Obstructed Defecation Research Articles

Avoiding Clustering and Urge in Transanal Surgery for Deep Distal Rectocele

Discrimination between functional and morphological influences in obstructive defecation syndrome is challenging. The predictability of surgical success is still in discussion. Final understanding of the rectally induced variability in colonic motility is still missing, so that morphological changes cannot solely serve as indication. Finally the physiology of the enteric nervous system has to be taken into account in choosing an approach. A modified Sullivan procedure was tested in the treatment of distal deep rectocele with respect to short- and long-term results for complications, obstructive symptoms and explicitly with regard to urge and clustering complaints. Between January 2009 and January 2014, 35 women complaining of obstructive symptoms with distal deep rectocele were operated on in a modified Sullivan technique. There were no intraoperative nor early postoperative complications; 4 weeks postoperatively no urge or clustering was discovered. In a long-term questionnaire, more than 80% of the patients were satisfied with the procedure; the mean obstructive defecations score was lowered by 9 points.

Long-Term Assessment of a Prospective Cohort of Patients Undergoing Laparoscopic Sacrocolpopexy.

To report long-term outcomes after laparoscopic sacrocolpopexy. We conducted a prospective descriptive cohort study on 331 consecutive patients who underwent laparoscopic sacrocolpopexy for symptomatic prolapse (Pelvic Organ Prolapse Quantification [POP-Q] system stage 2 or greater) at one center, with minimum 1.5 years of follow-up by April 30, 2014. Primary outcome measures were Patient Global Impression of Change score and failure at the apex (C≥-1 cm; POP-Q stage 2 or greater). Secondary outcomes were anatomical failure in other compartments, duration of follow-up, occurrence and time point of complications, reinterventions, and functional outcomes by response to a standardized 24-question interview on prolapse and bladder, bowel, and sexual function. Assessment was by an experienced clinician not involved in patient management. The follow-up rate was 84.6% (280/331); 185 of 331 (55.9%) patients were both physically examined and interviewed, and 95 of 331 (25.7%) were interviewed only. The median age at interview was 72 years (interquartile range 13 years), with a follow-up period of 85.5 months (interquartile range 46 months). Approximately 83% (231/280) reported improvement; 5.7% (16/280) were unchanged, 5.7% (16/280) felt slightly worse, and 6.8% (17/280) reported clear deterioration. Anatomical failure at point-C was 8.6% (16/185); anterior (22.2%, 41/185) and posterior (28.6%, 53/185) prolapse were more common than apical prolapse. Of those with level-I anatomical cure, 10.1% (17/185) felt worse; half of them (9/17) because of prolapse in another compartment. The others had urinary problems (41.2%, 7/17), obstructive defecation (11.8%, 2/17), or dyspareunia (11.8%, 2/17). Conversely, the majority of patients with recurrence at the vault (62.5%, 10/16) self-reported to be improved. The reoperation rate was 17.8% (48/270), including 19 (7.0%) for graft-related complications and nine (3.3%) for prolapse. More than four out of five patients (82.5%) felt improved 86 months after laparoscopic sacrocolpopexy. Of those not improved, two thirds had recurrent prolapse; however, typically mid-vaginal. The other third reported urinary or bowel problems or dyspareunia. Reintervention for prolapse was 3.3%. The most common reasons for reoperation were graft-related complications (7.0%) and urinary incontinence (6.7%).

Long-term effect of TST STARR+ for obstructed defecation syndrome

目的： 评价TST STARR+治疗出口梗阻型便秘（ODS）的远期疗效。 方法： 回顾性收集2013年4月至2014年5月期间，江苏省徐州市中心医院肛肠科采用TST STARR+治疗的50例ODS患者手术资料和术后随访结果。全组分别于术后6个月、12个月及随访终点即2018年5月进行门诊或电话随访，随访内容包括术后并发症、症状严重度评分（Longo ODS评分，分值越高、代表症状越严重）和患者满意度[视觉模拟评分法（VAS），非常满意为8~10分，满意为5~7分，基本满意为3~4分，不满意为1~2分]。 结果： 全组患者手术时间平均28.3 min，切除标本壁宽度平均5.3 cm，所有标本组织学检查最深处达肠壁全层。术后住院时间平均8.5 d。有2例（4.0%）术后出现吻合口出血，5例（10.0%）出现急便感或轻度排粪失禁，6例（12.0%）出现肛门坠胀或疼痛。中位随访50（48~61）个月，其中48例（96.0%）完成早期（术后12个月）疗效评价，39例（78.0%）完成远期（术后≥48个月）疗效评价。ODS评分由术前16.3（14.7~17.9）分降至术后6、12和≥48个月的5.0（3.9~6.0）分、5.2（4.0~6.4）分和6.7（4.6~8.7）分，与术前比较，差异均有统计学意义（均P<0.001）；患者满意度VAS评分术后6、12和≥48个月分别为7.4（6.7~8.0）分、7.0（6.3~7.7）分和6.4（5.5~7.3）分。术后ODS症状复发10例（20.0%），其中术后12个月复发3例，随访终点时复发7例。随访终点满意度分级显示：非常满意17例（43.6%），满意9例（23.1%），基本满意5例（12.8%），不满意8例（20.5%），总体有效率为79.5%。 结论： TST STARR+治疗ODS远期疗效满意，但复发率相对较高。.

