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Dietz HP. Diagnosis of maternal birth trauma by pelvic floor ultrasound. Eur J Obstet Gynecol Reprod Biol 2023; 285:86-96. [PMID: 37087835 DOI: 10.1016/j.ejogrb.2023.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/01/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023]
Abstract
BRIEF SUMMARY Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.
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Sun G, de Haas RJ, Trzpis M, Broens PMA. A possible physiological mechanism of rectocele formation in women. Abdom Radiol (NY) 2023; 48:1203-1214. [PMID: 36745205 PMCID: PMC10115871 DOI: 10.1007/s00261-023-03807-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to determine the anorectal physiological factors associated with rectocele formation. METHODS Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected. RESULTS Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011). CONCLUSION Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.
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Affiliation(s)
- Ge Sun
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Robbert J de Haas
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Monika Trzpis
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
| | - Paul M A Broens
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.,Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
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Thorsen AJ. Management of Rectocele with and without Obstructed Defecation. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Background Pregnancy and childbirth are thought to be the strongest environmental risk factors for pelvic organ prolapse, but prolapse does occur in nulliparae. Aim To characterise prolapse in vaginal nulliparae. Material and methods This was a retrospective study using archived clinical and imaging data of 368 vaginally nulliparous women seen between 2006 and 2017 at two tertiary urogynaecological centres. Patients underwent a standardised interview, clinical examination and 3D/4D translabial ultrasound. Volume datasets were analysed by the second author, blinded against all clinical data, using post‐processing software on a personal computer. Significant prolapse was defined as Pelvic Organ Prolapse Quantification system stage ≥2 for the anterior and posterior compartment, and stage ≥1 for the central compartment. On imaging, significant prolapse was defined as previously described. Results Of 4297 women seen during the inclusion period, 409 were vaginally nulliparous, for whom 368 volume data sets could be retrieved. Mean age was 50 years (17–89) and mean body mass index 29 (16–64). Eighty‐one (22%) presented with prolapse symptoms. On clinical examination, 106 women (29%) had significant prolapse, mostly of the posterior compartment (n = 70, 19%). On imaging 64 women showed evidence of significant prolapse (17%), again mostly posterior (n = 47, 13%). Rectovaginal septal defects were even more common in 69 (19%). On multivariate analysis we found no differences between true nulliparae (n = 184) and women delivered exclusively by caesarean section (n = 184). Conclusions Prolapse occurs in vaginal nulliparae, but it has distinct characteristics. Rectocele predominates, while cystocele and uterine prolapse are uncommon. Pregnancy and caesarean delivery seem to have little effect.
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Affiliation(s)
| | - Leilani Chavez-Coloma
- University of Sydney, Sydney, NSW, Australia.,Department Of Obstetrics and Gynecology, Dr. Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Talia Friedman
- University of Sydney, Sydney, NSW, Australia.,Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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Dietz HP. Ultrasound imaging of maternal birth trauma. Int Urogynecol J 2021; 32:1953-1962. [PMID: 33595672 DOI: 10.1007/s00192-020-04669-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/28/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The term 'maternal birth trauma' has undergone substantial changes in meaning over the last 2 decades. Leaving aside psychological morbidity, somatic trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle. This review covers diagnosis of maternal birth trauma by translabial ultrasound imaging. METHODS Narrative review. RESULTS Tomographic imaging of pelvic structures with the help of 4D ultrasound, used since 2007, has allowed international standardization and seems to be highly reproducible and valid for the diagnosis of OASI and levator avulsion. CONCLUSIONS Translabial and exo-anal ultrasound allows the assessment of maternal birth trauma in routine clinical practice and the utilization of avulsion and sphincter trauma as key performance indicators of maternity services. It is hoped that this will lead to a greater awareness of maternal birth trauma among maternity caregivers and improved outcomes for patients, both in the short term and in the decades to come.
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Affiliation(s)
- Hans Peter Dietz
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, The University of Sydney, 62 Derby Street, Kingswood, NSW, 2747, Australia.
