Delivery, Obstetric; Female; Humans; Parity; Pelvic Floor; Pregnancy; Retrospective Studies; Ultrasonography
PubMed: 34705963
DOI: 10.1590/S0004-2803.202100000-52 -
Gynecologic and Obstetric Investigation 2021Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to...
OBJECTIVES
Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to analyze perioperative morbidity and mortality as well as long-term outcome of rectocele repair in combination with other perineal surgeries (RR combination) and compare this with solo rectocele repair (solo RR).
DESIGN
The type of study was case-control. Data of patients who received solo rectocele repair or rectocele repair in combination with other perineal surgeries between January 2011 and December 2015 were identified and reviewed in a prospectively maintained and IRB-approved database. Ninety-eight patients were included, including 41 patients in the solo RR group and 57 patients in the RR combination group. The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were observed.
METHODS
The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were compared, respectively. Covariate adjustment was analyzed by multivariate logistic and Cox regression analysis.
RESULTS
Ninety-eight patients with a median age of 57 were included, involving 41 patients in the solo RR group and 57 patients in the RR combination group. Other than the operative approach (p < 0.01), demographics and preoperative characteristics of the 2 groups were comparable. All variables, including length of stay, estimated blood loss, self-limiting rectal bleeding, transfusion, urinary retention, rectal stricture, rectal and perineal infection, rectovaginal abscess, reoperation, effective resolution of obstructive defecation symptoms, residual symptoms rate, and recurrence rate, were comparable among the 2 groups except for operative time (p = 0.03).
LIMITATIONS
This study is a single-center study, which may cause bias. In addition, the sample size is limited. Staging of rectocele and routine imaging studies were not performed.
CONCLUSIONS
Rectocele repair in combination with other perineal surgeries is feasible, and outcomes are comparable with solo rectocele repair. Transanal versus transvaginal repairs appear to have no influence on outcomes.
Topics: Biopsy; Constipation; Female; Humans; Perineum; Rectocele; Rectum; Treatment Outcome
PubMed: 34689138
DOI: 10.1159/000519516 -
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 -
World Journal of Gastrointestinal... Sep 2021Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).
BACKGROUND
Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).
AIM
To assess the current literature in regard to the outcome of the classical transperineal repair (TPR) of rectocele and its technical modifications.
METHODS
An organized literature search for studies that assessed the outcome of TPR of rectocele was performed. PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020. The main outcome measures were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and quality of life.
RESULTS
After screening of 306 studies, 24 articles were found eligible for inclusion to the review. Nine studies (301 patients) assessed the classical TPR of rectocele. The median rate of postoperative improvement in ODS symptoms was 72.7% (range, 45.8%-83.3%) and reduction in rectocele size ranged from 41.4%-95.0%. Modifications of the classical repair entailed omission of levatorplasty, addition of implant, concomitant lateral internal sphincterotomy, changing the direction of plication of rectovaginal septum, and site-specific repair.
CONCLUSION
The transperineal repair of rectocele is associated with satisfactory, yet variable, improvement in ODS symptoms with parallel increase in quality-of-life score. Several modifications of the classical TPR were described. These modifications include omission of levatorplasty, insertion of implants, performing lateral sphincterotomy, changing the direction of classical plication, and site-specific repair. The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.
PubMed: 34621481
DOI: 10.4240/wjgs.v13.i9.1063 -
Journal of Clinical Medicine Sep 2021The incidence of pelvic organ prolapse (POP) is increasing in our aging society. We aimed to evaluate the clinical usefulness of translabial ultrasound (TLUS) by...
The incidence of pelvic organ prolapse (POP) is increasing in our aging society. We aimed to evaluate the clinical usefulness of translabial ultrasound (TLUS) by comparing the findings of POP-Q examination and TLUS in advanced POP patients and we also aimed to evaluate the prevalence of rectocele and enterocele on the TLUS. We analyzed the TLUS and POP-Q exam findings of 363 symptomatic POP patients who visited our clinic from March 2019 to April 2021. We excluded three patients who had conditions mimicking POP, as revealed by the TLUS. The most common POP type was anterior compartment POP (68.61%), followed by apical compartment (38.61%) and posterior compartment (16.11%) POP. Agreement between the POP-Q exam and TLUS was tested using Cohen's kappa (κ). values < 0.05 were considered statistically significant. The incidence of rectocele or enterocele was only 1.67% (6/360) and there was no rectocele or enterocele in most patients (246/252, 96.63%) when the POP-Q exam revealed posterior compartment POP, suggesting that they only had posterior vaginal wall relaxation. The positive predictive value of the POP-Q exam for detecting rectocele or enterocele (as revealed by TLUS) was only 2.38%, whereas the negative predictive value was 100%. In conclusion, the application of TLUS is useful in the diagnosis of POP, especially for differentiation of true POP from conditions mimicking POP. The correlation between the POP-Q exam and TLUS is low, especially in posterior compartment POP, and therefore, patients with POP-Q exam findings suggesting posterior compartment POP should undergo TLUS to check for rectocele or enterocele. The use of TLUS in the diagnosis of POP patients can improve the accuracy of the diagnosis of POP patients in conjunction with a POP-Q exam.
