Posterior pelvic floor dysfunction: there is an immediate need to standardize terminology

Abstract

Should the terms “rectocele,” “posterior vaginal wall descent,” “posterior vaginal wall prolapse,” or even “posterior colpocele” be used as if they were synonyms? Personally, I would very much prefer the term “posterior colpocele” because of its simplicity and conciseness. We performed a Med-line search on the US National Health Library system “Pubmed” for the aforementioned terms. With the term “posterior colpocele,” you can identify 5 papers, 16 can be found with the term “posterior vaginal wall descent,” 127 with “posterior vaginal wall prolapse,” and finally, 605 (six-hundred-and-five!) with the term “rectocele.” Such a huge disproportion confirms inappropriate use of these terms. In a gynecological physical examination, whatever the classification system you are adopting, you can simply observe the vaginal wall. In case of descent, you will just see a “colpocele,” anterior or posterior. A rectal examination or imaging study will tell you what is behind it. At present, defecography is the most widespread and clinically relevant diagnostic tool in describing what is behind the posterior vaginal wall. Radiologists have developed their own defecographic definitions for rectocele. Mellgren’s classification of rectocele into three different degrees according to its depth in centimeters is the most popular [17]. Moreover, if you look at Mellgren’s series of 2.816 defecographic studies in symptomatic subjects, a rectocele was identified in 27% of cases, but an enterocele was observed in 19% of patients, an intussusception in 31%, a rectal prolapse in 13%, and 21% had mixed findings. Of interest, 23% of those symptomatic subjects ended with a normal defecographic study. Previous studies have shown that a rectocele can be radiologically demonstrated in up to 80% of asymptomatic subjects [23], and up to 16% can be deeper than 2 cm [5]. Thus, rectocele does not necessarily relate to bowel dysfunction, and it is clear now that it also scarcely relates to posterior colpocele. Kenton et al. (1999) have investigated with defecography 98 women undergoing surgery for vaginal prolapse [13]. A rectocele was identified in 78% of women, but there was no relationship between the degree of posterior vaginal wall prolapse and the presence of a rectocele. Therefore, we should start adopting appropriate terms for appropriate conditions. More importantly, correct terminology is necessary for interdisciplinary dialogue. As we all know, gynecological repair of the posterior vaginal wall has a very long tradition. The gynecological literature on posterior vaginal wall repair shows an overall anatomical efficacity ranging from 76 to 96% [7]. In 1997, Kahn and Stanton first have raised the question of the functional impact of transvaginal surgery on bowel and sexual function, demonstrating a detrimental effect on both. All the gynecological series on the posterior site-specific fascial repair report no significant detrimental effect on Int Urogynecol J (2007) 18:369–371 DOI 10.1007/s00192-006-0300-x