Posterior vaginal wall prolapse does not correlate with fecal symptoms or objective measures of anorectal function

doi:10.1016/j.ajog.2006.07.034

American Journal of Obstetrics and Gynecology

Volume 195, Issue 6, December 2006, Pages 1742-1747

https://doi.org/10.1016/j.ajog.2006.07.034 Get rights and content

Objective

The purpose of this study was to evaluate the relationship among the degree of posterior vaginal wall prolapse, anorectal symptoms, and physiology.

Study design

This was a prospective study that included patients with fecal dysfunction and prolapse/urinary symptoms. A validated instrument for fecal incontinence and the ROME II criteria were used. Anal physiologic testing was performed selectively on the basis of bowel symptoms. Patients were divided into 2 groups by pelvic organ prolapse quantification score clinical examination: group I: Ap/Bp < –1, and group II: Ap/Bp ≥ –1. The association among the degree of prolapse, bowel symptoms, and physiologic findings was examined with the use of Fisher's exact test and logistic regression models.

Results

One hundred thirty-two patients with a mean age of 63 years (range, 24-90 years) were evaluated. There were 62 patients (47%) in group I and 70 patients (53%) in group II. Overall, 40.9% of the patients had constipation/obstructed defecation, and 25% of the patients had fecal incontinence. Ninety-seven patients underwent physiologic testing. At manometry, both resting and squeeze pressures were significantly higher in patients in group II. Overall, patients with a higher resting pressure (P = .001) and increased rectal capacity (P = .008) were more likely to be continent, and patients with a lower squeeze pressure were more likely to be incontinent (P = .001). Ultrasonography demonstrated anterior sphincter defect in 21.9% of the patients and a perineal body of <10 mm in 35.6% of the patients, with no correlation with the degree of prolapse. Patients with sphincter defects were 3 times more likely to have fecal incontinence (95% CI, 1.03, 8.75; P = .04). There was no association between electromyography and pudendal nerve terminal latencies and the degree of prolapse. Patients with prolonged pudendal nerve terminal latencies were more likely to be incontinent (P = .033). On defecography, 28% of the patients had concomitant enterocele, and 21.3% of the patients had intussusception, which was not detected by physical examination.

Conclusion

Anorectal symptoms do not correlate with the degree of posterior vaginal wall prolapse, nor does the presence of prolapse equate to abnormal physiologic test results. Bowel symptoms may result from primary anorectal abnormalities, which are demonstrated by physiologic studies.

Section snippets

Methods

This is an institutional review board–approved prospective observational cohort study of all patients with fecal dysfunction and prolapse or urinary symptoms who were evaluated at a multidisciplinary pelvic floor center (July 2003 to January 2005). Patients were first seen by a urogynecologist and were referred for colorectal evaluation in the presence of bowel symptoms that were detected on medical history intake. The exclusion criteria included women who were <18 years old, pregnancy, history

Comment

Despite the frequent coexistence of pelvic organ prolapse and bowel symptoms, a relationship between them has not been demonstrated. The main aim of our study was to investigate such a correlation in patients with pelvic floor dysfunction and to use anorectal physiologic studies to aid in the evaluation of bowel symptoms. We grouped patients as stages 0 to I or stages II through IV, which assumes the hymen is an important “cut off point” for symptom development.¹³ As reported in previous

Acknowledgments

We thank Joseph Feldman, DrPH, Professor of Preventive Medicine and Community Health, State University of New York (SUNY Downstate), Brooklyn, NY, Elina Yakirevich, RPA, Center for Pelvic Floor Dysfunction and Reconstructive Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY.

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Cited by (40)

