Constipation does not develop following elective hysterectomy: a prospective, controlled study

[Outpatient hysterectomy: criteria for acceptability and feasibility, survey among 152 surgeons]

OBJECTIVE

The aim of this study is to determine one-day hysterectomy's criteria of acceptability and feasibility.

MATERIALS AND METHODS

We realized an observational descriptive survey based on questionnaires which were sent to gynecologic surgeons. Criteria were defined as major when rate of favorable responses was superior to 70%.

RESULTS

Main major criteria were: definition of an age limit (80.3% of respondents), of a Body Mass Index limit (70%), no history of coronary artery disease (77.6%), no anticoagulant therapy with curative intent (95.4%) or antiplatelet (71.1%), no history of sleep apnea (77.4%), surgery within two hours (85.1%), definition of intraoperative bleeding limit (87.5%), no laparotomy (97.4%), no intra abdominal drainage (77.6%), presence of an accompanying at home (99.3%), pain evaluation (97.4%), absence of nausea before leaving (75.5%) and spontaneous urination (96.7%).

CONCLUSION

Our study determined major criteria to practice one-day hysterectomy. Decision should be based on a personalized benefice-risk balance analysis. Final decision belongs to patient, as her complete engagement is fundamental.

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.

Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology

OBJECTIVE

The objective of the study was to draw up French College of Obstetrics and Gynecology (CNGOF) clinical practice guidelines based on the best available evidence concerning hysterectomy for benign disease.

METHODS

Each recommendation for practice was allocated a grade, which depends on the level of evidence (clinical practice guidelines).

RESULTS

Hysterectomy should be performed by a high-volume surgeon (>10 hysterectomy procedures per year) (gradeC). Stimulant laxatives taken as a rectal enema are not recommended prior to hysterectomy (gradeC). It is recommended to carry out vaginal disinfection using povidone-iodine solution prior to hysterectomy (grade B). Antibiotic prophylaxis is recommended during hysterectomy, regardless of the surgical approach (grade B). The vaginal or laparoscopic approach is recommended for hysterectomy for benign disease (grade B), even if the uterus is large and/or the patient is obese (gradeC). The choice between these two surgical approaches depends on other parameters, such as the surgeon's experience, the mode of anesthesia, and organizational constraints (duration of surgery and medical economic factors). Vaginal hysterectomy is not contraindicated in nulliparous women (gradeC) or in women with previous cesarean section (gradeC). No specific hemostatic technique is recommended with a view to avoiding urinary tract injury (gradeC). In the absence of ovarian disease and a personal or family history of breast/ovarian carcinoma, the ovaries should be preserved in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended with a view to reducing the risk of peri- or postoperative complications (grade B).

CONCLUSION

The application of these recommendations should minimize risks associated with hysterectomy.

[Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines]

OBJECTIVES

To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy.

MATERIAL AND METHOD

Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.

RESULTS

Urinary catheter should be removed before 24h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus).

CONCLUSIONS

Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.

Colorectal motor and sensory function after hysterectomy

PURPOSE

Women may develop constipation after hysterectomy. The pathophysiology and underlying mechanisms are poorly understood. They may originate from either neural damage of rectum and colon or changes in anatomical constellation of the remaining pelvic organs. The aim of this study is to evaluate sensory and motor functions of rectum and colon in women with newly developed constipation after hysterectomy in comparison with women without constipation and healthy controls after hysterectomy .

METHODS

Barostat measurements were performed in posthysterectomy women with constipation (PH-C), without constipation (PH-NC), and healthy controls (n = 10, every group). Outcome measures were rectal and colonic compliance (millilitre per millimetre of mercury), rectocolonic perception in reaction to mechanical distension (millimetre; VAS scores) and rectocolonic reflex (millilitre per millimetre of mercury).

RESULTS

No differences in rectal or colonic compliance were observed. Urge perception due to rectal distension increased significantly in controls (from 7 ± 5 to 41 ± 10 mm; p < 0.05) and PH-NC group (from 3 ± 1 to 24 ± 9 mm; p < 0.05), but not in PH-C patients (1 ± 1 to 11 ± 5 mm; ns). In healthy controls and the PN-NC group, respectively, 100 and 70 % of subjects reached the minimal threshold value for urge of 10 mm during the isobaric distension sequence. In the PH-C group, only two subjects (20 %) reached this threshold (p < 0.05). Rectal pain perception, phasic colonic motility and the rectocolonic reflex were intact in all three groups.

CONCLUSIONS

Colorectal motor and sensory function is generally well preserved in women with constipation after hysterectomy. It is unlikely that the symptom of constipation after hysterectomy has been caused by iatrogenic neuronal damage in these patients.

Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery

BACKGROUND AND AIM

Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy.

METHODS

Of the constipated patients, a hysterectomy group (n = 40), delivery group (n = 41), and a control group (n = 89), who had no history of either surgery or delivery before developing functional constipation were included. Their anorectal physiological tests and the effectiveness of biofeedback therapy were investigated.

