Descending perineum syndrome: new perspectives

Opinions of Gynecologists About Indication and Technique of Perineoplasty

Background. Perineoplasty is a frequently performed procedure as part of prolapse surgery. Despite its frequent use, there is a lack of evidence on the optimal indication, surgical technique and adverse outcomes. We intended to gain insight into the current opinions on indications and techniques of perineoplasty among (uro)gynecologists worldwide. Methods. We conducted a survey among members of the International UroGynecological Association (IUGA) to objectify indications for perineoplasty and aspects of surgical technique. Results. A total of 114 urogynecologists responded, with 98% performing perineoplasty. A total of 85% of respondents aimed to approximate the bulbocavernosus muscle, whereas 27% aimed to include the puborectal muscle as well. A total of 86% of respondents used 1-4 resorbable sutures, especially vicryl 2/0 (39%) or vicryl 0 (52%). According to the respondents, a "wide genital hiatus at physical examination" (87%) and "subjective complaints of a wide genital hiatus" (84%) were considered good/excellent indications for perineoplasty, whereas "fecal incontinence", "apical prolapse" and "perineal pain" were absolutely/mostly not a good indication. Reasons to not perform perineoplasty were pelvic pain (59%) and dyspareunia (64%). Most responders underlined the need for more research on this topic (8.5 out of 10). Conclusions. Perineoplasty is a frequently performed procedure. There is a wide variation in the indications for and surgical techniques of perineoplasty. Therefore, research is needed to identify which patients will benefit from perineoplasty and how to optimally perform this surgery.

The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients

BACKGROUND

Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear.

OBJECTIVE

This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity.

DESIGN

This was a prospective multicenter uncontrolled study.

SETTINGS

The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022.

PATIENTS

The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry.

MAIN OUTCOME MEASURES

Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score.

RESULTS

One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001).

LIMITATIONS

The study was limited by the small sample size and by the strong selection of the study population.

CONCLUSIONS

Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 .

LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES

ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Prevalence of Obstructed Defecation among Patients Who Underwent Hemorrhoidectomy and Correlation between Preoperative Constipation Score and Postoperative Patients' Satisfaction: A Prospective Study in Two Centers

BACKGROUND AND OBJECTIVES

obstructed defecation syndrome (ODS) is a common but underestimated condition that may affect the outcomes after hemorrhoidectomy. Therefore, the aim of this study was to determine the prevalence of obstructed defecation syndrome (ODS) among patients who underwent hemorrhoidectomy and to assess the correlation between preoperative constipation score and postoperative patients' satisfaction.

MATERIALS AND METHODS

This prospective study included adult patients who underwent hemorrhoidectomy for 3rd and 4th-grade hemorrhoidal diseases. All participant patients underwent an assessment of functional OD severity by the Agachan-Wexner Constipation Scoring System. All patients were subjected to conventional hemorrhoidectomy. At 6 months postoperatively, patients were assessed again for their constipation score and postoperative patients' satisfaction.

RESULTS

The study included 120 patients (62 males and 58 females) with a mean age of 38.7 ± 12.1 years. About one-quarter of patients (24.2%) had obstructed defecation (constipation score ≥12). ODS (constipation score ≥12) was found to be significantly more among older patients, female patients, especially those with multiple pregnancies and multiple labors, and those with perineal descent. The postoperative constipation score (5.6 ± 3.3 mean ± SD) showed significant improvement (p = 0.001) compared to (9.3 ± 3.9 mean ± SD) preoperatively. Postoperative patients' satisfaction (mean 12.3 ± 3.0) at 6 months had a negative correlation with preoperative total constipation score (r = -0.035, p = 0.702).

CONCLUSIONS

The prevalence of obstructed defecation among patients with hemorrhoids was higher than reported among the general population. High preoperative constipation scores had a negative correlation with postoperative patients' satisfaction. Routine preoperative measurement of ODS can allow the detection of this particular group of patients who require a more physical and psychological evaluation, in addition to special preoperative counseling.

Rectocele: victim of availability bias? Results of a Belgian survey of colorectal and gynecological surgeons

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.

Is perineal hypermobility an independent predictor of obstructive defecation?

INTRODUCTION AND HYPOTHESIS

Symptoms of obstructed defecation (OD) and anatomical abnormalities of the posterior compartment are prevalent in urogynecological patients. The aim of this study was to determine whether perineal hypermobility is an independent predictor of OD, as is the case for rectocele, enterocele and rectal intussusception.

METHODS

This is a retrospective study of 2447 women attending a tertiary urodynamic center between September 2011 and December 2016. The assessment included a structured interview, urodynamic testing, a clinical examination and 4D transperineal ultrasound. After exclusion of previous pelvic floor surgery and defined anatomical abnormalities of the anorectum, 796 patients were left for analysis. Perineal hypermobility was defined as rectal descent ≥ 15 mm below the symphysis pubis, determined in stored ultrasound volume datasets offline, using proprietary software, blinded to all other data. Any association between perineal hypermobility and symptoms of obstructed defecation was tested for by chi-square (X²) test.

