Pudendal nerve function in women with symptomatic utero-vaginal prolapse

Two Etiological Reasons of Constipation: Anterior Rectocele and Internal Mucosal Intussusception

Chronic constipation is a common problem in the general population. Rome III criteria can be used for the diagnosis of chronic constipation. The aim of this study is to emphasize the importance of anterior rectocele and mucosal intussusception as two etiological factors for chronic constipation. One hundred patients were included in this study after excluding other causes of the constipation by medical history, physical examination, and laboratory and radiological studies in 108 total patients who were admitted consecutively to the outpatient clinic of the general surgery department of Dr. Sadi Konuk Bakirkoy Education and Research Hospital with the complaint of constipation between June 2009 and January 2010. It was found that 75 % of these patients had anterior rectocele and 66 % of them had internal intussusception which cause chronic constsipation. Anterior rectocele and internal rectal mucosal intussusception must be kept in mind as two significant reasons for chronic functional constipation.

Medical and surgical management of pelvic floor disorders affecting defecation

Pelvic floor disorders that affect stool evacuation include structural (for example, rectocele) and functional disorders (for example, dyssynergic defecation (DD)). Meticulous history, digital rectal examination (DRE), and physiological tests such as anorectal manometry, colonic transit study, balloon expulsion, and imaging studies such as anal ultrasound, defecography, and static and dynamic magnetic resonance imaging (MRI) can facilitate an objective diagnosis and optimal treatment. Management consists of education and counseling regarding bowel function, diet, laxatives, most importantly behavioral and biofeedback therapies, and finally surgery. Randomized clinical trials have established that biofeedback therapy is effective in treating DD. Because DD may coexist with conditions such as solitary rectal ulcer syndrome (SRUS) and rectocele, before considering surgery, biofeedback therapy should be tried and an accurate assessment of the entire pelvis and its function should be performed. Several surgical approaches have been advocated for the treatment of pelvic floor disorders including open, laparoscopic, and transabdominal approach, stapled transanal rectal resection, and robotic colon and rectal resections. However, there is lack of well-controlled randomized studies and the efficacy of these surgical procedures remains to be established.

Treating pelvic floor disorders of defecation: management or cure?

Pelvic floor disorders that affect defecation consist of structural disorders (eg, rectocele) and functional disorders (eg, dyssynergic defecation). Evaluation includes a thorough history and physical examination, a careful digital rectal examination, and physiologic tests such as anorectal manometry, colonic transit study, and balloon expulsion test. Defecography and dynamic MRI may facilitate detection of structural defects. Management consists of education and counseling regarding bowel function, diet, laxatives, and behavioral therapies. Recently, several randomized, clinical trials have shown that biofeedback therapy is effective in dyssynergic defecation. Dyssynergia may also coexist in structural disorders such as solitary rectal ulcer syndrome or rectocele. Hence, before proceeding with surgery, neuromuscular training or biofeedback should be considered. Several surgical approaches, including stapled transanal rectal resection, have been advocated, but well-controlled randomized studies are lacking and their efficacy is unproven.

Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.

Chapitre E - Particularités du prolapsus génital de la blessée médullaire

This article discusses the particular problems of management of genital prolapse in women with neurogenic bladder. It seemed particularly important to emphasize the particular risks in this setting in view of the limited literature on the subject.

Impaired Function of the Levator Ani Muscle in the Grand Multipara and Great Grand Multipara

Repeated deliveries might disturb the levator function and increase defecation disorders. In this prospective study, we determined the electric activity of the levator ani muscle (LAM) in nullipara, multipara, grand multipara, and great grand multipara (20 subjects for each group). Multiparity, grand multiparity, and great grand multiparity were defined as women having 2 - 5, 6 - 9, and 10 and over deliveries, respectively. The number of deliveries of multipara, grand multipara and great grand multipara were 4.05 +/- 1.14 (2 - 5), 7.55 +/- 1.23 (6 - 9) and 12.2 +/- 2.16 (10 - 17), respectively. All women were asked whether they had experienced constipation, fecal or urinary incontinence, and/or pelvic pain. All women were also evaluated for pelvic organ prolapse. Electromyography (EMG) of the LAM at rest and on contraction was recorded. EMG is an electrical recording of muscle activity. Constipation, incontinence and pelvic organ prolapse were encountered in multipara, grandmultipara and great grand multipara women. The LAM EMG at rest and on contraction in the nullipara was accepted as control. Both the resting and contractile activities of the LAM were as follows: nullipara > multipara > grand multipara > great grand multipara. These findings indicate that levator dysfunction and defecation disorders are increased with repeated deliveries because of pudendal and/or levator ani nerve injury and traumatic injury to the LAM occurred with the mechanical stresses of vaginal deliveries.

