Complex pelvic floor failure and associated problems

Measuring the psychological burden of women with pelvic floor complaints: The psychometric characteristics of a new instrument

Background

To be able to optimize pelvic healthcare, it would be helpful to specifically assess women's psychological burden with pelvic floor complaints. In the absence of such an instrument, a new instrument was developed to measure this burden in women who seek help. In previous research, a comprehensive overview was yielded of women's restrictions and distress with pelvic floor complaints, and a conceptual model was developed of seven types of distress that were reflected by 33 statements. The present study was performed to investigate the psychometric properties of the new instrument, termed the Pelvic Floor Complaint-related Psychological Burden Inventory (PFC-PBI).

Methods

In an online survey data was collected from women with and without pelvic floor complaints on the 33 statements. The internal consistency of the types of distress was tested using item-total correlation analysis, Principal Component and Confirmatory Factor Analyses were performed, and the convergent and divergent validity of the types of distress was examined against existing questionnaires using the Multi-Trait Multi-Method methodology.

Results

Based on the factor analyses, a 10-item instrument was tested. Outcomes show excellent internal consistency of this instrument, comprising a single component. The PFC-PBI demonstrated satisfactory convergent and divergent validity.

Conclusions

This new measure appears to be a promising tool to inventory the psychological burden of women suffering from pelvic floor complaints. Research into its further development, implementation, and clinical use appears warranted.

Sexual functioning is not, but psychological burden is predictive for receiving help in pelvic physical therapy practice: A cross-sectional study

Background

Pelvic floor complaints are common among women and often accompanied by sexual dysfunction and psychological burden. They are also associated with pregnancy and childbirth. However, not all women with these complaints receive help in pelvic physical therapy practice. This study explored if pregnancy, parity, pelvic floor complaints, sexual functioning, and psychological burden are predictive of receiving help in pelvic physical therapy practice.

Methods

In a cross-sectional exploratory design, women completed an online survey about pelvic floor complaints, sexual function, and psychological burden. Binary logistic analysis was used to analyze the predictive value of the above-mentioned factors.

Results

Data from 542 participants were analyzed. Pregnancy and parity, PFC severity, psychological burden, and the interaction between pelvic floor complaints and psychological burden were significant predictors of receiving help. Against expectations, sexual functioning was not predictive of receiving help.

Conclusions

Women's psychological burden is an important factor in determining if or when women receive help in PPT practice. More research is needed to unravel the role of sexual functioning in the context of pelvic floor complaints and women's psychological burden. More insight into this area of expertise could possibly improve and enhance pelvic health care for women with pelvic floor complaints.

Early growth response 2, a novel target of pelvic organ prolapse, is highly expressed in anterior vaginal wall tissues with pelvic organ prolapse

Pelvic organ prolapse (POP) is a common disorder among women that negatively affects women's quality of life. Early growth response 2 (EGR2) is a transcription factor that regulates cell growth. The present study aimed to explore the role of EGR2 in POP progression and provided a new target for the treatment and prevention of POP. Firstly, we extracted primary vaginal anterior wall fibroblasts from POP tissues and non-POP tissues and then constructed an EGR2-silencing lentivirus for further study. Immunoblotting, qPCR, TUNEL assay, CCK-8 assay, dual luciferase assay, and ELISA assay were carried out. EGR2 expression was much higher in POP tissues than in control tissues, and EGR2 expression positively correlated with cytokine signaling 3 (SOCS3) expression. Knockdown of EGR2 increased cell proliferation, upregulated PCNA expression, and reduced apoptosis in POP fibroblasts. Moreover, we found that the knockdown of EGR2 increased COL1A1, COL3A1, and Elastin expression and decreased MMP2 and MMP9 activities, and knockdown of EGR2 increased TGF-β/Smad pathway activity in POP fibroblasts. Interestingly, the results of dual luciferase assay demonstrated that EGR2 was able to increase SOCS3 transcriptional activity. EGR2 knockdown alleviated the apoptosis of POP fibroblasts by reducing SOCS3 expression and improving the proliferation and collagen synthesis of POP fibroblasts. Overall, our study illustrated that EGR2 was highly expressed in POP tissues, and knockdown of EGR2 alleviated apoptosis and reduced matrix degradation in POP fibroblasts. This study might provide a new insight into the pathogenesis of POP.