STARR Operation in Management of Patients with Rectal Intussusception: Short Term Results

Aim: To evaluate the safety and efficacy of stapled transanal rectal resection (STARR), and its short -term outcomes (12- month) in patients with obstructive defectaion caused by rectal intussception. Patients and methods: A prospective observational study was performed including 25 women with rectal intussusception who underwent STARR in the period from April 2017 to March 2018. Data were collected prospectively from standardized questionnaires for the assessment of constipation [constipation scoring system, Longo’s obstructed defecation syndrome (ODS) score system, symptom severity score], patient satisfaction and quality of life (Patient Assessment of Constipation-Quality of Life Questionnaire). Results: The preoperative status, perioperative and postoperative complications at baseline 3, 6 and 12 months were assessed. At a 12-months follow-up, a significant improvement in the constipation scoring system, ODS score system, symptom severity score, and quality of life was observed. The self-reported definitive outcome was excellent in 8 (30%) patients, fairly good in 4 (16%), good in 11 (44%), and poor in 2 (10%). Conclusion: STARR can be performed safely without major morbidity and with very good short-term results in treating patients with obstructed defecation from rectal intussusception

Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations.

Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches. A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery. Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia. Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.

Short term outcome of laparoscopic ventral mesh rectopexy for rectal and complex pelvic organ prolapse: case series.

Laparoscopic ventral mesh rectopexy (LVMR) is a technique gaining more recognition for the management of pelvic floor disorders, such as external rectal prolapse (ERP), high grade internal rectal prolapse (IRP) and rectocele. LVMR also allows correction of coexisted pelvic organ prolapse. This study aimed to evaluate the safety, efficacy and functional outcome of LVMR for rectal and complex pelvic organ prolapse. All patients who underwent LVMR from February 2014 to October 2017 were included into the study. The patients were evaluated preoperatively and three months postoperatively. Surgical complications and functional results in terms of fecal incontinence (measured with the Wexner Incontinence Score= WIS) and constipation (measured with the Wexner Constipation Score= WCS) were analyzed. Thirty (4 males) patients underwent LVMR. Seventeen (56.6%) patients had complex pelvic organ prolapse according to MRI findings. Median operative time and postoperative stay were 110 minutes and 4 days, respectively. No mesh-related complication and recurrence were observed. Before surgery, 21 (70%) patients had complained about symptoms of obstructed defecation. WCS decreased significantly from median 19 to 6 (p <0.001). Preoperative median WIS of 9 patients was 14 and went down to 6 postoperatively (p= 0.008). WCS significantly improved after LVMR in patients with symptomatic rectocele combined with enterocele or sigmoidocele (p= 0.005), and significant improvement was also observed in patients with symptomatic rectocele combined with gynecologic organ prolapse, preoperative median WCS was 18 and the postoperative value fell to 8 (p= 0.005). LVMR is an effective surgical option for rectal and complex pelvic organ prolapse with short-term follow-up.

The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery

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.