RESULTS

The volume of desire to defecate was greater in the hysterectomy group than in the control group (86.5 ± 55.0 mL vs 62.9 ± 33.7 mL; P = 0.03), and more than 240 mL of maximal volume of toleration was more frequently noted in the hysterectomy group (32.5%) than in the delivery group (14.6%) and control group (13.5%) (P = 0.02).The failure of balloon expulsion was more frequently noted in the delivery group (44.0%) than in the hysterectomy group (15.0%) and control group (25.0%) (P = 0.01). The defecation satisfaction score was significantly increased after biofeedback therapy in the hysterectomy group (2.0 ± 2.7 vs 7.8 ± 1.5, P < 0.001), the delivery group (1.6 ± 2.1 vs 6.7 ± 2.0, P < 0.001), and the control group (2.5 ± 2.7 vs 6.9 ± 2.1, P < 0.001).

CONCLUSIONS

Rectal hyposensitivity could have been the characteristic mechanism in the hysterectomy group, whereas dyssynergic defecation could have been the cause in the delivery group. Biofeedback therapy was effective for both groups.

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.

Perioperative bowel habits of women undergoing gynecologic surgery: a pilot study

OBJECTIVES

To describe perioperative bowel habits of women undergoing gynecologic surgery.

METHODS

This prospective cohort study included women undergoing gynecologic surgery. Before surgery, participants completed the Bristol Stool Form Scale (BSFS), a validated instrument describing stool characteristics consistent with transit categories: slow (BSFS 1-2), normal (BSFS 3-5), and fast (BSFS 6-7). For 2 weeks after surgery, the participants recorded daily medications and bowel movements (BM), and completed BSFS. The χ(2) test, the Fisher exact test, analysis of variance, t tests, and ordinal regression were used.

RESULTS

Preoperatively, most (70%) of 340 women had normal stool transit, with 15% having slow transit and 7% having fast transit. Complete postoperative data were available for 170 (50%). Mean ± SD time to first postoperative BM was 2.8 ± 1.4 days with transit classification: 48% normal, 32% slow, and 20% fast.

CONCLUSIONS

Most women had normal stool transit both preoperatively and postoperatively. Time to first BM was longer after open surgery by approximately 3 days.

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

BACKGROUND

While bowel and bladder dysfunction are recognized consequences of a radical hysterectomy, the effects of a simple hysterectomy on anorectal sensorimotor functions, particularly rectal sensation, vary among studies and the effects on rectal compliance remain unknown. Our aims were to prospectively evaluate anorectal sensorimotor functions before and after a hysterectomy.

METHODS

Anal pressures, rectal compliance, capacity, sensation, and bowel symptoms were assessed before, at 2 months, and at 1 year after a simple vaginal hysterectomy for benign indications in 19 patients. Rectal staircase (0-44 mmHg, 4-mmHg steps), ramp (0-200 mL at 50, 200 and 600 mL min(-1)) and phasic distentions (8, 16, and 24 mmHg above operating pressure) were performed.

KEY RESULTS

Anal resting (63 ± 4 before, 56 ± 4 mmHg after) and squeeze pressures (124 ± 12 before, 124 ± 12 mmHg after), rectal compliance and capacity (285 ± 12 before, 290 ± 11 mL 1 year after), and perception of phasic distentions were not different before vs after a hysterectomy. Sensory thresholds for first sensation and the desire to defecate were also not different, but pressure and volume thresholds for urgency were somewhat greater (Hazard ratio = 0.7, 95% CI [0.5, 1.0]) 1 year after (vs before) a hysterectomy. Rectal pressures were higher (P < 0.0001) during fast compared with slow ramp distention; this rate effect was greater at 1 year after a hysterectomy, particularly at 100 mL (P = 0.04).

CONCLUSIONS & INFERENCES

A simple vaginal hysterectomy has relatively modest effects (i.e., somewhat reduced rectal urgency and increased stiffness during rapid distention) on rectal sensorimotor functions.

Relationships between pelvic floor symptoms and function in irritable bowel syndrome

BACKGROUND

Pelvic floor dyssynergia (PFD) within irritable bowel syndrome (IBS) is often overlooked and the relationship between symptoms and physiology is relatively unexplored. Our aims were to determine relationships between clinical features and anorectal function in non-diarrhea predominant IBS (non-D IBS) patients and whether certain clinical or physiological features predict PFD in IBS.

METHODS

Two groups of patients were evaluated. Group I: 32 female non-D IBS patients with >or=2 symptoms suggesting PFD underwent comprehensive symptom and anorectal function assessment. Group II: 32 female non-D IBS patients recruited from the community underwent symptom assessment.

KEY RESULTS

Prevalence of PFD symptoms was similar in both groups. In group I patients, increased frequency of digitation was associated with a longer balloon expulsion time (P = 0.03). Higher scores for anal pain were associated with both a low resting anal pressure (P = 0.04) and a shorter duration of maximum squeeze (P = 0.03). Reduced perineal descent was associated with anxiety (P = 0.03) and depression (P = 0.01). A shorter duration of maximum squeeze was associated with higher parity (P = 0.02) and previous hysterectomy (P = 0.047). Duration of PFD symptoms was higher (P = 0.02) and maximum tolerated volume was lower (P = 0.05) in 22 patients with a physiological diagnosis of PFD compared to 10 without PFD. No symptoms independently predicted a physiological diagnosis of PFD.

CONCLUSIONS & INFERENCES

Important relationships between certain PFD symptoms and disordered anorectal physiology have been demonstrated in these non-D IBS patients. However, symptoms alone could not predict PFD, and certain clinical features should therefore highlight the need for comprehensive anorectal function tests.