Restrictions and distress in daily, social, and sexual functioning, and intimate relationships in women with pelvic floor complaints: A mixed-method study

Women with pelvic floor complaints experience restrictions and distress in their daily, social, and sexual functioning, and their intimate relationships. We interviewed forty-eight women to unravel differences between women receiving and not receiving pelvic physical therapy and between pregnant, parous, and nulliparous women in preparation for theory development. We analyzed data in a mixed-method design using NVivo and Leximancer. Sexual dysfunction, relationship dynamics, the nature and severity of restrictions and distress, and coping strategies appear to vary between women receiving and not receiving therapy. Specific combinations of restrictions and distress are present in pregnant, parous, and nulliparous women, and might influence women's decision to seek help.

Patient pathway in a tertiary referral pelvic floor unit: Telephone triage assessment clinic

BACKGROUND

To meet the increasing demands for colorectal pelvic floor services, a dedicated telephone triage assessment clinic (TTAC) was set up to establish a more efficient pathway, and reduce waiting times and patient's visits to the hospital. The primary aim of this study was to review TTAC in patients suffering from pelvic floor dysfunction and assess its feasibility. Secondary aims include measurement of waiting times for TTAC, main presenting complaints, and main treatment outcomes, including the need for review by a consultant surgeon.

METHODS

Review of data collected retrospectively in a single tertiary referral center collected from an institutional database.

KEY RESULTS

Between January 2016 and October 2017, 1192 patients referred to our pelvic floor unit were suitable for TTAC. Of these, 694 patients had complete records. There were 66 without follow-up after the initial TTAC, leaving 628 patients for analysis. In all, 86% were females and 14% were males, with a mean age of 52 years (range: 18-89). The median waiting time for TTAC was 31 days (range: 0-184). The main presenting complaint during the TTAC was obstructive defecation in 69.4%, fecal incontinence in 28.5%, and rectal prolapse in 2.1%. In our study, 611 patients had conservative management (97.3%), with a median of three sessions per patient (range: 1-16), while 82 patients (13.1%) needed a surgical intervention. Only 223 patients (35.5%) were reviewed by a consultant at some stage during the study period.

CONCLUSIONS AND INFERENCES

To optimize resources, an adequate triage system allowed us to streamline the pathway for each individual patient with pelvic floor dysfunction according to their symptoms and/or test results with the aim of reducing waiting times and expediting treatment.

Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study

Introduction

Despite the fact that the literature reports various restrictions and types of distress in women with pelvic floor complaints, a comprehensive overview of women's sexual and psychological burden emerging from these complaints is lacking, which compromises our ability to assess and grasp the impact to women.

Aim

This study was performed to conceptualize women's sexual and psychological burden and create a more comprehensive overview on this topic from both women's and health care providers’ perspectives. Furthermore, this research intended to identify items to populate a to-be-developed instrument to assess sexual and psychological burden.

Methods

In Group Concept Mapping, 125 statements were used about restrictions and distress that women with pelvic floor complaints experienced. Women with, and health care providers with and without pelvic floor complaints (13 women and 3 men) sorted the statements into comprehensive self-labeled clusters and rated their nature and severity. Multidimensional scaling and hierarchical cluster analyses were performed to identify a conceptual model of coherent clusters of statements. Item-total correlations of severity scores were calculated to identify statements that can be used in future research to represent women's sexual and psychological burden.

Main Outcome Measure

A conceptual model emerged, and outcomes of item-total correlations were then examined again using the conceptual model.

Results

Seven distress clusters were identified, namely, loss of control, sexual distress, feeling insecure, feeling wronged, feeling helpless, feeling angry, and feeling disappointed. Feeling insecure appeared more pervasive than other distresses. Furthermore, 33 statements were identified that can be used in future research to develop an instrument to assess sexual and psychological burden representing both women's and health care providers’ perspectives.

Conclusion

The conceptual model and list of statements may concisely represent the sexual and psychological burden of women with pelvic floor complaints from both women's and health care providers’ perspectives on this topic.