Pelvic floor preservation

The pelvic floor in women is a highly vulnerable structure and a complex functional unit. The anatomical and functional defect of this complex system determines a variable association of complaints related to the urinary, genital and low intestinal tracts. Pelvic floor laxity depends on muscle injury and progressive pelvic floor weakening; connective tissue degradation, pelvic denervation and devascularization and anatomic modifications determ a decline in mechanical strength and dyssinergic pelvic floor function, predisposing to prolapsed. Female pelvic organ prolapse (POP), sexual dysfunction, urinary incontinence (UI), chronic obstructive defecation syndrome (OFD), constipation are different faces of pelvic floor dysfunction, and their incidence increases dramatically with age and menopause.The hormonal changes in menopause can cause weakening of the pelvic floor muscles. Pregnancy, childbirth, chronic straining to open bowels and heavy lifting can also weaken pelvic floor muscles, and during menopause incontinence, pelvic organ prolapse, bowel or bladder urgency may become more and more frequent, impairing significantly the quality of life. Pelvic floor exercises have shown to improve incontinence (bladder and bowel), pelvic organ prolapse and urinary urgency: if correctly done, pelvic floor exercises are a strategy to preserve pelvic floor anatomy and function. In aging women, a multitude of factors affects the final result of the pelvic floor preservation or the reconstructive surgery such as aging-associated changes in muscle tone and nerve function or changes in the function of the bladder or of the rectum: an understanding of the underlining functional status of pelvic organs is very important in aging women before proceeding to surgery. Vaginal atrophy is frequent in menopausal women and it also carries a higher risk of complications for pelvic floor reconstruction, particularly when trans-vaginal prostheses are needed. Risk of mesh erosion is higher in women affected by vaginal atrophy, and shrinkage of the prosthetic material can lead to intractable dyspareunia in women with an atrophic vagina. Pelvic floor surgeons frequently use pre- and post-operative administration of local estrogen preparations to overcome such problems. The pelvic floor dysfunction, particularly in elderly women, should be evaluated in a multidisciplinary centres where urologists, gynaecologists and colorectal specialists can interact to manage a complex patient.

Clinical and physiological risk factors for fecal incontinence in chronically constipated women.

Fecal incontinence (FI) and chronic constipation (CC) are disabling symptoms that cause a significant public health problem. The pathophysiology of combined constipation and FI is not fully understood. Our aim was to delineate the clinical, physiological and anatomical factors that may contribute to the association of FI and CC. A retrospective study was performed in a pelvic floor unit in a tertiary medical center. Consecutive female patients diagnosed with CC were included, and further divided into two groups according to the co-occurrence of FI. Demographic characteristics, anorectal physiology (obtained by manometry) and pelvic anatomical pathology (as assessed by dynamic pelvic ultrasound) were recorded and subsequently compared. A total of 267 women were included in the study. Of those, 62 patients (23%) had an associated FI (CCFI). The CCFI group had higher body mass index (BMI) levels and a trend toward younger average age as compared to the group without FI (CCNFI). The number of vaginal and instrumental deliveries was similar in both groups. Anal resting and squeeze pressures were significantly lower in the CCFI group (64 ± 21 vs 48 ± 18, p = 0.004 and 141 ± 136.2 vs. 97.5 ± 38.6, p = 0.02, respectively). Rectal sensation abnormalities were common, but did not differ between both groups. Dyssynergic defecation and rectocele were more common in the CCNFI group (68% vs. 51%, p = 0.04 and 39% vs. 24%, p = 0/045, respectively. Lower anal pressures and higher BMI were found among women with coexisting FI and CC. Pelvic floor anatomical and functional abnormalities are common in women diagnosed with CC and FI, but dyssynergia and diagnosis of significant rectocele, which cause obstructed defecation, were more common in the CCNFI group.

A Minimally Invasive Technique for the 1-Stage Treatment of Complex Pelvic Floor Diseases: Laparoscopic-Pelvic Organ Prolapse Suspension.

The aim of this prospective study was to assess the safety and effectiveness of a new single laparoscopic operation devised to relieve obstructed defecation, gynecologic and urinary symptoms in a large series of female patients with multiorgan pelvic prolapse. We submitted 384 female patients to laparoscopic pelvic organ prolapse suspension operation, a new technique based on suspension of the middle pelvic compartment, by using a polypropylene mesh and followed up 368 of them, with defecography performed 12 months after surgery and a standardized protocol. The 368 patients were followed-up for 36.3 (±4.4) months, Recurrence rate was 4.9% for obstructed defecation syndrome and 3.3% for stress urinary incontinence. Complication rate was 2.9%. The mean period of daily activity resumption was 16.3 days (±4.8 days). Anorectal and urogynecologic symptoms and scores significantly improved after the operation (P < 0.001), with no worsening of anal continence. Incidence of postoperative fecal urgency was 0%. Postoperative defecography showed a significant (P < 0.001) improvement of all parameters in 315 patients (82%). Short Form 36 Health Survey score significantly improved after the operation (P < 0.01). An excellent/good overall Satisfaction Index was reported by 78.0% of patients. In our experience the Laparoscopic-Pelvic Organ Prolapse Suspension seems to be safe and effective as a 1-stage treatment of associated pelvic floor diseases. Randomized studies with an appropriate control group and longer follow-up are now needed to assess the effectiveness of this promising technique.

