The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery

Barbed Versus Nonbarbed Suture for Posterior Colporrhaphy: A Randomized Controlled Trial

IMPORTANCE

There is limited literature or even consensus on the suture material used for posterior vaginal repairs.

OBJECTIVES

This study aimed to compare outcomes of barbed versus nonbarbed delayed absorbable suture used for posterior colporrhaphy.

STUDY DESIGN

This study conducted a randomized controlled trial of 72 women undergoing posterior repair using standardized technique-concurrent procedures permitted with barbed (n = 36) or nonbarbed (n = 36) suture. Standardized examinations, validated questionnaires, and a visual analog scale (VAS) were completed at baseline, 6 weeks, and 12 months, and a telephone interview was conducted at 6 months. The primary outcome was posterior compartment pain at 6 weeks, measured by a VAS.

RESULTS

Seventy-two women enrolled, with follow-up rates 6 weeks (100%), 6 months (90.3%), and 12 months (73.6%). Demographics were similar between groups. A VAS with movement was not different between groups at 6 weeks. The odds of experiencing vaginal pain, having myofascial pain on examination, or being sexually active postoperatively were not different between the groups. There were no differences in the length of posterior colporrhaphy, surgical times, or hospital length of stay between the groups. Suture passes were lower in the nonbarbed group (median, 4 vs 7; P = <0.001), and suture burden was higher in the nonbarbed group (median, 26.9 vs 10.5 cm; P = <0.001). There was overall improvement in Pelvic Floor Distress Inventory Short Form 20 prolapse and colorectal subscores but no differences between groups. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form 12 scores improved, and dyspareunia decreased at 6 and 12 months in both groups. In addition, there were few anatomic recurrences at 6 weeks (0%) and 12 months (3.4%) and few adverse events.

CONCLUSIONS

This study found no differences in primary or secondary outcomes; however, both suture types resulted in clinical improvements in quality-of-life measures and sexual function.

Value of pelvic examination in women with pelvic organ prolapse: A systematic review

BACKGROUND

Recent recommendations from the French High Authority of Health on pelvic organ prolapse (POP) management underline the value of a pelvic examination.

OBJECTIVES

The aim of this paper was to analyze the literature and identify the best evidence available regarding pelvic examination for women presenting prolapse-associated symptoms in terms of diagnosis and predictability of treatment success.

SEARCH STRATEGY

The databases were queried similarly using Medical Subject Headings (MeSH) and non-MeSH terms broadly related to pelvic examination and POP management.

SELECTION CRITERIA

We included studies assessing the diagnostic contribution of pelvic examination (correlation with symptoms) and its value for assessing the risk of pessary failure or recurrence after reconstructive surgery.

DATA COLLECTION AND ANALYSIS

We assessed peer-reviewed articles on PubMed, Embase, and Cochrane database up to May 2023. The methodological quality of all the included studies was assessed using the ROBINS-E or RoB2 tools.

MAIN RESULTS

In all, 67 studies were retained for the review. Prolapse-associated symptoms are poorly correlated with POP diagnosis. The symptom that is best correlated with the POP stage is the presence of a vaginal bulge (moderate to good correlation). The factors most strongly associated with the risk of recurrence after surgery or pessary failure are clinical: essentially a higher POP stage before surgery, levator ani muscle avulsion, and vaginal and genital measurements.

CONCLUSIONS

In women complaining of prolapse-associated symptoms, a pelvic examination (vaginal speculum and digital vaginal examination) can confirm the presence of POP and identify risk factors for treatment failure or recurrence after surgical management or pessary placement. A higher stage of POP and levator ani muscle avulsion-discernible on pelvic examination-are major risk factors for POP recurrence or treatment failure. These features must be taken into account in the treatment choice and discussed with the patient.

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.