Brand AM, Rosas S, Waterink W, et al. Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study. Sex Med 2022;10:100504.

A Comparative Study on the Effects of High-Intensity Focused Electromagnetic Technology and Electrostimulation for the Treatment of Pelvic Floor Muscles and Urinary Incontinence in Parous Women: Analysis of Posttreatment Data

OBJECTIVES

Pelvic floor muscles (PFMs) weakening and urinary incontinence (UI) represent health issues that have a negative impact on daily life. This study compares the immediate efficiency of high-intensity focused electromagnetic (HIFEM) therapy and electrostimulation for the treatment of weakened PFMs, accompanied by the UI.

METHODS

Ninety-five parous women were considered for the study. Symptomatic patients received either HIFEM or electrostimulation treatment. Treated patients completed 10 therapies scheduled 2 to 3 times per week (HIFEM) or every other day (electrostimulation). Patients underwent examination by 3-dimensional transperienal ultrasound at the baseline and posttreatments. Levator-urethra gap, anteroposterior diameter, laterolateral diameter of levator hiatus, and hiatal area were measured. In addition, Pelvic Floor Disability Index 20 questionnaire and subjective evaluation of patient's intimate health were assessed.

RESULTS

Enrolled patients were divided into group I (n = 50, HIFEM), group II (n = 25, electrostimulation), and group III (n = 20, control) according the indication and treatment modality. Three-dimensional ultrasounds showed positive changes in dynamics of the pelvic floor posttreatment (decreased anteroposterior diameter, laterolateral diameter, and hiatal area). However, the significant (P < 0.05) changes of pelvic floor integrity were observed only in group I. In addition, group I achieved greater level of improvement in Pelvic Floor Disability Index 20 questionnaire compared with group II (52% and 18% respectively; P < 0.001). Substantially fewer patients in group I reported urine leakage after treatments.

CONCLUSIONS

Posttreatment results suggest that HIFEM technology is suitable for treatment of PFMs weakening and showed to be more effective when compared with electrostimulation in short-term. Therefore, we recommend HIFEM as treatment option for weakened PFMs and UI.

Molecular mechanism of extracellular matrix disorder in pelvic organ prolapses

Pelvic organ prolapses (POP) notably reduces the quality of life in elderly populations due to bladder and bowel dysfunction, incontinence, and coital problems. Extracellular matrix (ECM) disorder is a pivotal event in the progression of POP, but to date, its specific underlying mechanism remains unclear. The ligaments of patients with POP and healthy controls were collected to compare the expression of Homeobox11 (HOXA11) and transforming growth factor β (TGF-β1) via immunohistochemical analysis. HOXA11 and TGF-β1 were overexpressed or knocked down in fibroblast cells to explore their effects on the expression of collagen and matrix metalloproteinases (MMPs). HOXA11 and TGF-β1 were greatly reduced in the ligaments of patients with POP. The overexpression and downregulation of HOXA11 and TGF-β1 can mediate ECM disorder via regulating expression of collagen (Col) and MMPs. In addition, HOXA11 and TGF-β1 exerted synergistic effect on the expression of Col and MMPs. The present study identified that HOXA11 and TGF-β1 serve critical roles in mediating ECM disorders, which may be of clinical significance for the diagnosis and treatment of patients with POP.

Long-term Anatomical and Functional Results of Robot-Assisted Pelvic Floor Surgery for the Management of Multicompartment Prolapse: A Prospective Study

BACKGROUND

Long-term data on robot-assisted sacrocolporectopexy for the treatment of multicompartment pelvic organ prolapse are scarce. With the rising prevalence of prolapse and increasing surgical repair, it is essential to evaluate long-term results.

OBJECTIVE

This study aimed to evaluate long-term functional and anatomic outcomes after sacrocolporectopexy.

DESIGN

This is a prospective, observational cohort study.

SETTINGS

This study was conducted at a teaching hospital with tertiary referral function for patients with gynecological/rectal prolapse.

PATIENTS

All patients undergoing robot-assisted sacrocolporectopexy from 2011 to 2012 were included.

INTERVENTION

Robot-assisted sacrocolporectopexy was performed.