Khubchandani's procedure combined with stapled posterior rectal wall resection for rectocele.

BACKGROUNDObstructed defecation syndrome (ODS) is a widespread disease in the world. Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection (STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.AIMTo evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani’s procedure with stapled posterior rectal wall resection.METHODSA cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients (group A) underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 51 patients (group B) underwent the STARR procedure. Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.RESULTSIn group A, 42 patients underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min (group A) vs 39.24 ± 6.53 min (group B). Mean hospital stay was 3.15 ± 0.70 d (group A) vs 3.14 ± 0.54 d (group B). Mean blood loss was 10.91 ± 2.52 mL (group A) vs 10.14 ± 1.86 mL (group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was 17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm (group A) vs 4.18 ± 0.95 cm (group B) preoperatively to 1.19 ± 0.43 cm (group A) vs 1.54 ± 0.82 cm (group B) one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients’ (30/34, 88.2%) final outcomes were judged as effective and 4 (4/34, 11.8%) as moderate in group A, whereas in group B, 30 (30/37, 81.1%) patients’ outcomes were judged as effective, 5 (5/37, 13.5%) as moderate, and 2 (2/37, 5.4%) as poor.CONCLUSIONKhubchandani’s procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

The impact of pelvic floor multidisciplinary team on patient management: the experience of a tertiary unit.

PurposePelvic floor dysfunction is a common and heterogenous condition with numerous clinical manifestations, making the optimal management challenging. The traditional single-specialty approach may fail to address its complex nature. Currently, there are no published data on the impact of joint pelvic floor multidisciplinary team (MDT) meetings on patient management.Patients and methodsThis study represents a retrospective analysis of prospectively collected data on female patients discussed at a joint pelvic floor MDT over a 12-month period in a tertiary referral center.ResultsOne hundred fifty-two cases were included with a median age of 55 years (range 18–83) and a BMI of 32 kg/m2 (range 17–58). Lower urinary tract dysfunction was the predominant symptom in 75% (114/152). The pelvic organ prolapse symptom of a vaginal bulge was present in 11% (17/152). All cases of vaginal prolapse were accompanied by either urinary incontinence, 59% (10/17), or obstructive defecation, 41% (7/17). Fecal incontinence was recorded in 10% (15/152). Mesh-related complications were reported in 3% (4/152). The MDT recommended a change in the initial management plan in 20% (31/152) of cases, of whom 80% (25/31) were patients with complex urinary incontinence. The MDT agreed a change in the primary care team in 16% (25/152) of cases.ConclusionThere is an increasing regulatory requirement for patients with pelvic floor dysfunction to be discussed in an MDT setting. Findings demonstrate that joint pelvic floor MDT meetings are feasible and contribute to a change in the management of complex patients.

Post-operative clinical, manometric, and defecographic findings in patients undergoing unsuccessful STARR operation for obstructed defecation

To evaluate the reason for failure of STARR (stapled transanal rectal resection) operation for obstructed defecation. A retrospective study (June 2012-December 2017) was performed using a prospectively maintained database of patients who underwent STARR operation for ODS (obstructed defecation syndrome), complaining of persisting or de novo occurrence of pelvic floor dysfunctions. Postoperative St Mark's and ODS scores were evaluated. A VAS was used to score pelvic pain. Patients' satisfaction was estimated administering the CPGAS (clinical patient grading assessment scale) questionnaire. Objective evaluation was performed by dynamic proctography and anorectal manometry. Ninety patients (83.3% females) operated for ODS using STARR technique were evaluated. Median ODS score was 19 while 20 patients (22%) reported de novo fecal urgency and 4 patients a worsening of their preoperative fecal incontinence. Dynamic proctography performed in 54/90 patients showed a significant (> 3.0cm) rectocele in 19 patients, recto-rectal intussusception in 10 patients incomplete emptying in 24 patients. When compared with internal normal standards, anorectal manometry showed decreased rectal compliance and maximum tolerable volume in patients with urgency. Nine patients reported a persistent postoperative pelvic pain (median VAS score 6). Failure of STARR to treat ODS, documented by persisting ODS symptoms, fecal urgency, or chronic pelvic pain, is often justified by the persistence or de novo onset of alteration of the anorectal anatomy at defecation. This occurs in about half of the patients, but in 40% of the cases who complained of incomplete emptying or incontinence, anatomical abnormalities were not recognized.

