The 'bother' of obstructed defecation

Is the Visual Analogue Scale inferior to the Pelvic Organ Prolapse Distress Inventory for assessing symptom bother of pelvic organ prolapse?

AIMS

Disease-specific validated questionnaires are used to quantify symptom severity, but they are time consuming to complete and evaluate. A Visual Analogue Scale (VAS) assessment of bother is simpler and faster. The aim of this study is to compare VAS with individual and composite pelvic floor disability index-short form 20 items in predicting significant pelvic organ prolapse (POP).

METHODS

A retrospective analysis of data was obtained at a tertiary urogynaecological clinic between February 2017 and August 2018. All women filled out the PFDI-20 and underwent a standardised physician-directed interview, POP-Q and translabial ultrasound. Women with symptoms of POP were asked to indicate the degree of bother using a VAS. Receiver operating characteristic curves were used to evaluate the performance of individual Pelvic Organ Prolapse Distress Inventory (POPDI)-6 items, the six-item composite POPDI-6 score, and VAS in predicting significant POP on clinical and ultrasound examination.

RESULTS

The complete data sets of 231 women were analysed. Median VAS for POP was 2.9 (range 0-10). Median POPDI-6 individual and composite scores for items one to six were 2, 2, 2, 1, 2, 0 (all range 0-4) and 9 (range 0-22), respectively. The majority had significant prolapse on clinical examination (n = 195, 84%) and on ultrasound (n = 192, 83%). The composite POPDI-6 prolapse score provided areas under the curve of 0.68 and 0.64 for the prediction of clinical and sonographic POP, compared to 0.74 and 0.69, respectively, for VAS. The difference was not significant (P = 0.3 and 0.8, respectively).

CONCLUSIONS

The VAS score was not inferior to the POPDI-6 in predicting significant POP. It has the potential to simplify the assessment of symptom severity.

The relationship between obstructed defecation and true rectocele in patients with pelvic organ prolapse

We aimed to investigate the prevalence of true rectocele and obstructed defecation (OD) in patients with pelvic organ prolapse (POP), to investigate the correlation between true rectocele and OD, and to understand the diagnostic value of translabial ultrasound (TLUS) in the diagnosis of true rectocele. The patients who scheduled for POP surgery were enrolled in this study. Patients who had previous reconstructive pelvic surgery or repair of rectocele were excluded. Birmingham Bowel and Urinary symptoms questionnaires and Longo's obstructed defecation syndrome scoring system were used to assess the bowel symptoms of patients. TLUS was used to evaluate anatomical defects. P value <0.05 was considered statistically significant, and confidence intervals were set at 95%. 279 patients were included into this study. The prevalence rate of OD was 43%, and the average value of ODS score was 6.67. 17% patients presented straining at stool, 33% presented incomplete emptying, 13% presented digitations, and 12% required laxatives or enema. The prevalence rate of true rectocele was 23%. Defecation symptoms were significantly correlated with age, levator-ani hiatus, levator-ani muscle injury and true rectocele. Logistic regression showed that true rectocele and increased levator-ani hiatus were independent risk factors of OD. True rectocele was significantly correlated with straining at stool, digitation, incomplete emptying and requirement of laxatives or enema.In POP patients, the prevalence rate of true rectocele and OD was 23% and 43%, respectively. True rectocele was related to OD. TLUS was a valuable approach in anatomical evaluation of POP.

Digital rectal examination in the evaluation of rectovaginal septal defects

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the diagnostic potential of digital rectal examination in the identification of a true rectocele.

METHODS

This is a retrospective observational study utilising 187 archived data sets of women presenting with lower urinary tract symptoms and/or pelvic organ prolapse between August 2012 and November 2013. Evaluation included a standardised interview, ICS-POPQ, rectal examination and 4D translabial ultrasound. The main outcome measure was the diagnosis of rectocele by digital rectal palpation on Valsalva manoeuvre. This diagnosis correlated with the sonographic diagnosis of rectocele to determine agreement between digital examination and ultrasound findings.

RESULTS

Complete data sets were available for 180 participants. On imaging, the mean position of the rectal ampulla was 11.07 (-36.3 to 44.3) mm below the symphysis pubis; 42.8% (77) had a rectocele of a depth of ≥10 mm. On palpation, a rectocele was detected in 60 women (33%). Agreement between palpation and imaging was observed in 77%; the kappa was 0.52 (CI 0.39-0.65). On receiver operator characteristic analysis, the area under the curve was 0.854 for the relationship between rectocele pocket depth and the detection of rectocele on palpation.

CONCLUSION

Moderate agreement was found between digital rectal examination for rectocele and translabial ultrasound findings of a "true rectocele". Digital rectal examination may be used to identify these defects in clinical practice. Extending the clinical examination of prolapse to include rectal examination to palpate defects in the rectovaginal septum may reduce the need for defecatory proctograms for the assessment of obstructive defecation and may help triage patients in the management of posterior compartment prolapse.