PubMed: 34575378
DOI: 10.3390/jcm10184267 -
The Cochrane Database of Systematic... Sep 2021Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required.
OBJECTIVES
To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome.
SEARCH METHODS
We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author.
SELECTION CRITERIA
Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information.
DATA COLLECTION AND ANALYSIS
Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE.
MAIN RESULTS
Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE.
AUTHORS' CONCLUSIONS
In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
Topics: Bayes Theorem; Defecation; Defecography; Female; Humans; Pelvic Floor Disorders; Ultrasonography
PubMed: 34553773
DOI: 10.1002/14651858.CD011482.pub2 -
Cell Death & Disease Sep 2021Inflammatory bowel disease (IBD) has a close association with transketolase (TKT) that links glycolysis and the pentose phosphate pathway (PPP). However, how TKT...
Inflammatory bowel disease (IBD) has a close association with transketolase (TKT) that links glycolysis and the pentose phosphate pathway (PPP). However, how TKT functions in the intestinal epithelium remains to be elucidated. To address this question, we specifically delete TKT in intestinal epithelial cells (IECs). IEC TKT-deficient mice are growth retarded and suffer from spontaneous colitis. TKT ablation brings about striking alterations of the intestine, including extensive mucosal erosion, aberrant tight junctions, impaired barrier function, and increased inflammatory cell infiltration. Mechanistically, TKT deficiency significantly accumulates PPP metabolites and decreases glycolytic metabolites, thereby reducing ATP production, which results in excessive apoptosis and defective intestinal barrier. Therefore, our data demonstrate that TKT serves as an essential guardian of intestinal integrity and barrier function as well as a potential therapeutic target for intestinal disorders.
Topics: Adenosine Triphosphate; Animals; Apoptosis; Cell Proliferation; Colitis; Colon; Energy Metabolism; Epithelial Cells; Female; Gene Deletion; Gene Ontology; Intestinal Mucosa; Intestines; Ki-67 Antigen; Mice, Inbred C57BL; Mice, Knockout; NADP; Rectocele; Transketolase; Up-Regulation; Mice
PubMed: 34535624
DOI: 10.1038/s41419-021-04142-4 -
Journal of Mid-life Health 2021Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20...
BACKGROUND
Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20 (PFDI-20) in evaluation of vault prolapse.
MATERIALS AND METHODS
Prospective study in 20 women with posthysterectomy vault prolapse of Stage 2 and above. The outcome measure was to calculate PFDI-20 score in all cases before surgical intervention and to recalculate it again in 6 months after different surgical procedures for vault prolapse and to statistically compare the PFDI-20 score in different types of surgery over 4 years period at a tertiary referral hospital for surgical treatment. Prolapse was classified using Pelvic Organ Prolapse Quantification and intraoperative findings. All women were operated for vault prolapse as per hospital protocol and stage of prolapse by either vaginal sacrospinous fixation or abdominal sacrocolpopexy.
RESULTS
Mean age, parity, and body mass index were 54.8 years, 3.5, and 22.71 kg/m respectively. Preceding surgery was vaginal hysterectomy in 75% women and abdominal hysterectomy in 25% women. Complaints were bulge or mass feeling at perineum (100%), pressure in lower abdomen and perineum (55%), and constipation (60%). The type of prolapse was vault prolapse (100%), cystocele (100%), rectocele (100%), and enterocele (45%). The range of PFDI-20 was 88-152 with mean being 123.50 ± 22.71 before surgery while its range decreased significantly to 80-126 with mean being 106.40 ± 16.45 after surgery ( < 0.01). Mean postoperative PFDI-20 score was 107.40 in vaginal sacrospinous fixation group and was 105.30 in abdominal sacrocolpopexy group and was not statistically different ( = 0.18).