Characteristics of women with chronic pelvic pain referred to physiotherapy treatment after multidisciplinary assessment: a cross-sectional study.

Background and aims Chronic pelvic pain (CPP) in women is a complex condition that can seriously impact health and quality of life. Clinical guidelines for CPP place great demands on healthcare professionals, as they require both specialized knowledge about the pelvic area and knowledge of the mechanisms of chronic pain. To ensure best possible assessment and treatment of these women it is important to bring about more knowledge of the special CPP features. The purpose of this paper is to describe the characteristics of women with CPP evaluated at the University Hospital of North Norway, and further referred to physiotherapy. The frequency of having a history of abuse or previous pelvic surgery will also be reported, and analyses performed to investigate if subjective health status differs between women with and without these experiences. Methods We collected cross-sectional data from 62 women with CPP aged 20-65 (mean age 38.0), referred to physiotherapy after assessment by medical specialists. Data were collected by semi-structured interviews for demographic variables and medical history, and self-administered questionnaires on pain intensity, sexual function, urinary incontinence (UI), anal incontinence (AI), obstructed defecation syndrome (ODS), subjective health complaints (SHC) and symptoms of anxiety and depression. Results Pain duration of more than 10 years was reported by 42%, mean pain score was 4.7/10, and analgesics were used weekly by 48%. Previous pelvic or abdominal surgery was reported by 71%, and sick leave >12 weeks the last year by 34%. Reduced sexual desire was reported by 78%, dyspareunia by 73%, UI by 54%, AI by 23%, and obstructed defecation syndrome (ODS) by 34%. More than 90% reported musculoskeletal or pseudoneurologic complaints. Anxiety and depression scores defined as requiring treatment were reported by 40%. Abuse was reported by 50%, and associated with significantly more reports of ODS (p=0.02), more SHC (p=0.02) and higher anxiety scores (p=0.009). Analgesic use and sick leave were significantly higher both among women with a history of abuse (p=0.04 and p=0.005) and among those with previous surgery (p=0.04 and p=0.02). Women with previous surgery reported significantly lower pain intensity during intercourse than those without previous surgery (p=0.008). Conclusions Women with CPP have complex symptoms and high scores for both physical and psychological complaints. Women exposed to abuse have especially high scores related to analgesic use, sick leave, ODS, anxiety and SHC. Women with previous surgery report more analgesic use and sick leave, and lower pain intensity during intercourse, than those without previous surgery. Implications This study illustrates the complexity of CPP and highlights the need for health professionals to have specialized knowledge of the possible features of the condition. Previous abuse seems to be more associated with poor scores on several health outcomes than surgery, but this needs to be investigated further.

Intérêt de la toxine botulinique A dans le traitement des troubles pelvi-périnéaux de la personne âgée

The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly. The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated. Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended. BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.

Altemeier\u2019s procedure for complete rectal prolapse; outcome and function in 43 consecutive female patients

BackgroundThe aim of this retrospective study was to evaluate morbidity, mortality, postoperative function and recurrences in patients treated by Altemeier’s rectosigmoidectomy for complete rectal prolapse in a referral center for pelvic floor functional disorders.MethodsPeri-operative data on 43 consecutive female patients were reviewed. At follow-up any change in pelvic floor function and recurrences were determined. Thirty four patients were assessed at a median interval of 49 (2–135) months, six being deceased for reason not related to the prolapse and three lost to follow-up.ResultsPost-operative complications at 30 days occurred in 18 patients (38%). Major complication occurred in only one patient that was pneumonia with lung failure. Major complications were not related to the ASA score, BMI or age [average age 76.4]. There was no post-operative mortality at 30 days.At long-term follow-up functional results demonstrate a statistically significant decrease in the Obstructive Defecation Syndrome (ODS) score, but no statistically significant changes in the Vaizey score, the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) score and the urinary retention score. ODS score decreased with respect to levatorplasty and the change was statistically significant instead of Vaizey score in which were not.At the same follow-up there were 12 (35%) cases of recurrence with an estimated risk at 48 months of 40%. There were no statistically significant differences between patients with and without recurrence regarding age (p = 0.188), BMI (p = 0.864), ASA score (p = 0.433), previously repaired prolapse (p = 0.398), previous hysterectomy (p = 0.705), length of resected bowel (p = 0.126), and levatorplasty (p = 0.304). Patient satisfaction showed a mean of 8.8 and 6.4 respectively in patients without and with recurrences (p = 0.012).ConclusionsAltemeier’s procedure had in our series low complications rate and no mortality. It offered improved evacuation in constipated patients while didn’t improve fecal and urinary continence. Recurrence of prolapse was 40% at four years.