The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery
2019, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Saks et al13 and Fialkow et al14 found an association between the presence but not the severity of posterior vaginal wall prolapse and obstructed defecation symptoms. However, many studies have failed to find any relationship.4–12 Often the authors have concluded that the lack of this relationship suggests posterior wall prolapse not being a causal factor behind obstructed defecation symptoms.3,6,10,13
Defecation symptoms are common among women with pelvic organ prolapse. However, the relationship between posterior vaginal wall prolapse and defecation symptoms remains debatable. Even though there is a plausible biomechanical rationale for posterior wall prolapse to cause obstructed defecation, previous studies have drawn contradictory conclusions regarding the association.
We aimed to examine the association between posterior vaginal wall prolapse and defecation symptoms by assessing the following: (1) does prevalence of defecation symptoms increase along with posterior wall prolapse severity, (2) is postoperative symptom improvement greater in women who underwent posterior compartment procedures in comparison with those who did not, and (3) is symptom improvement related to the symptom’s correlation with the degree of prolapse?
We used data from a nationwide longitudinal cohort study with 3515 women undergoing pelvic organ prolapse surgery. We measured the prevalence of 9 defecation symptoms at baseline and at 6 and 24 months after surgery using the short form of the Pelvic Floor Distress Inventory. Baseline degree of prolapse was categorized in stages as defined by the Pelvic Organ Prolapse Quantification System. The relationship between the degree of posterior wall prolapse and prevalence of bothersome defecation symptoms was studied with logistic regression and adjusted for patient characteristics and severity of anterior wall and apical prolapse. Generalized estimating equations were used to assess the longitudinal change in symptom prevalence in groups of participants with and without repair for posterior vaginal compartment. Correlations between symptom improvement and symptom dependency on the degree of prolapse was assessed by calculating Pearson’s correlation coefficient.
The stage of posterior wall prolapse (stage 2 vs stage 0) correlated with splinting, straining, incomplete evacuation, fecal incontinence of liquid stool, pain during defecation, fecal urgency, and anorectal prolapse (adjusted odds ratios, 2.7, 2.1, 2.0, 1.5, 2.1, 1.4, and 2.2, respectively; P ≤ .007 for all). Flatal incontinence and fecal incontinence of solid stool were not associated with the severity of posterior vaginal wall prolapse. Obstructed defecation symptoms (splinting, straining, and incomplete evacuation) improved more in women undergoing posterior compartment surgery compared with women undergoing repair for other compartments. The greatest improvement at follow-up was observed for those symptoms that showed strongest association with the degree of prolapse at baseline.
Obstructed defecation symptoms are dependent on the posterior wall anatomy. Women presenting with posterior wall prolapse, and these symptoms can expect to improve after surgery. Other defecation symptoms also improve after pelvic organ prolapse surgery, but they are not as specific to posterior wall anatomy as obstructed defecation symptoms.
Defecatory dysfunction and fecal incontinence in women with or without posterior vaginal wall prolapse as measured by pelvic organ prolapse quantification (POP-Q)
2017, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Defecatory dysfunction (difficulty in defecation with excessive straining to empty the bowels, feeling of incomplete bowel emptying, constipation, and manual evacuation with digital assistance) is often present in patients with POP [3–5]. However, it is unclear whether the abnormal anatomical positions of the bladder, bowel, and uterus compromise bladder and bowel function directly, or whether abnormal anatomy and dysfunction of the pelvic floor share a common etiology [6–13]. Gynecologists do not always inquire about bowel dysfunction [14], and Dua et al. [10] reported that colorectal symptoms may be ignored in women presenting to gynecology clinics with prolapse.
Pelvic Floor Dysfunction is a complex condition that may be asymptomatic or may involve a loto f symptoms. This study evaluates defecatory dysfunction, fecal incontinence, and quality of life in relation to presence of posterior vaginal prolapse.
265 patients were divided into two groups according to posterior POP-Q stage: posterior POP-Q stage ≥2 and posterior POP-Q stage <2. The two groups were compared regarding demographic and clinical data; overall POP-Q stage, percentage of patients with defecatory dysfunction, percentage of patients with fecal incontinence, pelvic floor muscle strength, and quality of life scores. The correlation between severity of the prolapse and severity of constipation was calculated using ρ de Spearman (rho).
Women with Bp stage ≥2 were significantly older and had significantly higher BMI, numbers of pregnancies and births, and overall POP-Q stage than women with stage <2. No significant differences between the groups were observed regarding proportion of patients with defecatory dysfunction or incontinence, pelvic floor muscle strength, quality of life (ICIQ-SF), or sexual impact (PISQ-12). POP-Q stage did not correlate with severity of constipation and incontinence. General quality of life perception on the SF-36 was significantly worse in patients with POP-Q stage ≥2 than in those with POP-Q stage <2.
The lack of a clinically important association between the presence of posterior vaginal prolapse and symptoms of constipation or anal incontinence leads us to agree with the conclusion that posterior vaginal prolapse probably is not an independent cause defecatory dysfunction or fecal incontinence.
Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review
2016, Gastroenterology Clinics of North America
Citation Excerpt :
However, multiple studies have shown that the degree of bowel symptoms does not correlate with severity of prolapse (and therefore response to surgical intervention).112–114 Furthermore, when physiologic tests (ARM, pudendal nerve latency testing, surface EMG, transanal ultrasonography, or defecography) were added to the work-up, there was still no correlation between degree of bowel symptoms and severity of posterior vaginal wall prolapse.116 Patients with rectoceles should be counseled on the use of vaginal splinting during bowel movements.
Consistently inconsistent, the posterior vaginal wall
2016, American Journal of Obstetrics and Gynecology
Citation Excerpt :
The limitation of our physical examination in predicting symptoms is clear and not reassuring. Adding physiological testing (anal manometry, pudendal terminal motor latencies, electromyography) to physical examination and imaging in patients, the authors concluded that there is no correlation between posterior vaginal wall prolapse with bowel symptoms or objective measures of anorectal function.5 The authors studying ODS symptoms and their relationship to rectocele concluded that rectoceles were not associated with increased severity of ODS symptoms, anorectal abnormalities, or pelvic floor dyssynergia.
Posterior vaginal wall prolapse is one of the most common prolapses encountered by gynecological surgeons. What appears to be a straightforward condition to diagnose and treat surgically for physicians has proven to be frustratingly unpredictable with regard to symptom relief for patients. Functional disorders such as dyssynergic defecation and constipation are often attributed to posterior vaginal wall prolapse. Little scientific evidence supports this assumption, emphasizing that structure and function are not synonymous when treating posterior vaginal wall prolapse. Rectoceles, enteroceles, sigmoidoceles, peritoneoceles, rectal and intraanal intussusception, rectal prolapse, and descending perineal syndrome are all conditions that have an impact on the posterior vaginal wall. All too often these different anatomic conditions are treated with the same surgical approach, addressing a posterior vaginal wall bulge with a traditional posterior colporrhaphy. Studies that examine the correlation between stage of posterior wall prolapse and patient symptoms have failed to reliably do so. Surgical outcomes measured by prolapse staging appear successful, yet patient expectations are often not met. As increasing attention is being placed on patient satisfaction outcomes concerning surgical treatments, this fact will need to be addressed. Surgeons will have to clearly communicate what can and what cannot be expected with surgical repair of posterior vaginal wall prolapse.
Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists
2015, Digestive and Liver Disease
Citation Excerpt :
The success rate is good in the short term but declines with time and the complication rate is very high (3a-B). FI is reported to be associated with pelvic organ prolapse in 50–75% of patients with rectal prolapse [113], 32–40% with rectal intussusception [112,348–350] and 20–54% with genital prolapses [351–357]. Up to 13–30% of patients with a rectocele and prolapse have FI, usually to a greater extent [351,358,359].
Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field.
The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.
Clinical examination of prolapse
2009, Progres en Urologie
L’examen clinique demeure l’un des temps fondamentaux de l’évaluation des prolapsus pelviens. Il ne saurait être réduit à l’interrogatoire, qui, seul, ne peut préciser l’importance du prolapsus ni sa localisation. Il apparaît fiable avec la même valeur que les examens complémentaires pour les prolapsus antérieurs et moyens. Il doit être complété par des explorations pour les prolapsus postérieurs. Il ne varie pas en fonction de la journée ni des examinateurs à condition qu’il ait bien été sensibilisé par la position debout.
Physical examination is still very contributing in the evaluation of female pelvic organ prolapse. Related symptoms do predict neither the severity nor the location of the prolapse. The accuracy and the reliability of the physical examination are high for the anterior and middle compartments but insufficient for the evaluation of the posterior compartment, which should include imaging and manometric tests. The physical examination does not show any difference between morning and afternoon and its reliability is independent of the examiner particularly if performed in the patient standing.

View all citing articles on Scopus

: Presented at the Thirty-Second Annual Meeting of the Society of Gynecologic Surgeons, April 3-5, 2006, Tucson, AZ.

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Transactions from the Thirty-Second Annual Scientific Meeting of the Society of Gynecologic SurgeonsPosterior vaginal wall prolapse does not correlate with fecal symptoms or objective measures of anorectal function

Objective

Study design

Results

Conclusion

Section snippets

Methods

Comment

Acknowledgments

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Surg

Am J Obstet Gynecol

Am J Obstet Gynecol

A practical guide to basic anorectal physiology investigations

Contemp Surg

How useful are manometric tests of anorectal functions in the management of defecation disorders?

Am J Gastroenterol

Transactions from the Thirty-Second Annual Scientific Meeting of the Society of Gynecologic Surgeons
Posterior vaginal wall prolapse does not correlate with fecal symptoms or objective measures of anorectal function