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Emile SH, Balata M, Omar W, Khafagy W, Elgendy H. Specific Changes in Manometric Parameters are Associated with Non-improvement in Symptoms after Rectocele Repair. Int Urogynecol J 2020; 31:2019-2025. [PMID: 32691118 DOI: 10.1007/s00192-020-04444-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The present study aimed to assess the changes in manometric parameters after transperineal repair (TPR) of rectocele and interpret failure of symptom improvement in light of these changes. METHODS This was an observational cohort study on patients with anterior rectocele who underwent TPR in the period of February 2016 to February 2019. Data collected included patients' demographics, rectocele size, Wexner constipation and incontinence scores, anal pressures, and rectal sensation before and 12 months after TPR. Analysis of data was done by paired t-test and chi-square test. RESULTS Forty-six female patients with a mean age of 43.2 ± 10.7 years were included. After a mean follow-up of 13.9 ± 2.7 months, 30 (65.2%) patients reported clinical improvement and 16 (34.8%) had no significant improvement. At 12 months after rectocele repair, the entire cohort studied showed an insignificant increase in the mean anal pressures and a significant decrease in the thresholds of first rectal sensation, first urge, intense urge, and maximum tolerable volume (MTV). Patients who clinically improved showed similar physiologic changes to the entire cohort examined, whereas patients who had no clinical improvement showed significant increases in the mean anal pressures and insignificant decreases in rectal sensation and MTV. CONCLUSION Patients who showed clinical improvement showed insignificant increases in anal pressures and significant decreases in thresholds of first rectal sensation, first urge, intense urge, and MTV. Contrarily, patients who did not show clinical improvement showed significant increases in anal pressures and insignificant reduction in sensory thresholds.
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Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt. .,General Surgery Department, Faculty of Medicine, Mansoura University Hospitals, Elgomhuoria Street, Mansoura city, Egypt.
| | - Mohammed Balata
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
| | - Waleed Omar
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
| | - Wael Khafagy
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
| | - Hesham Elgendy
- Colorectal Surgery Unit, General Surgery Department, Mansoura faculty of medicine, Mansoura University, Mansoura city, Egypt
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Gaj F, Biviano I, Trecca A, Lai Q, Andreuccetti J. Early and late effects of the sequential transfixed stich technique for the treatment of the symptomatic rectocele without rectal mucosa prolapse. MINERVA CHIR 2020; 75:83-91. [PMID: 32009331 DOI: 10.23736/s0026-4733.20.08175-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Different surgical techniques have been proposed for rectocele repair. However, controversial aspects exist on the best approach to use. The study aims to report the early and late outcomes of the sequential transfixed stich technique (STST) for the treatment of rectocele in the absence of mucosal prolapse. METHODS One hundred patients presenting a symptomatic rectocele were treated with STST from January 2010 through August 2015. Patients with mucosal prolapse were not considered eligible for STST. After a period of 24 months from surgery, all the patients were clinically evaluated with the intent to investigate the risk of recurrence of the preoperative symptoms. RESULTS All the patients were women (median age=54.7 years; ranges=37-75). Median discharge time was 1.5 days. One-month severe complications were: hemorrhoid thrombosis (6.0%), self-solved bleeding (6.0%), urinary retention (4.0%), anal secretion (4.0%) and urinary incontinence (1.0%). No post-operative cases of fecal incontinence were observed. Two years after surgery, 76.0% of patients reported a global improvement of the preoperative symptoms, with 73 and 35% of cases showing a reduced difficulty in the evacuation and need for digitation. Only 8.0% of patients showed a recurrence of the initial symptoms. CONCLUSIONS The STST is a feasible, safe, and cost-effective technique for the treatment of the rectocele without rectal mucosal prolapse. The method does not increase the risk of postoperative anal incontinence and presents a short hospital stay. STST presents long-term results in line with other transvaginal and transanal approaches.
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Affiliation(s)
- Fabio Gaj
- Department of General Surgery and Organ Transplantation, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Ivano Biviano
- Unit of Gastroenterology and Operative Endoscopy, Santa Maria alle Scotte Hospital, Siena, Italy
| | | | - Quirino Lai
- Department of General Surgery and Organ Transplantation, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy -
| | - Jacopo Andreuccetti
- Unit of General and Mini-Invasive Surgery, San Camillo Hospital, Trento, Italy
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Dietz HP, Gómez M, Atan IK, Ferreira CSW. Association between vaginal parity and rectocele. Int Urogynecol J 2018; 29:1479-1483. [PMID: 29464300 DOI: 10.1007/s00192-017-3552-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 12/20/2017] [Indexed: 12/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Rectocele is common in parous women but also seen in nulliparae. This study was designed to investigate the association between vaginal parity and descent of the rectal ampulla/rectocele depth as determined by translabial ultrasound (TLUS). METHODS This retrospective observational study involved 1296 women seen in a urogynaecological centre. All had undergone an interview, clinical examination and 4D ultrasound (US) imaging supine and after voiding. Offline analysis of volume data was undertaken blinded against other data. Rectal ampulla position and rectocele depth were measured on Valsalva. A pocket depth of 10 mm was used as a cutoff to define rectocele on imaging. RESULTS Most women presented with prolapse (53%, n = 686); 810 (63%) complained of obstructed defecation (OD). Clinically, 53% (n = 690) had posterior-compartment prolapse with a mean Bp of -1 [standard deviation (SD)1.5; -3 to 9 cm]. Mean descent of the rectal ampulla was 10 mm below the symphysis (SD 15.8; -50 to 41). A rectocele on imaging was found in 48% (n = 618). On univariate analysis, OD symptoms were strongly associated with rectal descent, rectocele depth and rectocele on imaging (all P < 0.001). The prevalence of a rectocele seen on imaging increased with vaginal parity (P < 0.001). One-way analysis of variance (ANOVA) of vaginal parity against rectal descent and rectocele depth showed a dose-response relationship (both P < 0.001). CONCLUSIONS Vaginal parity was strongly associated with descent of the rectal ampulla and rectocele depth. This relationship approximated dose-response characteristics, with the greatest effect due to the first vaginal delivery.