PEOPLE: Lifestyle and comorbidities as risk factors for pelvic organ prolapse-a systematic review and meta-analysis PEOPLE: PElvic Organ Prolapse Lifestyle comorbiditiEs

INTRODUCTION AND HYPOTHESIS

The literature is scarce regarding the effects of comorbidities, clinical parameters, and lifestyle as risk factors for pelvic organ prolapse (POP). This study was performed to systematically review the literature related to body mass index (BMI), waist circumference, diabetes mellitus (DM), hypertension (HT), dyslipidemia, chronic constipation, smoking, chronic cough, occupation, and striae and varicose veins as determinants for POP.

METHODS

Search terms in accordance with Medical Subject Headings were used in PubMed, Embase, LILACS, and the Cochrane Library. Clinical comparative studies between women with and without POP and containing demographic and/or clinical raw data related to lifestyle and/or comorbidities were included. The ROBINS-I (risk of bias in non-randomized studies of interventions) instrument was used. Fixed-effects and random-effects models were used for homogeneous and heterogeneous studies, respectively.

RESULTS

Forty-three studies were included in the meta-analysis. BMI < 25 kg/m2 was found to be a protective factor for POP [OR 0.71 (0.51, 0.99); p = 0.04], and BMI > 30 kg/m2 was a risk factor for POP [OR 1.44 (1.37, 1.52); p < 0.00001]. Waist circumference (≥ 88 cm) was reported as a risk factor for POP [OR 1.80 (1.37, 2.38); p < 0.00001], along with HT [OR 1.18 (1.09, 1.27); p = 0.04], constipation [OR 1.77 (1.23, 2.54); p < 0.00001], occupation [OR 1.86 (1.21, 2.86); p < 0.00001], persistent cough [OR 1.52 (1.18, 1.94); p < 0.0001]), and varicose veins [OR 2.01 (1.50, 2.70); p = 0.12].

CONCLUSIONS

BMI < 25 kg/m2 is protective while BMI > 30 kg/m2 is a risk factor for POP. Large waist circumference, dyslipidemia, HT, constipation, occupation, persistent cough, and varicose veins are also determinants for POP.

Robot-Assisted Sacrocolpopexy versus Trans-Vaginal Multicompartment Prolapse Repair: Impact on Lower Bowel Tract Function

BACKGROUND

This study evaluated the effectiveness, safety, and possible changes in bowel symptoms after multicompartment prolapse surgery by comparing two different surgical approaches, transvaginal mesh surgery with levatorplasty (TVMLP) and robot-assisted sacrocolpopexy (RSC).

METHODS

All patients underwent pelvic (POP-Q staging system) and rectal examination to evaluate anal sphincter tone in the lithotomy position with the appropriate Valsalva test. The preoperative evaluation included urodynamics and pelvic magnetic resonance defecography. Patient Global Impression of Improvement (PGI-I) at follow-up measured subjective improvement. All patients completed Agachan-Wexner's questionnaire at 0 and 12 months of follow-up to evaluate bowel symptoms.

RESULTS

A total of 73 cases were randomized into the RSC group (36 cases) and TVMLP group (37 cases). After surgery, the main POP-Q stage in both groups was stage I (RCS 80.5% vs. TVMLP 82%). There was a significant difference (p < 0.05) in postoperative anal sphincter tone: 35%. The TVMLP group experienced a hypertonic anal sphincter, while none of the RSC group did. Regarding subjective improvement, the median PGI-I was 1 in both groups. At 12 months of follow-up, both groups exhibited a significant improvement in bowel symptoms.

CONCLUSIONS

RSC and TVMLP successfully corrected multicompartment POP. RSC showed a greater improvement in the total Agachan-Wexner score and lower bowel symptoms.

