Current Trends in Management of Defecatory Dysfunction, Posterior Compartment Prolapse, and Fecal Incontinence

Changes in bowel symptoms after different pelvic organ prolapse surgeries among elderly women at the 1-year follow up

OBJECTIVE

To investigate the prevalence of bowel symptoms in patients with pelvic organ prolapse (POP), to evaluate the changes in bowel symptoms after different POP surgeries, and to identify risk factors for unrelieved bowel symptoms.

METHODS

This was an observational prospective cohort study conducted at Peking University First Hospital from 2020 to 2021. Demographic, clinical, and therapeutic data were collected. Participants underwent POP Quantification examination and completed the Pelvic Floor Distress Inventory-20 questionnaire at baseline and 1 year postoperatively.

RESULTS

The prevalence of bowel symptoms and bothersome bowel symptoms in women with POP was 46.38% and 24.40%, respectively. Surgical correction of prolapse was associated with significant relief in bowel symptoms (P < 0.05). Colpocleisis may relieve bowel symptoms better than reconstructive surgeries (41% vs. 31%, P = 0.048). However, 35% of women had at least one bowel symptom at the 1-year follow up. A long perineal body (Pb) and levator ani muscle injury were found to be predictors of unrelieved bowel symptoms in patients undergoing colpocleisis and those undergoing reconstructive surgery, respectively (odds ratio [OR] 2.306, 95% confidence interval [CI] 1.112-4.783, P = 0.025 and OR 3.245, 95% CI 1.266-8.317, P = 0.014, respectively), and perineoplasty was a protective factor for women who underwent colpocleisis (OR 0.102, 95% CI 0.025-0.417, P = 0.001) CONCLUSION: Women with POP have a high prevalence of bowel symptoms. Although bowel symptoms can be relieved after POP surgeries, one-third of women still experience bowel symptoms. A long Pb and levator ani muscle injury were associated with unrelieved bowel symptoms, while perineoplasty was a protective factor.

Defecatory Dysfunction

Normal defecation is a complex and coordinated physiologic process that involves the rectum, anus, anal sphincter complex, and pelvic floor muscles. Any alteration of this process can be considered defecatory dysfunction, a term that covers a broad range of disorders, including slow-transit constipation, functional constipation, and functional or anatomic outlet obstruction. Evaluation should include history, physical, and consideration of additional testing such as colonoscopy, colonic transit studies, defecography, and/or anorectal manometry. Depending on the etiology, management options can include conservative measures such as dietary or lifestyle modifications, medications, pelvic floor physical therapy, or surgical repair.

Identifying the health care-initiated and self-initiated interventions used by women for the management of rectal emptying difficulty secondary to obstructive defecation: a scoping review protocol

OBJECTIVE

This scoping review aims to identify interventions used by women for the management of rectal emptying difficulty secondary to obstructive defecation.

INTRODUCTION

Rectal emptying difficulty is typically a symptom of obstructive defecation syndrome. Even though a range of interventions are already available for this condition, this review is necessary to increase understanding of what interventions women find useful and are acceptable for them. This depth of understanding will facilitate the development of a specific care pathway to support women living with rectal emptying difficulty secondary to obstructive defecation syndrome.

INCLUSION CRITERIA

This review will consider studies that include adult women (over 18 years of age) living in the community who have experienced difficulty with rectal emptying secondary to obstructive defecation and who have not had surgical intervention. Exclusion criteria include prolapse surgery and surgical techniques, oral laxatives, vaginal pessaries, cognitive impairment, pregnancy, and those residing in care homes.

METHODS

The databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Emcare, AMED, Web of Science, Scopus, PROSPERO, Open Grey, ClinicalTrials.gov, International Clinical Trials Registry Platform Search Portal, UK Clinical Trials Gateway, International Standard Randomised Controlled Trial Number Registry, JBI Evidence Synthesis, Epistemonikos, Cochrane Library, and gray literature. Studies conducted in English from any time period will be considered for inclusion. The titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review.

Postoperative pelvic dysfunctions associated with the reconstruction of the pelvic floor

BACKGROUND

The authors were aiming to conduct the comparative analysis of the frequency of formation of pelvic dysfunctions after surgical correction of genitalia prolapse in women by a vaginal approach using native tissue repair of the vaginal paries and synthetic implants.

METHODS

The study included 546 patients with stage II-IV genitalia prolapse according to the POP-Q classification. The quality of life was assessed using PD-QL and PFIQ-7 questionnaires. The 1st group included patients after native tissue repair (N.=314), the 2^nd - after surgery with the use of synthetic implants (N.=232).