Innervation of the rectovaginal wall in patients with rectocele compared to healthy controls

AIMS

To evaluate if pelvic floor innervation differed in patients with rectocele compared to control subjects and to assess if nerve fiber density of the rectovaginal wall correlated to the clinical presentation of rectocele.

METHODS

Biopsies from 24 female patients with posterior vaginal wall prolapse stage II (ICS-classification) and rectocele verified at defecography were compared to specimens from age and parity-matched control subjects without posterior vaginal wall prolapse. Nerve fiber density was measured using protein gene product (PGP-9.5) antibodies at immunohistochemistry. Anorectal symptoms were recorded using bowel and anorectal function questionnaires.

RESULTS

The two groups were comparable in age and parity. Mean nerve fiber immunofluorescence intensity was 150.3 +/- 12.5 SD in the patient group compared to 139.3 +/- 8.5 SD in the control group (P < 0.01). Symptoms of anorectal dysfunction were more common in the patient group compared to control subjects (P < 0.01) but there was no difference in anal continence. At logistic regression analysis, nerve fiber immunofluorescence intensity showed no significant correlation to age, menopausal age, parity, body mass index (BMI), prolapse quantification, or any specific self-reported anorectal symptom. Increased nerve fiber immunofluorescence intensity was correlated to increased perineal descent (OR 1.3, 95% CI 1.1-2.1) although not to the size of the rectocele (OR 0.5, 95% CI 0.9-1.2).

CONCLUSIONS

Our results show that rectocele may be associated with increased rectovaginal innervation, suggestive of reinnervation of the rectovaginal wall. Nerve fiber density correlated poorly with findings at clinical and radiological examination. Neurochemical characterization of the rectovaginal wall may provide further understanding of the pathogenesis of rectocele.

Pelvic organ prolapse, constipation, and dietary fiber intake in women: a case-control study

OBJECTIVE

This study was undertaken to determine whether there is an association among pelvic organ prolapse, constipation, and dietary fiber intake.

STUDY DESIGN

Sixty consecutive women with prolapse were compared with 30 control women without prolapse. All women completed 2 validated questionnaires to assess constipation and dietary fiber intake. Multivariate analysis was performed.

RESULTS

The risk for constipation was greater in women with prolapse than controls (odds ratio 4.03, 95% CI 1.5-11.4). Median insoluble fiber intake was significantly lower in women with prolapse (2.4 g) than controls (5.8 g, P < .01). The increased risk for constipation was reduced but remained significant after controlling for age and insoluble dietary fiber intake (odds ratio 2.9, 95% CI 1.1-13.5).

CONCLUSION

Women with pelvic organ prolapse are at a higher risk for constipation than controls. This increased risk for constipation is partially explained by lower intake of dietary insoluble fiber by women with prolapse than controls.

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Biofeedback for anismus: has placebo effect been overlooked?

OBJECTIVE

Multiple uncontrolled studies have concluded that biofeedback is successful in treating anismus. This study's objective was to assess the physiological effects of placebo and biofeedback treatment on patients with anismus and to correlate changes with clinical improvement.

PATIENTS AND METHODS

Twelve patients with symptoms and electrophysiological findings of anismus were studied. Initial assessment included a detailed history, symptom assessment by linear analogue scales, anorectal manometric and electrophysiological studies, colon transit scintigraphy, and scintigraphic proctography. Patients underwent 5 days of placebo treatment, followed 1 week later by re-assessment of symptoms and physiological studies. Five days of biofeedback was then given followed by another complete re-assessment 1 week later. A final interview was performed 2 months later. All assessments were by an independent observer who was not responsible for the treatments.

RESULTS

Seven patients reported an overall improvement in symptoms following placebo treatment. A total of seven patients reported improvement following biofeedback, three of whom had already reported an improvement with placebo. One patient who reported improvement following placebo had worsening of symptoms following biofeedback. The only symptoms or tests which changed more with biofeedback than placebo were anal pressure and electromyographic activity on attempted defaecation in the left lateral position. There was no demonstrable correlation between change in symptoms and change in physiological tests. The scintigraphic 'ejection fraction' of the rectum was unchanged by treatment.

CONCLUSION

Clinical improvement in previous studies may in part be due to placebo effect and observer bias. Improvement with biofeedback may be due to physiological changes which are not detected with conventional anorectal physiological tests.

Techniques of rectocele repair and their effects on bowel function

Gynecologists have traditionally evaluated rectocele repair by its effect on vaginal function; coloproctologists have traditionally evaluated its effect on bowel function. Hence different operative criteria and surgical techniques have arisen, but with very little prospective, objective evaluation. The purpose of this review is to describe the surgical techniques used to repair the rectocele and the most common investigations used during its evaluation. Anorectal investigations identify concomitant pathology, may explain pathophysiology, provide objective outcome criteria and attempt to predict the patients that will most benefit from surgery. However, because of the complex neuromuscular, physiological and mechanical interactions that contribute to impaired rectal emptying, their usefulness in improving functional outcome has been limited. Many patients experience improvement, but still are left with some symptoms of impaired defecation despite anatomic correction.