The Contributions of Internal Intussusception, Irritable Bowel Syndrome, and Pelvic Floor Dyssynergia to Obstructed Defecation Syndrome.

Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms. This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms. Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument. This study was conducted at a tertiary care university medical center (Massachusetts General Hospital). The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016. The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score. Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p < 0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores. The study was limited because it was an observational study from a single center. Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.

Evaluating the efficacy of biofeedback for chronic constipation using the constipation severity instrument and constipation-related quality of life measure

Background: Many studies have described using biofeedback to treat chronic constipation, but few reports have addressed its impact on quality of life (QOL). Objective: The aim was to evaluate the effect of biofeedback with a validated Constipation Severity Instrument (CSI) and Constipation-Related QOL (CRQOL) measure. Design: Prospectively collected data with retrospective analysis. Setting: Tertiary care academic center. Patients and Methods: Patients referred to the Center for Pelvic Physiology with chronic constipation and objective signs of pelvic floor dyssynergia, who received a complete course of biofeedback therapy and returned all of their questionnaires, were enrolled in the study. Questionnaires were given upon initial evaluation, immediately after the complete course of biofeedback, and 6 months later. Main Outcome Measures: Improvement of dyssynergia symptom and QOL by CSI and CRQOL. Sample Size: A total of 25 patients (20 females and 5 males) were included. Results: Overall, 75% of patients reported satisfactory symptom and QOL improvement. CSI total scores decreased after treatment (35.0 vs. 31.0, P = 0.06) and at 6-month follow-up (35.0 vs. 30.0, P = 0.05). Only the obstructive defecation (OD) subscale of CSI improved significantly after treatment (median 21.0 vs. 16.5, P

Innervation of the entire internal anal sphincter in a mouse model of Hirschsprung's disease: a first report.

Impaired function of the internal anal sphincter (IAS) may be implicated in postoperative obstructed defecation (POD) that may complicate Hirschsprung's disease (HD) patients. While innervation of part of the IAS in HD has been reported, accurate details based on anatomic landmarks that can explain the clinical morbidity seen in POD are lacking, and there appear to be no studies that specifically document the innervation of the "entire" IAS in HD. We used endothelin receptor-B knockout mice to represent HD (HD-mice) and C57B6 wild mice as controls (C-mice) to investigate the innervation of the entire IAS to assess the pathophysiology of POD experimentally. The end-point of the longitudinal muscle layer was used to define the border between the IAS and the circular muscle layer (CML). Specimens of anorectum from HD- and C-mice were immunostained with PGP 9.5 and S100 as general nerve markers, nNOS and VIP as parasympathetic nerve markers, TH as a sympathetic nerve marker, and calretinin as a reliable diagnostic marker for HD. Immunostained cells/fibers were quantified using ImageJ. On fluorescence microscopy, PGP 9.5, nNOS, and calretinin were significantly lower in the IAS of HD-mice than in C-mice (p < 0.05, respectively), while there were no significant differences between HD-mice and C-mice for S100, VIP, or TH. We are the first to confirm that the expression of histochemical markers of innervation is abnormal throughout the "entire" IAS in HD-mice. Application of this finding may be beneficial for preventing POD and requires further research.

American Urogynecologic Society Best-Practice Statement on Evaluation of Obstructed Defecation.

The symptoms of constipation and obstructed defecation are common in women with pelvic floor disorders. Female pelvic medicine and reconstructive surgery specialists evaluate and treat women with these symptoms, with the initial consultation often occurring when a woman has the symptom or sign of posterior compartment pelvic organ prolapse (including rectocele or enterocele) or if a rectocele or enterocele is identified in pelvic imaging. This best-practice statement will review techniques used to evaluate constipation and obstructed defecation, with a special focus on the relationship between obstructed defecation, constipation, and pelvic organ prolapse.