Evaluation of the Chinese version of the constipation scoring system in Chinese women with pelvic organ prolapse

Defecation disorder is one of the main symptoms in pelvic organ prolapse (POP) patients. Our study aims to translate the Chinese version of the constipation scoring system (CSS) questionnaire and test the reliability and validity of its application in Chinese POP women. We recruited 140 women suffering prolapse with stage II or above POP who reported at least one abnormal defecation symptom. We chose CRADI-8 as the criterion validity. Cronbach's α coefficient of the total score of CSS was 0.721, the ICC and Kappa coefficient of CSS total score were 0.877 and 0.424, respectively. The total score of CSS was significantly correlated with the CRADI-8 score (p < 0.001), and Spearman's coefficient was 0.491. The total score of CSS in the women with constipation (according to Rome III criteria) was greater than that of patients without constipation (p < 0.001), and the total score of CSS was significantly different before and after surgery (p < 0.001), which was consistent with the change of CRADI-8. The median of the preoperative group was 6(3,10), and the median of the postoperative group was 3(0,7). These data demonstrate that the Chinese version of the CSS questionnaire has great internal consistency, retest reliability, and construct validity. It may be widely used to evaluate constipation symptoms in women with pelvic organ prolapse in China.

Contemporary Use and Techniques of Laparoscopic Sacrocolpopexy With or Without Robotic Assistance for Pelvic Organ Prolapse

Laparoscopic sacrocolpopexy with or without robotic assistance is an effective approach for the treatment of any pelvic organ prolapse when apical involvement is present.

The past 4 years have been consequential in the world of surgery to correct pelvic organ prolapse. In 2018, results of a large, multicenter randomized trial demonstrated very disappointing cure rates of traditional native tissue repairs at 5 years or more. In 2019, a vaginal mesh hysteropexy kit was removed from the market by the U.S. Food and Drug Administration only to subsequently demonstrate it provided better cure rates and similar risk profile to vaginal hysterectomy plus native tissue repair in its own 5-year study published in 2021. Meanwhile, the use and techniques of laparoscopic sacrocolpopexy with or without robotic assistance have evolved such that it is commonly adapted to treat all support defects for patients with uterovaginal or posthysterectomy prolapse. This article is intended to provide an overview of the contemporary use and techniques of laparoscopic sacrocolpopexy based on the evidence and our clinical experience.

Perioperative and Long-Term Anatomical and Subjective Outcomes of Laparoscopic Pectopexy and Sacrospinous Ligament Suspension for POP-Q Stages II-IV Apical Prolapse

The aim of this paper was to analyze perioperative and long-term outcomes in 114 women undergoing surgery for POP-Q ≥ 2 apical prolapse: sacrospinous ligament colpo/hysteropexy (SSLF/SSHP)—61; laparoscopic pectopexy (LP)—53. Validated questionnaires (PGI-I, ISI, #35 EPIQ, PFIQ-7, PFDI-20) were completed at baseline and follow-up. POP-Q stages II, III and IV were diagnosed in 1 (0.9%), 84 (73.7%) and 29 (25.4%) patients, respectively. Mean operative time and hospital stay were 151.8 ± 36.2 min/2.6 ± 1.1 days for LP and 69 ± 20.4 min (p < 0.001)/2.7 ± 1.0 days for SSLF. Severe intraoperative complications occurred in two (1.8%) patients. Mean follow-up was 26.9 ± 12 and 37.3 ± 17.5 months for LP and SSLF, respectively. At follow-up, significant improvement for all POP-Q points was observed in both groups (p < 0.001). Shortening of total vaginal length was found in both groups, but predominantly in SSLF patients (p = 0.01). The sensation of vaginal bulge (EPIQ) was reduced, and total PFDI-20 and PFIQ-7 scores improved (p < 0.04) in both groups. Subjective success was reported by 40 (75.5%) LP and 44 (72.1%) SSLF patients. ISI detected no deterioration in urinary incontinence. PGI-I, PFDI-20, #35 EPIQ, PFIQ-7 and ISI did not differ between the groups. In conclusion both, SSLF and LP for apical prolapse generate good anatomical and subjective outcomes, with protective effect on the anterior compartment observed for LP.

Obstructed defecation syndrome in the first week after pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

Research shows that patients are concerned about postoperative bowel function after pelvic reconstructive surgery. The objectives of this study were to estimate the proportion of patients with obstructed defecation syndrome (ODS), a subtype of constipation, in the week after surgery, to identify associated patient-level and perioperative characteristics and the associated bother.