Variation in pudendal nerve terminal motor latency according to disease

PURPOSE

The aims of this study were first to establish whether any difference among pudendal nerve terminal motor latency (PNTML) values exists relative to diagnosis, second to determine whether left and right latencies are similar, and third to assess any correlation between age and neuropathy. Latency was elicited three times on each side, and an average latency was recorded as a result.

MATERIALS AND METHODS

Between June 1989 and April 1995, 1,026 patients (775 females and 251 males) underwent PNTML study. These patients were divided into four groups according to diagnosis: Group I, fecal incontinence; Group II, chronic constipation; Group III, idiopathic rectal pain; Group IV, rectal prolapse. Overall mean age was 61.5 (range, 6-95) years. Student's t-test was used to calculate statistical differences. Patients were then analyzed according to age and gender. Correlation was calculated with the nonparametric Mann-Whitney U test.

RESULTS

Unilateral or bilateral prolongation of PNTML was noted in 90 patients (21.2 percent) in Group I, 80 (20.4 percent) in Group II, 22 (18.1 percent) in Group III, and 38 (42.6 percent) in Group IV. Average PNTML on the left side was 1.88 ms in Group I, 1.94 ms in Group II, 1.98 ms in Group III, and 2.12 ms in Group IV. Average PNTML on the right side was 1.85 ms in Group I, 1.94 ms in Group II, 1.99 ms in Group III, and 2.07 ms in Group IV. The only statistically significant differences in PNTML were between Groups I and IV (left, P < 0.005; right, < 0.05) and between females and males (P < 0.0001).

CONCLUSION

There is no statistically significant difference between latencies of left and right pudendal nerves. Similarly, there are no statistically significant differences among patients with fecal incontinence, chronic constipation, or chronic idiopathic rectal pain. Normal latency can be expected in patients with constipation or fecal incontinence. However, patients with rectal prolapse have a more prolonged PNTML. Age is correlated with a higher incidence of pudendal neuropathy. This study reveals significant overlap among PNTML values and diagnosis.

Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence

OBJECTIVE

To investigate the aetiological importance of bowel dysfunction in patients with uterovaginal prolapse and urinary stress incontinence.

DESIGN

Observational study using a questionnaire about obstetric history and bowel function, and anorectal physiological studies.

SETTING

Physiology unit and gynaecological outpatients departments of two teaching hospitals.

SUBJECTS

Twenty-three women with uterovaginal prolapse (mean age 57 years), 23 women with urinary stress incontinence (mean age 52 years) and 27 control women (mean age 52 years).

RESULTS

There was no statistically significant difference between the three groups in their parity, age or birthweight of their children. However, straining at stool as a young adult prior to the development of urogynaecological symptoms was significantly more common in women with uterovaginal prolapse (61% vs 4%, P < 0.001) and women with urinary stress incontinence (30% vs 4%, P < 0.05), compared with controls. A bowel frequency of less than twice per week as a young adult was also more common in women with uterovaginal prolapse than in control women (48% vs 8%, P < 0.001). At the time of consultation, 95% of the women with uterovaginal prolapse were constipated, compared with only 11% of control women. Many of these women also needed to digitate to achieve rectal evacuation. Compared with controls, women with uterovaginal prolapse had a prolonged pudendal nerve terminal motor latency (1.9 ms vs 2.2 ms, respectively, P = 0.003). Women with stress incontinence of urine had a normal pudendal nerve latency (2.0 ms). Other tests of anorectal function were normal.

CONCLUSIONS

Constipation, in addition to obstetric history, appears to be an important factor in the pathogenesis of uterovaginal prolapse.

Does squatting reduce pelvic floor descent during defaecation?

Neurogenic faecal and urinary incontinence result from a stretch-induced injury to the pelvic nerves, from difficult childbirth or from chronic straining at stool. It has been suggested that the condition occurs less frequently in societies where the squatting position is used during defaecation, and that squatting may minimize pelvic floor descent. This is a prospective study which evaluates the position of the pelvic floor during defaecation straining in 52 patients. The position of the perineum was measured at rest and during maximal defaecation straining using a perineometer, with the patient in the left lateral, sitting and squatting positions. There was a significant difference in the position of the perineum at rest and on straining between the left lateral position and both the sitting and squatting positions. However, there was no significant difference at rest or on straining between the sitting and squatting positions. These results show that squatting does not reduce pelvic floor descent during defaecation straining, and imply that squatting would not help reverse stretch-induced pudendal nerve damage.