Effects of vaginal hysterectomy on anorectal sensorimotor functions--a prospective study

Normal values for assessment of anal sphincter morphology, anorectal motion, and pelvic organ prolapse with MRI in healthy women

BACKGROUND

Endoanal MRI and MR defecography are used to identify anal sphincter injury and disordered defecation. However, few studies have evaluated findings in asymptomatic healthy people. The effects of BMI and parity on rectoanal motion and evacuation are unknown.

METHODS

In 113 asymptomatic females (age 50 ± 17 years, Mean ± SD) without risk factors for anorectal trauma, anal sphincter appearance, anorectal motion, and pelvic organ prolapse were evaluated with MRI. The relationship between age, BMI, and parity and structural findings were evaluated with parametric and non-parametric tests.

RESULTS

The anal sphincters and puborectalis appeared normal in over 90% of women. During dynamic MRI, the anorectal angle was 100 ± 1º (Mean ± SEM) at rest, 70 ± 2° at squeeze, and 120 ± 2° during defecation. The change in anorectal angle during squeeze (r = -.25, P < .005), but not during evacuation (r = .13, P = .25) was associated with age. In the multivariable models, BMI (P < .01) and parity (P < .01) were, respectively, independently associated with the intersubject variation in the anorectal angle at rest and the angle change during squeeze. Ten percent or fewer women had had descent of the bladder base or uterus 4 cm or more below the pubococcygeal line or a rectocele measuring 4 cm or larger. Only 5% had a patulous anal canal.

CONCLUSIONS

In addition to age, BMI and parity also affect anorectal motion in asymptomatic women. These findings provide age-adjusted normal values for rectoanal anatomy and pelvic floor motion.

Effects of Hysterectomy on Pelvic Floor Disorders: A Longitudinal Study

BACKGROUND

Hysterectomy might adversely affect pelvic floor functions and result in many different symptoms, such as urinary and anal incontinence, obstructed defecation, and constipation.

OBJECTIVE

The aim of this prospective study was to evaluate the influence of hysterectomy on pelvic floor disorders.

DESIGN

This was a prospective and longitudinal study.

SETTINGS

The study was conducted at the Ankara University Department of Surgery and the Dr Zekai Tahir Burak Women's Health Research and Education Hospital between September 2008 and March 2011.

PATIENTS

The study was performed on patients who underwent hysterectomy for benign pathologies.

MAIN OUTCOME MEASURES

A questionnaire about urinary incontinence (International Continence Society scoring), anal incontinence, constipation, and obstructed defecation (Rome criteria and constipation severity score), along with an extensive obstetric history, was administered preoperatively and postoperatively annually for 4 years.

RESULTS

Patients (N = 327) who had completed each of the 4 annual postoperative follow-ups were included in this study. Compared with the preoperative observations, the occurrence of each symptom was significantly increased at each of the follow-up years (p < 0.001). Over the 4 postoperative years, the frequencies for constipation (n = 245) were 7.8%, 8.2%, 8.6%, and 5.3%; those for obstructed defecation (n = 269) were 4.5%, 5.2%, 4.1%, and 3.0%; those for anal incontinence (n = 252) were 4.8%, 6.3%, 6.0%, and 5.2%, and those for urinary incontinence (n = 99) were 12.1%, 12.1%, 11.1%, and 13.1%. In addition, patients who had no preoperative symptom (n = 70) from any of the selected symptoms showed a postoperative occurrence of at least 1 of these symptoms of 15.8%, 14.3%, 11.4%, and 8.6% for the postoperative years 1, 2, 3, and 4.

LIMITATIONS

Although the study had several limitations, no comparison with a control population was the most important one.

CONCLUSIONS

Hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions in patients who had no previous symptoms.

Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry

BACKGROUND & AIMS

Disordered defecation is attributed to pelvic floor dyssynergia. However, clinical observations indicate a spectrum of anorectal dysfunctions. The extent to which these disorders are distinct or overlap is unclear; anorectal manometry might be used in diagnosis, but healthy persons also can have abnormal rectoanal pressure gradients during simulated evacuation. We aimed to characterize phenotypic variation in constipated patients through high-resolution anorectal manometry.

METHODS

We evaluated anorectal pressures, measured with high-resolution anorectal manometry, and rectal balloon expulsion time in 62 healthy women and 295 women with chronic constipation. Phenotypes were characterized by principal components analysis of high-resolution anorectal manometry.

RESULTS

Two healthy persons and 71 patients had prolonged (>180 s) rectal balloon expulsion time. A principal components logistic model discriminated healthy people from patients with prolonged balloon expulsion time with 75% sensitivity and a specificity of 75%. Four phenotypes discriminated healthy people from patients with abnormal balloon expulsion times; 2 phenotypes discriminated healthy people from those with constipation but normal balloon expulsion time. Phenotypes were characterized based on high anal pressure at rest and during evacuation (high anal), low rectal pressure alone (low rectal) or low rectal pressure with impaired anal relaxation during evacuation (hybrid), and a short anal high-pressure zone. Symptoms were not useful for predicting which patients had prolonged balloon expulsion times.

CONCLUSIONS

Principal components analysis of rectoanal pressures identified 3 phenotypes (high anal, low rectal, and hybrid) that can discriminate among patients with normal and abnormal balloon expulsion time. These phenotypes might be useful to classify patients and increase our understanding of the pathogenesis of defecatory disorders.