CONCLUSION
PFDI-20 score can be used to see the adverse impact of vault prolapse on pelvic floor and to assess the beneficial effect of different types of surgeries on the score.
PubMed: 34526746
DOI: 10.4103/jmh.JMH_102_20 -
Annals of Palliative Medicine Aug 2021This study sought to investigate the effects of internal sphincterotomy of the anus in the treatment of defecation disorders in patients with outlet obstructive and... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
This study sought to investigate the effects of internal sphincterotomy of the anus in the treatment of defecation disorders in patients with outlet obstructive and mixed constipation.
METHODS
This study included 250 patients, who met the Rome III criteria for functional defecation disorder-associated constipation and were admitted to the Proctology Department in the People's Hospital of Dazu District between July 2014 and June 2016. The patients were randomly divided into the traditional medical treatment group (n=125) and the surgical treatment group (n=125), and received traditional treatment and internal anal sphincterotomy, respectively. All patient clinical data were retrospectively analyzed. Indices relating to anorectal pressure, electromyographic indices of abdominal muscles, sleep quality, anxiety and depression, defecography and anal healing before and after treatment were measured, and the effects of the different treatment modalities on defecation disorders were analyzed.
RESULTS
The total treatment effective rate was significantly higher in the surgical treatment group than in the traditional treatment group (P<0.05). The Constipation Scoring System scores at time points 1, 2 and 3 were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). After treatment, the Hospital Anxiety and Depression Scale and Pittsburg Sleep Quality Index scores were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). After treatment, the rectal resting pressure and 10SR were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001). After treatment, the negative conversion rate of the balloon expulsion test was significantly higher in the surgical treatment group than in the traditional treatment group (P<0.05), while the rectocele, perineum descending distance, and anorectal angle of the efforts phase were significantly lower in the surgical treatment group than in the traditional treatment group (P<0.001).
CONCLUSIONS
Internal anal sphincterotomy can significantly relieve defecation disorders and clinical symptoms, improve sleep quality, eliminate psychological disorders, and promote patient recovery.
TRIAL REGISTRATION
Chinese Clinical Trial Registry ChiCTR2100048818.
Topics: Anal Canal; Constipation; Defecation; Defecography; Humans; Lateral Internal Sphincterotomy; Retrospective Studies
PubMed: 34488361
DOI: 10.21037/apm-21-1190 -
Journal of Ayub Medical College,... 2021Magnetic resonance imaging (MRI) has been commonly used in the assessment of preoperative pelvic organ prolapse to evaluate anatomical defects prior to surgery. This...
BACKGROUND
Magnetic resonance imaging (MRI) has been commonly used in the assessment of preoperative pelvic organ prolapse to evaluate anatomical defects prior to surgery. This study aimed at evaluating the dynamic MRI reliability in the determination of pelvic organ prolapse and to assess its compliance with the physical examination for preoperative planning of women.
METHODS
A prospective cross-sectional study was performed at the radiology department of the Jinnah Postgraduate Medical Centre Karachi from April-October 2019. All women irrespective of age and parity status having obstructed defecation, constipation, organ prolapse, pelvic pain, or stress urinary incontinence undergoing dynamic pelvic MRI were consecutively enrolled. A brief history was obtained followed by a physical examination for pelvic organ prolapse followed by MRI examination. Kappa coefficient was applied to see the agreement of physical examination with MRI finding.
RESULTS
A total 38 women were included. A significantly moderate agreement was observed between MRI and physical exam findings with respect to the presence or absence of cystocele (K=0.554, p<0.001), rectocele (K=0.632, p<0.001), and enterocele (K=0.587, p<0.001). However, agreement with respect to the MRI and physical examination findings on uterine descent was non-significant (K=0.130, p 0.421).
CONCLUSIONS
MRI examination is an effective diagnostic modality in determination of the pelvic organ prolapse in suspected symptomatic patients. MRI could add value primarily in research areas, taking into account its ability to examine the entire pelvis.
Topics: Cross-Sectional Studies; Female; Humans; Magnetic Resonance Imaging; Magnetic Resonance Spectroscopy; Pelvic Organ Prolapse; Prospective Studies; Reproducibility of Results
PubMed: 34487642
DOI: No ID Found