Association between vaginal parity and rectocele

Differences in Pelvic Organ Prolapse and Diastasis Recti Abdominis Between Primiparous and Age-Matched second-Parous Females After Vaginal Delivery: A Retrospective Cohort Study

Purpose

This study aims to investigate the differences in pelvic floor dysfunction (PFD) and diastasis recti abdominis (DRA) between primiparous and second-parous females with known risk factors controlled.

Patients and Methods

49 primiparous and 49 age-matched second-parous postpartum after spontaneous vaginal delivery were included between October and December 2023. Independent variables include weight, height, body mass index (BMI), fetal weight, gestational weight gain (GWG). Main outcome measurements include vaginal resting pressure (VRP) and maximum voluntary contraction pressure (MVCP) indicating pelvic floor muscle strength, the stage of anterior (APOP) and posterior pelvic organ prolapse (PPOP) and inter-recti distance (IRD) indicating DRA. Independent t-test and Chi-square test of independence were used to analyze differences between two groups for continuous and categorical variables, respectively.

Results

No significant differences were found in terms of vaginal pressure measurements between two groups (VRP: t (96) = 0.07, p = 0.942; MVCP: t (96) = 0.40, p = 0.689). Second-parous group showed significantly more severe DRA with larger IRD than primiparous group (t (96) = -2.405, p = 0.018). No significant association was found between parity and APOP stage (χ2(1) = 2.67, p = 0.102) in this current study; however, second-parous females demonstrated greater PPOP stage than primiparous females (χ2(1) = 5.24, p = 0.022).

Conclusion

Second-parous females at similar age are more likely to experience PPOP than primiparous group after spontaneous vaginal delivery. Greater public attention with plausible actions should be taken for second-parous female group to prevent more severe postpartum pelvic floor dysfunction.

Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era

BACKGROUND

More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful.

PURPOSE

We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

Transvaginal rectocoele repair for the surgical treatment of a "symptomatic" rectocoele when conservative measures fail: A 12 year experience of 215 patients

BACKGROUND

Conservative measures are first-line treatment for a "symptomatic" rectocoele, while surgery to correct the anatomical defect may be considered in selected cases. The standard repair offered in our trust is a native tissue transvaginal rectocoele repair (TVRR) combined with levatorplasty. The primary aim of the study was to conduct a retrospective study to assess the outcome of this procedure, while secondary aims were to assess whether specific characteristics and symptoms were associated with response to surgery.

METHODS

We conducted a retrospective review of 215 patients who underwent TVRR in a single tertiary referral center between 2006 and 2018. In total, 97% of patients had symptoms of obstructive defecation syndrome (ODS) and 81% had a feeling of vaginal prolapse/bulge. We recorded in-hospital and 30 days post-operative complications and pre- and post-operative symptoms.

KEY RESULTS

The majority of patients selected for surgery had rectocoele above 4 cm or medium size with contrast trapping. Mean length of hospital stay was 3.2 days. The in-hospital complication rate was 11.2% with the most common complications being urinary retention (8.4%). Mean length of follow-up was 12.7 months (SD 13.9, range 1.4-71.5) with global improvement of symptoms reported in 87.9% cases. Feeling of vaginal bulge improved in 80% of patients while ODS-related symptoms improved in 58% of cases.

CONCLUSIONS & INFERENCES

The data suggest that TVRR might be a valid option in patients with rectocoele when conservative treatment has failed. Overall patient satisfaction is good, with improvement of ODS symptoms.

Higher Symptom Score, Larger Residual Rectocele, and Lower Rectal Compliance Predict Failure of Improvement after Surgical Treatment of Rectocele

Background Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair.

Methods The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography.

Results A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09–1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43–6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907–0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15.

Conclusions Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele

BACKGROUND

Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome (ODS).

AIM

To assess the current literature in regard to the outcome of the classical transperineal repair (TPR) of rectocele and its technical modifications.

METHODS

An organized literature search for studies that assessed the outcome of TPR of rectocele was performed. PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020. The main outcome measures were improvement in ODS symptoms, improvement in sexual functions and continence, changes in manometric parameters, and quality of life.

RESULTS

After screening of 306 studies, 24 articles were found eligible for inclusion to the review. Nine studies (301 patients) assessed the classical TPR of rectocele. The median rate of postoperative improvement in ODS symptoms was 72.7% (range, 45.8%-83.3%) and reduction in rectocele size ranged from 41.4%-95.0%. Modifications of the classical repair entailed omission of levatorplasty, addition of implant, concomitant lateral internal sphincterotomy, changing the direction of plication of rectovaginal septum, and site-specific repair.

CONCLUSION

The transperineal repair of rectocele is associated with satisfactory, yet variable, improvement in ODS symptoms with parallel increase in quality-of-life score. Several modifications of the classical TPR were described. These modifications include omission of levatorplasty, insertion of implants, performing lateral sphincterotomy, changing the direction of classical plication, and site-specific repair. The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.

Rectal-vaginal pressure gradient in patients with pelvic organ prolapse and symptomatic rectocele

Objective

The aim of this study is to examine the relationship between rectal–vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP).

Method

Patients with posterior vaginal prolapse staged III or IV in accordance with the POP Quantitation classification method who were scheduled for pelvic floor reconstructive surgery in the years 2016–2019 were included in the study. Rectocele was diagnosed using translabial ultrasound, and obstructed defecation (OD) was diagnosed in accordance with the Roma IV diagnostic criteria. Both rectal and vaginal pressure were measured using peritron manometers at maximum Vasalva. To ensure stability, the test was performed three times with each patient.

Results

A total of 217 patients were enrolled in this study. True rectocele was diagnosed in 68 patients at a main rectal ampulla depth of 19 mm. Furthermore, 36 patients were diagnosed with OD. Symptomatic rectocele was significantly associated with older age (p < 0.01), a higher OD symptom score (p < 0.001), and a lower grade of apical prolapse (p < 0.001). The rectal–vaginal pressure gradient was higher in patients with symptomatic rectocele (37.4 ± 11.7 cm H₂O) compared with patients with asymptomatic rectocele (16.9 ± 8.4 cm H₂O, p < 0.001), and patients without rectocele (17.1 ± 9.2 cm H₂O, p < 0.001).

Conclusion

The rectal–vaginal pressure gradient was found to be a risk factor for symptomatic rectocele in patients with POP. A rectal–vaginal pressure gradient of > 27.5 cm H₂O was suggested as the cut-off point of the elevated pressure gradient.

Repair of Posterior Vaginal Wall Defect Using Biologic Graft for Stage III-POP-Q Pelvic Organ Prolapse in a Patient with History of a J-Pouch

Surgical correction is considered in women with symptomatic pelvic organ prolapse (POP). There is an expected increase in the prevalence of surgical correction due to an aging population within the United States. Individuals with previous colorectal surgery present a unique challenge considering the changes in pelvic anatomy. This case discusses the challenges of posterior colporrhaphy in a patient with previous, remote J-pouch surgery. In traditional posterior colporrhaphy, randomized controlled trials have not shown any benefit of graft augmentation (Maher, 2016). However, the utilization of a biologic graft to improve anatomical correction is discussed in this unique case. Short term anatomical success was obtained without immediate complications in the postoperative period. In a patient with a history of ulcerative colitis with colorectal resection and a J-pouch, surgery can be challenging due to alterations of pelvic anatomy. Modification of the standard surgical approach may be required to achieve success.