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Affiliation(s)
- Hans Peter Dietz
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, University of Sydney, Penrith, Australia.
| | - Mariángeles Gómez
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, University of Sydney, Penrith, Australia
- Tomografía Computada de Buenos Aires, entidad afiliada a la Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Ixora Kamisan Atan
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, University of Sydney, Penrith, Australia
- Department of Obstetrics & Gynecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Caroline S Wanderley Ferreira
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, University of Sydney, Penrith, Australia
- Department of Physiotherapy, Federal University of Pernambuco, Recife, Brazil
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Rachaneni S, Atan IK, Shek KL, Dietz HP. Digital rectal examination in the evaluation of rectovaginal septal defects. Int Urogynecol J 2017; 28:1401-1405. [PMID: 28213798 DOI: 10.1007/s00192-017-3285-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/25/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to evaluate the diagnostic potential of digital rectal examination in the identification of a true rectocele. METHODS This is a retrospective observational study utilising 187 archived data sets of women presenting with lower urinary tract symptoms and/or pelvic organ prolapse between August 2012 and November 2013. Evaluation included a standardised interview, ICS-POPQ, rectal examination and 4D translabial ultrasound. The main outcome measure was the diagnosis of rectocele by digital rectal palpation on Valsalva manoeuvre. This diagnosis correlated with the sonographic diagnosis of rectocele to determine agreement between digital examination and ultrasound findings. RESULTS Complete data sets were available for 180 participants. On imaging, the mean position of the rectal ampulla was 11.07 (-36.3 to 44.3) mm below the symphysis pubis; 42.8% (77) had a rectocele of a depth of ≥10 mm. On palpation, a rectocele was detected in 60 women (33%). Agreement between palpation and imaging was observed in 77%; the kappa was 0.52 (CI 0.39-0.65). On receiver operator characteristic analysis, the area under the curve was 0.854 for the relationship between rectocele pocket depth and the detection of rectocele on palpation. CONCLUSION Moderate agreement was found between digital rectal examination for rectocele and translabial ultrasound findings of a "true rectocele". Digital rectal examination may be used to identify these defects in clinical practice. Extending the clinical examination of prolapse to include rectal examination to palpate defects in the rectovaginal septum may reduce the need for defecatory proctograms for the assessment of obstructive defecation and may help triage patients in the management of posterior compartment prolapse.
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Affiliation(s)
- Suneetha Rachaneni
- School of Clinical and Experimental Medicine , University of Birmingham, Birmingham, UK.
| | | | - Ka Lai Shek
- Department of Obstetrics and Gynecology, Liverpool Clinical School, University of Western Sydney, Parramatta, Australia
| | - Hans Peter Dietz
- Department of Obstetrics and Gynecology, Sydney Medical School Nepean, University of Sydney, Penrith, Australia
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Shek KL, Dietz HP. Assessment of pelvic organ prolapse: a review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:681-692. [PMID: 26865209 DOI: 10.1002/uog.15881] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/27/2016] [Accepted: 01/30/2016] [Indexed: 06/05/2023]
Affiliation(s)
- K L Shek
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Western Sydney University, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
- Department of Obstetrics and Gynaecology, Nepean Clinical School, University of Sydney, Sydney, Australia
| | - H P Dietz
- Department of Obstetrics and Gynaecology, Nepean Clinical School, University of Sydney, Sydney, Australia
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Levator avulsion is not associated with symptom bother of female pelvic organ prolapse. Arch Gynecol Obstet 2015; 292:629-33. [DOI: 10.1007/s00404-015-3633-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 01/22/2015] [Indexed: 12/28/2022]
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