Digital rectal examination in the evaluation of rectovaginal septal defects

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction.

METHODS

An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed.

RESULTS

The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP.

CONCLUSIONS

The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Does Rectocele on Defecography Equate to Rectocele on Physical Examination in Patients With Defecatory Symptoms?

OBJECTIVES

Our primary objective was to determine the association between rectocele size on defecography and physical examination in symptomatic patients. Our secondary objective was to describe the associations between both defecography and physical examination findings with defecatory symptoms and progression to surgical repair of rectocele.

METHODS

We performed a retrospective review of all patients referred to a female pelvic medicine and reconstructive surgery clinic with a diagnosis of rectocele based on defecography and/or physical examination at a single institution from 2003 to 2017. Patients who did not have defecatory symptoms, did not undergo defecography imaging, or did not have a physical examination in a female pelvic medicine and reconstructive surgery clinic within 12 months of defecography imaging were excluded.

RESULTS

Of 200 patients, 181 (90.5%) had a rectocele diagnosed on defecography and 170 (85%) had a rectocele diagnosed on physical examination. Pearson and Spearman tests of correlation both showed a positive relationship between the rectocele size on defecography and rectocele stage on physical examination; however, one was not reliable to predict the results of the other (Pearson correlation = 0.25; Spearman ρ = 0.29). The strongest predictor of surgery was rectocele stage on physical examination (P < 0.001). Size of rectocele on defecography was not a strong independent predictor for surgery (P = 0.01), although its significance improved with the addition of splinting (P = 0.004).

CONCLUSIONS

Our results suggest that rectocele on defecography does not necessarily equate to rectocele on physical examination in patients with defecatory symptoms. Rectocele on physical examination was more predictive for surgery than rectocele on defecography.

Does the presence of a true radiological rectocele increase the likelihood of symptoms of prolapse?

INTRODUCTION AND HYPOTHESIS

Posterior compartment prolapse is commonly due to a 'true' rectocele, i.e., a diverticulum of the rectal ampulla. This condition is associated with symptoms of obstructed defecation and may contribute to prolapse symptoms. We tested the hypothesis: 'A true rectocele is an independent predictor of symptoms of prolapse.'

METHODS

This was a retrospective cohort study of patients presenting to a urogynecology unit for symptoms of pelvic floor dysfunction between September 2011 and June 2016. Assessment included a structured interview, POP-Q examination and 4D TLUS. Ultrasound volume data were acquired on Valsalva. Offline measurements were performed by analysis of stored volume data sets at a later date, blinded to all clinical data.

RESULTS

One hundred six patients were excluded because of incomplete data. Of the remainder, Bp was the most distal point on POP-Q in 348. Statistical analysis was performed on this cohort. Mean age was 60 (33-86) years and mean BMI 31 (18-55) kg/m². One hundred fifty-three patients (44%) presented with symptoms of prolapse; 272 were diagnosed with a true rectocele on TLUS. Bp on POP-Q and true rectocele on TLUS were both significantly associated with prolapse symptoms; however, on multivariate analysis the latter became nonsignificant (p = 0.059). Receiver-operating characteristic (ROC) analysis confirmed that the presence of a true rectocele on TLUS did not contribute significantly to symptoms of prolapse (AUC 0.66 for model with rectocele, AUC 0.65 without).

CONCLUSIONS

The presence of a true rectocele on TLUS does not seem to contribute substantially to the manifestation of clinical symptoms of prolapse.

Association between vaginal parity and rectocele

INTRODUCTION AND HYPOTHESIS

Rectocele is common in parous women but also seen in nulliparae. This study was designed to investigate the association between vaginal parity and descent of the rectal ampulla/rectocele depth as determined by translabial ultrasound (TLUS).

METHODS

This retrospective observational study involved 1296 women seen in a urogynaecological centre. All had undergone an interview, clinical examination and 4D ultrasound (US) imaging supine and after voiding. Offline analysis of volume data was undertaken blinded against other data. Rectal ampulla position and rectocele depth were measured on Valsalva. A pocket depth of 10 mm was used as a cutoff to define rectocele on imaging.

RESULTS

Most women presented with prolapse (53%, n = 686); 810 (63%) complained of obstructed defecation (OD). Clinically, 53% (n = 690) had posterior-compartment prolapse with a mean Bp of -1 [standard deviation (SD)1.5; -3 to 9 cm]. Mean descent of the rectal ampulla was 10 mm below the symphysis (SD 15.8; -50 to 41). A rectocele on imaging was found in 48% (n = 618). On univariate analysis, OD symptoms were strongly associated with rectal descent, rectocele depth and rectocele on imaging (all P < 0.001). The prevalence of a rectocele seen on imaging increased with vaginal parity (P < 0.001). One-way analysis of variance (ANOVA) of vaginal parity against rectal descent and rectocele depth showed a dose-response relationship (both P < 0.001).

CONCLUSIONS

Vaginal parity was strongly associated with descent of the rectal ampulla and rectocele depth. This relationship approximated dose-response characteristics, with the greatest effect due to the first vaginal delivery.