MAIN OUTCOME MEASURES

The primary outcome was the anatomic cure rate after 1 and 4 years, defined as simplified pelvic organ prolapse quantification stage 1 vaginal apical prolapse and no external rectal prolapse or internal rectal prolapse present. Kaplan-Meier curves were used for determination of recurrence-free intervals. Secondary outcomes were functional pelvic floor symptoms (symptoms of bulge, obstructed defecation, fecal incontinence, urogenital distress inventory) and quality of life (Pelvic Floor Impact Questionnaire).

RESULTS

Fifty-three patients were included. After 12 and 48 months, the recurrence-free intervals based on Kaplan-Meier estimates were 100% and 90%. In total, there were 10 recurrences: 2 apical and 8 internal rectal prolapses. Symptoms of bulge (94%-12%; p < 0.0005), fecal incontinence (62%-32%; p < 0.0005), obstructed defecation (59%-24%; p = 0.008), and median Pelvic Floor Impact Questionnaire scores (124-5; p = 0.022) improved significantly at final follow-up. Median urogenital distress inventory scores showed improvement after 1 year (30-13; p = 0.021).

LIMITATIONS

This was an observational, single-center study with selective postoperative imaging.

CONCLUSIONS

Ninety percent of patients were recurrence free 48 months after robot-assisted sacrocolporectopexy. Symptoms of vaginal bulge, quality of life, constipation, and fecal incontinence improved significantly. However, a subgroup of patients showed persistent bowel complaints that underlie the complexity of multicompartment prolapse. See Video Abstract at http://links.lww.com/DCR/B265. RESULTADOS ANATÓMICOS Y FUNCIONALES A LARGO PLAZO DE LA CIRUGÍA DE PISO PÉLVICO ASISTIDA POR ROBOT EN EL TRATAMIENTO DEL PROLAPSO MULTICOMPARTIMENTAL: UN ESTUDIO PROSPECTIVO: Los datos a largo plazo sobre la sacrocolporectopexia asistida por robot para el tratamiento del prolapso multicompartimental de órganos pélvicos son escasos. Con el aumento de la prevalencia del prolapso y el aumento de la reparación quirúrgica, es esencial evaluar los resultados a largo plazo.Evaluar los resultados funcionales y anatómicos a largo plazo después de la sacrocolporectopexia.Estudio prospectivo observacional de cohorte.Hospital de enseñanza con función de referencia terciaria para pacientes con prolapso ginecológico/rectal.Todos los pacientes sometidos a sacrocolporectopexia asistida por robot en 2011-2012.Sacrocolporectopexia asistida por robot.El resultado primario fue la tasa de curación anatómica a uno y cuatro años, definida como etapa 1 de prolapso apical vaginal en la cuantificación del prolapso de órganos pélvicos simplificado, y sin prolapso rectal externo o prolapso rectal interno presentes. Se utilizaron curvas de Kaplan Meier para determinar los intervalos libres de recurrencia. Los resultados secundarios fueron síntomas funcionales del piso pélvico (síntomas de abultamiento, obstrucción defecatoria, incontinencia fecal, inventario de molestias urogenitales) y calidad de vida (cuestionario de impacto del piso pélvico).Se incluyeron 53 pacientes. Después de 12 y 48 meses, el intervalo libre de recurrencia basado en las estimaciones con método Kaplan Meier fue del 100% y 90%, respectivamente. En total hubo diez recurrencias: dos apicales y ocho prolapsos rectales internos. Los síntomas de abultamiento (94% a 12%; p <0.0005), incontinencia fecal (62% a 32%; p <0.0005), obstrucción defecatoria (59% a 24%; p = 0.008) y puntajes promedio del cuestionario de impacto del piso pélvico (124 a 5; p = 0.022) mejoraron significativamente en el seguimiento final. Las puntuaciones medias del inventario de molestias urogenitales mostraron una mejoría después de un año (30 a 13; p = 0.021).Estudio observacional de centro único con imagenología postoperatoria selectiva.Noventa por ciento de los pacientes estaban libres de recurrencia 48 meses después de la sacrocolporectopexia asistida por robot. Los síntomas de abultamiento vaginal, la calidad de vida, el estreñimiento y la incontinencia fecal mejoraron significativamente. Sin embargo, un subgrupo de pacientes mostró molestias intestinales persistentes que subrayan a la complejidad del prolapso multicompartimental. Consulte Video Resumen en http://links.lww.com/DCR/B265.