RESULTS

In the 1^st group de-novo dysfunctions were revealed as follows: stress urinary incontinence: in 4.9% of women, urgency: in 2.2%, obstructive urination: in 8.0%; constipation or fecal and flatal incontinence: none. The index of pelvic floor dysfunction decreased from 50±14% to 8±2%. The index of influence on the quality of life decreased from 81±14% to 9% after 12 months. In the 2^nd group, de-novo dysfunctions were revealed as follows: stress urinary incontinence: in 9.5% of women, urgency: in 9.1%, obstructive urination: in 23.7%; constipation or fecal and flatal incontinence: 1 patient (0.4%). In patients of the 2^nd group, there was a decrease in the pelvic floor dysfunction index from 48±12% to 10±2%. The index of influence on the quality of life decreased from 79±15% to 5% after 12 months.

CONCLUSIONS

The use of synthetic implants causes the formation of de novo pelvic dysfunctions more often than the native tissue repair.

Evaluation and management of defecatory dysfunction in women

PURPOSE OF REVIEW

To summarize the current recommendations for the evaluation and management of defecatory dysfunction in women and highlight key relationships between defecatory dysfunction and other pelvic floor disorders, including pelvic organ prolapse, fecal incontinence, and voiding dysfunction.

RECENT FINDINGS

Conservative measures including lifestyle modifications, pharmacotherapy, and biofeedback continue to be the mainstay of treatment with newer therapies emerging. Physiologic testing and/or radiologic imaging should be considered for those who fail conservative therapy or are clinically complex. Surgical management is appropriate for carefully selected patients with anatomic causes of defecatory dysfunction. Further research is needed on surgical outcomes and patient expectations.

SUMMARY

Pelvic floor disorders, including defecatory dysfunction, have a significant societal impact and are highly prevalent among women. Given its potential complexity, a broader focus is needed when evaluating women with defecatory symptoms and effective treatment may require multidisciplinary care.

Women's experiences of managing digitation: do we ask enough in primary care?

The aim of this paper was to consider the available evidence for the current management of pelvic organ prolapse, which is a common presentation in primary care. However, not all women will present, only presenting when symptoms become bothersome. Particular attention was paid to understanding the problem of rectocele and its influence on obstructive defaecation symptoms. The burden of rectocele and its consequences are not truly known. Furthermore, healthcare professionals may not always enquire about bowel symptoms and patients may not disclose them. Complex emotions around coping and managing stress add to the challenges with seeking healthcare. Therefore, the impact on the lived experience of women who have difficulty with rectal emptying can be significant. The review identified a dearth of knowledge about women living with the problem of obstructive defaecation resulting in the use of digitation. Improving the management of digitation, an under-reported problem, is necessary to improve the quality of life for women. Primary care needs to increase access to conservative measures for women struggling with bothersome symptoms, such as constipation, the need to digitate or anxiety.

Rectocele plication: description of a novel surgical technique and review of clinical results

INTRODUCTION AND HYPOTHESIS

A rectocele is the bulging of the anterior rectal wall into the posterior vaginal compartment. The route of surgical repair can be transvaginal, transrectal or abdominal. The aim of this retrospective study is to describe a novel transvaginal surgical procedure and investigate the associated subjective and objective clinical outcomes.

METHODS

Database records were retrieved for all women who underwent a rectocele plication for the period from January 2010 until December 2015 in a referral urogynecology unit with a minimum follow-up period of 12 months. This transvaginal technique entails a plication of the anterior rectal wall by suturing of the rectal muscularis layer. Clinical findings and quality of life (QOL) metrics were evaluated and reported on.

RESULTS

One hundred thirty-nine women met the initial inclusion criteria with full data available for 123. The presenting symptoms included a vaginal bulge in 73 (52.5%), overactive bladder (OAB) in 73 (52.5%), obstructed defecation (OD) in 49 (35.3%) and anal incontinence (AI) in 35 (25.2%). The majority of women (n = 72, 51.8%) had stage 3-4 posterior prolapse. The mean follow-up period was 27 ± 15 months. The postoperative symptoms were significantly improved for all, except AI (p = 0.43). There was a significant improvement in posterior prolapse (p < 0.001) with the majority of women noted to have a stage 0 or 1 (n = 109; 88.6%) posterior prolapse at follow-up.

CONCLUSIONS

The rectocele plication is a novel surgical technique with good subjective and objective clinical outcomes in the medium term.