The role of the MR-fluoroscopy in the diagnosis and staging of the pelvic organ prolapse.

INTRODUCTION: The aim of the study is to investigate the efficacy of the magnetic resonance fluoroscopy in the diagnosis and staging of the pelvic prolapse. MATERIALS AND METHODS: The study consisted of 46 patients who were known to have pelvic prolapses from their vaginal examination. Thirty women who underwent vaginal exam and shown not have pelvic prolapse were selected as a control group. Firstly, pelvic sagittal FSE T2 weighted images of all the women were acquired in 0.3 T open MR equipment than sagittal MR-fluoroscopic images using spoiled gradient echo sequences were obtained during pelvic strain. Physical examination and MR-fluoroscopic findings were compared. The relationship between the stages of prolapse established by both of the methods was evaluated statistically with Pearson's correlation analysis. RESULTS: Physical examination and MR findings were very concordant in the diagnosis of pelvic prolapse and statistical correlations in the stages of prolapse were established between both of the methods (P<0.01 for anterior and middle comportment, P<0.05 for posterior comportment). CONCLUSION: We conclude that MR-fluoroscopy is a non-invasive, easily applied, dynamic useful method without contrast agent in the diagnosis and staging of pelvic organ prolapse.

Rectoanal inhibition and rectocele: physiology versus categorization.

Some authors divide rectoceles into those with chronic evacuatory difficulty and normal genital position (type 1) and those with associated pelvic organ prolapse (type 2). This study assessed whether there are physiological differences between these two clinical rectocele types. Female patients were assessed by conventional anorectal manometry, vector manometry, parametric assessment of the rectoanal inhibitory reflex (RAIR), and defecography. Subjects included 33 volunteer controls without anorectal disease, 14 patients with type I rectocele, and 26 patients with type II rectocele. Significant differences were noted for resting pressure measurements (maximal resting anal pressure and vector volume) between rectocele types and between type I patients and controls. Significant differences were noted for squeeze parameters (maximal squeeze pressure and vector volume) only between rectocele types. There were minimal differences in parameters of the RAIR, with a reduced slope of inhibition in the proximal sphincter for both rectocele groups and a reduced maximal inhibitory pressure in the intermediate and distal sphincter of type 1 rectocele patients. There were no differences in transient excitation of the pressure wave during the RAIR reflex to account for pressure variations with no measured differences in rectocele depth (type 1, 2.87 +/- 0.7 cm; type 2, 2.84 +/- 1.4 cm) There are few physiological differences between the different clinical categories of rectocele patients based on the presence or absence of associated genital prolapse.

[Pelvic organ prolapse]. / Deszensus und Prolaps.

Pelvic organ prolapse of the female is a common disease with age dependent increase in incidence. The committee for standardisation of the International Continence Society recently suggested to avoid classical terms such as cystocele, rectocele or enterocele for the description of prolapse and to replace them by defined landmarks. The "Pelvic Organ Prolapse Quantification" (POPQ) was developed and five different grades of prolapse were defined. This is a true gain for scientific documentation but needs some effort to be implemented in routine practical work. Previous normal vaginal delivery is statistically highly correlated with prolapse, followed by climacteric involution, constitutional factors, physical work, chronic bronchitis, and overweight respectively. The diagnosis is confirmed by clinical examination. Defects of the supportive structures can be precisely assessed with dynamic magnetic resonance imaging. Time will show whether this costly method will become part of routine diagnostic procedures. A patient with moderate prolapse or few complaints may be treated conservatively with pelvic floor training or electrotherapy. Modern pessaries are tried as first line therapy or for patients unwilling to undergo surgery. Local estrogen application should routinely be prescribed for perimenopausal patients. In the last decade laparoscopic techniques have been established in addition to standard methods of pelvic floor reconstruction. These techniques do not follow a new surgical strategy but realise the minimal invasive approach to established methods of pelvic floor reconstruction. Of note, laparoscopic fixation is very convenient for young women who want to preserve their uterus. Long time follow up is not available for most techniques.

The anatomic and functional variability of rectoceles in women.

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.

Posterior vaginal prolapse and bowel function.

OBJECTIVE: This study's objectives were to describe symptoms related to bowel dysfunction in women with uterovaginal prolapse and to compare these symptoms according to extent of posterior vaginal prolapse. STUDY DESIGN: One hundred forty-three women completed a questionnaire assessment of bowel function and underwent standardized physical examination according to the International Continence Society's system for grading uterovaginal prolapse. RESULTS: The mean age was 59.2 years (SD 11.8 years); 78% of the women were postmenopausal. According to the furthest extent of posterior vaginal prolapse at point Bp, 22 (15.5%) were in stage 0, 46 (32.4%) were in stage I, 50 (35.2%) were in stage II, 23 (16.2%) were in stage III, and 1 (0.7%) was in stage IV. Ninety-two percent of women reported having bowel movements at least every other day. When asked whether straining was required for them to have a bowel movement, 38 (26.6%) reported never or rarely, 71 (49.6%) reported sometimes, 20 (14.0%) reported usually, and 14 (9.8%) reported always. When asked whether they ever needed to help stool come out by pushing with a finger in the vagina or rectum, 98 (69.0%) reported never or rarely, 30 (21.1%) reported sometimes, 8 (5.6%) reported usually, and 6 (4.2%) reported always. Twenty-three women (16.1%) had fecal incontinence, with 11 having loss of control of stool less often than once a month and 12 having it more often than once a month. When asked whether to rate how much they were bothered by their bowel function on a scale of 1 to 10, with 1 being not at all and 10 being extremely, 51.7% of women chose 1 to 4, 20.3% chose 5 to 7, and 28% chose >/=8. There were no clinically significant associations between any of the questions related to bowel function and severity of posterior vaginal prolapse. CONCLUSION: Women with uterovaginal prolapse frequently have symptoms related to bowel dysfunction, but this is not associated with the severity of posterior vaginal prolapse.

An anatomic and functional assessment of the discrete defect rectocele repair.

OBJECTIVE: The aim of this study was to describe the anatomic and functional results of the discrete fascial defect rectocele repair. STUDY DESIGN: Sixty-nine women underwent rectocele repair at Duke University Medical Center during a 3-year period beginning January 1, 1994. Repair was limited to reapproximation of discrete defects in the rectovaginal fascia, without levator plication or perineorrhaphy. Outcome measures included Pelvic Organ Prolapse Quantitation measurements, prolapse stage, and a symptom questionnaire. Univariate and nonparametric tests were used as appropriate. RESULTS: Before the operation 46% patients (32/69) reported constipation, 39% (27/69) reported splinting, 32% (22/69) reported tenesmus, and 13% (9/69) reported fecal incontinence. The median preoperative posterior Pelvic Organ Prolapse Quantitation stage was 2 (1-4). Pelvic Organ Prolapse Quantitation stage had improved for all but 2 women at 6 weeks. Eighteen percent (8/43) had recurrent rectoceles at 12 months. Mean values for the points describing the posterior vaginal wall improved >2 cm (P <.0001). Although perineorrhaphy was not performed, the genital hiatus decreased by 2. 3 cm (P <.0001), with no significant change in the length of the perineal body. Functional results mirrored anatomic results, with statistically significant improvements for all symptoms. CONCLUSIONS: The discrete defect rectocele repair provides anatomic correction of rectoceles with alleviation of associated symptoms for most women.