The histological microstructure and in vitro mechanical properties of the human female postmenopausal perineal body

OBJECTIVE

The perineal body connects muscles from the pelvic floor and is critical for support of the lower part of the vagina and proper function of the anal canal. We determined mechanical parameters and volume fractions of main components of the human female postmenopausal perineal body.

METHODS

The specimens were taken from 15 fresh female cadavers (age 74 ± 10, mean ± standard deviation). Seventy-five specimens from five regions of the perineal body were processed histologically to assess volume fractions of tissue components using stereological point testing grid. Fifteen specimens taken from the midline region were loaded uniaxially with 6 mm/min velocity until tissue rupture to determine Young's modulus of elasticity, ultimate stresses, and strains.

RESULTS

The perineal body was composed of collagen (29%), adipose cells (27%), elastin (7%), smooth muscle (11%), and skeletal muscle (3%). The residual tissue (19%) constituted mostly peripheral nerves, lumina of blood vessels, fibroblasts, and fibrocytes. Young's modulus of elasticity at midline region was 18 kPa (median) at small and 232 kPa at large deformations, respectively. The ultimate stress was 172 kPa and the ultimate strain was 1.4.

CONCLUSIONS

We determined the structural and mechanical parameters of the perineal body. The resultant data could be used as input for models simulating pelvic floor prolapse or dysfunction.

Composite mesh design for delivery of autologous mesenchymal stem cells influences mesh integration, exposure and biocompatibility in an ovine model of pelvic organ prolapse

The widespread use of synthetic transvaginal polypropylene mesh for treating Pelvic Organ Prolapse (POP) has been curtailed due to serious adverse effects highlighted in 2008 and 2011 FDA warnings and subsequent legal action. We are developing new synthetic mesh to deliver endometrial mesenchymal stem cells (eMSC) to improve mesh biocompatibility and restore strength to prolapsed vaginal tissue. Here we evaluated knitted polyamide (PA) mesh in an ovine multiparous model using transvaginal implantation and matched for the degree of POP. Polyamide mesh dip-coated in gelatin and stabilised with 0.5% glutaraldehyde (PA/G) were used either alone or seeded with autologous ovine eMSC (eMSC/PA/G), which resulted in substantial mesh folding, poor tissue integration and 42% mesh exposure in the ovine model. In contrast, a two-step insertion protocol, whereby the uncoated PA mesh was inserted transvaginally followed by application of autologous eMSC in a gelatin hydrogel onto the mesh and crosslinked with blue light (PA + eMSC/G), integrated well with little folding and no mesh exposure. The autologous ovine eMSC survived 30 days in vivo but had no effect on mesh integration. The stiff PA/G constructs provoked greater myofibroblast and inflammatory responses in the vaginal wall, disrupted the muscularis layer and reduced elastin fibres compared to PA + eMSC/G constructs. This study identified the superiority of a two-step protocol for implanting synthetic mesh in cellular compatible composite constructs and simpler surgical application, providing additional translational value.

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy

Purpose

To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR.

Methods

All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences.

Results

A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates.

Conclusion

High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

Levator ani deformation during the second stage of labour

A very important medical problem for females is urinary incontinence, sometimes associated with faecal incontinence and pelvic organ prolapse. One of the most common reasons these issues are increasing is clearly the muscle damage during childbirth. This article focusses on understanding the complex behaviour of the levator ani muscles involved in the second stage of labour. A geometrical model obtained from a 23-year-old nulliparous woman was used to simulate childbirth. Several assumptions were introduced in order to simplify the problem without significantly affecting the global response of the system. An anisotropic hyperelastic model was used to characterize the material behaviour; the muscle fibres were assumed to be mostly orientated circumferentially. In addition, particular attention was also put to the boundary conditions of the model. The introduction of the constraints imposed by the coccyx bone in the central area of the levator ani group represents one the most important improvement compared to previous computational models. The maximum deformation and stress were found in the pubococcygeus muscle of the levator ani group. A stretch value close to 2.2 was determined by considering different material parameters. The results seem convincing with respect to medical observation and previous analysis. However, there are still some limitations concerning the material definition and the geometry and trajectory of the head that can be further improved.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort

BACKGROUND

The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined.