RESULTS

For the 796 patients analyzed, median age was 52 (range, 16-88) years with a mean BMI of 27 (range, 15-64) kg/m². Average vaginal parity was two (range, 0-8). Reported OD symptoms in this group included sensation of incomplete emptying in 335 (42%), straining at stool in 300 (37%) and digitation in 83 (10%). At least one of those symptoms was reported by 424 (53%) women; 153 showed perineal hypermobility. There was no significant association between perineal hypermobility and OD symptoms on univariate testing.

CONCLUSIONS

We found no evidence of an independent association between perineal hypermobility and obstructed defecation.

MR defecography in ano-rectal dysfunction: a clinical-radiological correlation study

Background

The aim of this work is to assess the diagnostic accuracy of MR defecography in ano-rectal dysfunction [ARD] for proper treatment planning.

Results

MR defecography was done to 30 patients with ARD for detection of its functional and structural causes. Increased perineal descent was detected in 70% of cases, rectocele in 46.7%, rectal intussusception in 40%, cystocele in 26.7%, uterine prolapse in 27.7%, enterocele in 13.3%, and paradoxical puborectalis contraction in 30%.

Conclusion

MR defecography is an essential diagnostic tool for optimum management of ano-rectal dysfunction patients.

Descending Perineum Associated With Pelvic Organ Prolapse Treated by Sacral Colpoperineopexy and Retrorectal Mesh Fixation: Preliminary Results

Introduction and hypothesis: Descending Perineum Syndrome (DPS) is a coloproctologic disease and the best treatment for it is yet to be defined. DPS is frequently associated with pelvic organ prolapse (POP) and it is reasonable to postulate, that treatment of POP will also have an impact on DPS. We aimed to evaluate the subjective satisfaction and improvement of DPS for patients who have undergone a sacral colpoperineopexy associated with retrorectal mesh for concomitant POP.

Methods: This retrospective cohort study, conducted between February 2010 and May 2016 included all women who had undergone surgery to treat POP and DPS. Improvement of POP was assessed clinically and subjective satisfaction was assessed with a survey.

Results: Among the 37 operated patients, 31 responded to the questionnaire and 77.4% were satisfied with this surgical procedure. 94.6% were objectively cured for POP. There was a 60% improvement rate for constipation, 63.5 and 68% were cured or improved for ODS and the need for digital maneuvers respectively.

Conclusion: Sacral colpoperineopexy associated with retrorectal dorsal mesh appears to objectively and subjectively improve POP associated with DPS.

Current treatment of pelvic organ prolapse correlated with chronic pelvic pain, bladder and bowel dysfunction

PURPOSE OF REVIEW

The purpose of this review is to critically analyze the relationship between symptoms of abnormal emptying of the bladder, urgency, pelvic pain, anorectal dysfunction and pelvic organ prolapse (POP) and to present evidence in order to show how many of the above mentioned symptoms can be cured or substantially improved by repair of specific pelvic ligaments.

RECENT FINDINGS

In this review, we provide evidence to show how often these dysfunctions occur and how they can be cured in 42-94% by appropriate pelvic floor surgery in the longer term, up to 2 years. Laxity in ligaments and/or vaginal membrane due to damaged connective tissue may prevent the normal opening and closure mechanism of urethra and anus, because muscles need finite lengths to contract properly. Hypermobility of the apex can irritate the pelvic plexus causing chronic pelvic pain. In consequence, dysfunctions as abnormal emptying of the bladder, urgency, pelvic pain, fecal incontinence and obstructed defecation can occur in women with different degrees of POP.

SUMMARY

In conclusion, it has to be recognized that women bothered by these symptoms should be examined for POP and appropriately advised for possibility of cure by pelvic floor surgery after careful selection. VIDEO ABSTRACT.

Functional Disorders of Constipation: Paradoxical Puborectalis Contraction and Increased Perineal Descent

Paradoxical puborectalis contraction (PPC) and increased perineal descent (IPD) are subclasses of obstructive defecation. Often these conditions coexist, which can make the evaluation, workup, and treatment difficult. After a thorough history and examination, workup begins with utilization of proven diagnostic modalities such as cinedefecography and anal manometry. Advancements in technology have increased the surgeon's diagnostic armamentarium. Biofeedback and pelvic floor therapy have proven efficacy for both conditions as first-line treatment. In circumstances where PPC is refractory to biofeedback therapy, botulinum toxin injection is recommended. Historically, pelvic floor repair has been met with suboptimal results. In IPD, surgical therapy now is directed toward the potentially attendant abnormalities such as rectoanal intussusception and rectal prolapse. When these associated abnormalities are not present, an ostomy should be considered in patients with IPD as well as medically refractory PPC.