METHODS

Women completed a preoperative and postoperative ODS questionnaire and postoperative bowel diary. Characteristics of women with and without postoperative ODS were compared. Chi-squared or Fisher's exact tests compared categorical variables. Student's t test or Wilcoxon rank-sum tests compared continuous variables. Multivariate logistic regression was assessed for independent effects. Wilcoxon rank-sum tests compared the groups with regard to bother. Spearman correlation coefficients described the relationship among bother, postoperative ODS score, and bowel diary variables.

RESULTS

Of the 186 participants enrolled, 165 completed the postoperative ODS questionnaire. Of these, 39 women (23.6%, 95% CI 17.2-30.1) had postoperative ODS. Postoperative ODS was significantly associated with preoperative ODS (p < 0.001), posterior colporrhaphy (p = 0.03), surgery type (p = 0.01), and longer duration of surgery (p = 0.03). Using multivariate logistic regression controlling for age, only preoperative ODS was significantly associated with postoperative ODS (OR 2.68, 95% CI 1.73-4.17). Women with postoperative ODS reported more bother with their defecatory symptoms (p < 0.001). The degree of bother was significantly associated with postoperative ODS score (p < 0.001).

CONCLUSION

Using a validated disease-specific questionnaire to identify ODS, this complication was identified in 23.6% of patients in the week after pelvic reconstructive surgery. Preoperative ODS was a significant and important risk factor for this complication.

Obstructed Defecation Symptom Severity and Degree of Rectal Hypermobility and Folding Detected by Dynamic Ultrasound

ABSTRACT

We used dynamic pelvic floor ultrasound to investigate the relationship between obstructed defecation symptom (ODS) severity and the degree of rectal hypermobility/folding. In this retrospective study, women who presented with ODS from October 2017 to January 2019 and underwent an interview, pelvic examination, and pelvic floor ultrasound were recruited. Patients were diagnosed with abdominal constipation, dyssynergia, or pelvic constipation. Pelvic constipation patients were categorized based on their reported frequency of incomplete emptying of stool (<50% or ≥50% of bowel movements) representing mild and severe ODS, respectively. Using dynamic ultrasound, rectal hypermobility was quantified via rectovaginal septum length at rest and Valsalva and its compression ratio, where shorter lengths and larger compression ratios are indicative of increased rectal hypermobility. One hundred twenty-one patients (41 with abdominal constipation, 7 with dyssynergia, and 73 with pelvic constipation) were included. Compression ratios were higher in women with severe versus mild ODS (17.36 ± 16.89 vs 36.38 ± 25.82, P = 0.0039). The risk of having severe symptoms was 4 times greater (odds ratio = 4.2, 95% confidence interval = 1.4 to 12.6, P = 0.01) among those with a high compression ratio (≥20%) after controlling for age, body mass index, and levator plate descent angle. Incomplete emptying was weakly, positively, linearly correlated with rectal hypermobility/folding (r = -0.2724, -0.3767 to 0.3922, and P = 0.0197, 0.0010, 0.0006, respectively). Women with more severe ODS experienced more rectal hypermobility/folding as measured via dynamic ultrasound-a cheaper, effective alternative to magnetic resonance defecography for evaluation of obstructed defecation.

Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum

BACKGROUND

Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading.

OBJECTIVE

This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth.

STUDY DESIGN

We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression.

RESULTS

Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes.

CONCLUSION

Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.

Perineorrhaphy Compared With Pelvic Floor Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree Perineal Tear: A Randomized Controlled Trial

OBJECTIVE

To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree obstetric injury diagnosed at least 6 months postpartum.

METHODS

We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited.

RESULTS

From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% [95% CI 42-78%], odds ratio 19 [95% CI 5-69]). The surgery group was superior to physical therapy regarding all secondary endpoints.

CONCLUSION

Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02545218.