METHODS

A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management.

RESULTS

Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15).

CONCLUSION

Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

Are rectoceles the cause or the result of obstructed defaecation syndrome? A prospective anorectal physiology study

AIM

To determine the relationship between obstructed defaecation syndrome (ODS) and rectoceles.

METHOD

From December 2007 to November 2011, all female patients with ODS were prospectively evaluated with full interview, clinical examination and anorectal physiology testing. The characteristics of patients with and without rectoceles were compared, and logistic regression was utilized to identify factors predictive of patients having a rectocele beyond the introitus.

RESULTS

Of 239 patients with ODS, 90 (mean age: 52.3 ± 1.7 years) had a rectocele. Patients with rectoceles (R+) had a similar prevalence of incomplete emptying compared with patients with no rectocele (R-) (P ≥ 0.21), but only R+ patients reported splinting with defaecation (36.7% vs 0%; P < 0.0001). Anorectal manometry measurements, including mean resting pressure, maximum resting pressure and maximum squeeze pressure, were similar between groups (P ≥ 0.12). There were also no significant differences in rectal compliance (maximum tolerated volume) or rectal sensitivity (volume of first sensation) (P ≥ 0.65). R+ patients had greater difficulty expelling a 60 cm(3) balloon (70.1% R+ patients vs 57.5% R- patients; P = 0.05), but the prevalence of pelvic floor dyssynergia, as quantified by nonrelaxation on electromyography (EMG) testing, was similar to that of R- patients (P = 0.49). Logistic regression suggested that only difficulty with balloon expulsion was associated with higher odds of having a rectocele (OR = 3.00; P = 0.002), whereas mean resting pressure, EMG nonrelaxation and symptoms of incomplete emptying were not (P ≥ 0.12).

CONCLUSION

Rectoceles are not associated with an increased severity of ODS-type symptoms, anorectal abnormalities or pelvic floor dyssynergia in patients with ODS. This suggests that rectoceles may be the result, rather than the cause, of ODS.

Laparoscopic ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of 245 consecutive patients

AIM

This retrospective study aimed to determine functional results of laparoscopic ventral rectopexy (LVR) for rectal prolapse (RP) and symptomatic rectoceles in a large cohort of patients.

METHOD

All patients treated between 2004 and 2011 were identified. Relevant patient characteristics were gathered. A questionnaire concerning disease-related symptoms as well as the Cleveland Clinic Incontinence Score (CCIS) and Cleveland Clinic Constipation Score (CCCS) was sent to all patients.

RESULTS

A total of 245 patients underwent operation. Twelve patients (5%) died during follow-up and were excluded. The remaining patients (224 women, nine men) were sent a questionnaire. Indications for LVR were external RP (n = 36), internal RP or symptomatic rectocele (n = 157) or a combination of symptomatic rectocele and enterocele (n = 40). Mean age and follow-up were 62 years (range 22-89) and 30 months (range 5-83), respectively. Response rate was 64% (150 patients). The complication rate was 4.6% (11 complications). A significant reduction in symptoms of constipation or obstructed defaecation syndrome was reported (53% of patients before vs 19% after surgery, P < 0.001). Mean CCCS during follow-up was 8.1 points (range 0-23, SD ± 4.3). Incontinence was reported in 138 (59%) of the patients before surgery and in 32 (14%) of the patients after surgery, indicating a significant reduction (P < 0.001). Mean CCIS was 6.7 (range 0-19, SD ± 5.2) after surgery.

CONCLUSION

A significant reduction of incontinence and constipation or obstructed defaecation syndrome after LVR was observed in this large retrospective study. LVR therefore appears a suitable treatment for RP and rectocele with and without associated enterocele.

Evaluation and surgical treatment of rectal prolapse: an international survey

AIM

Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP.

METHOD

A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail.

RESULTS

In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients.

CONCLUSION

The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.