High-resolution anorectal manometry for diagnosing obstructed defecation syndrome associated with moderate rectocele compared to healthy individuals.

BACKGROUND: Few studies have investigated healthy female individuals (HFI) and those with obstructed defecation syndrome associated with moderate rectocele in women (MRW), identified using three-dimensional high-resolution anorectal manometry (3D HRAM) parameters that correlate with age stratification. OBJECTIVE: We aimed to explore the clinical diagnostic values of the MRW and HFI groups using 3D HRAM parameters related to age stratification. METHODS: A prospective non-randomized controlled trial involving 128 cases from the MRW (treatment group, 68 cases) and HFI (control group, 60 cases) groups was conducted using 3D HRAM parameters at Tianjin Union Medical Center between January 2017 and June 2022, and patients were divided into two subgroups based on their ages: the ≥50 and < 50 years subgroups. RESULTS: Multivariate binary logistic regression analysis showed that age (P = 0.024) and rectoanal inhibitory reflex (P = 0.001) were independent factors affecting the disease in the MRW group. Compared to the HFI group, the receiver operating characteristic (ROC) curve demonstrated that the 3D HRAM parameters exhibited a higher diagnostic value for age (Youden index = 0.31), urge to defecate (Youden index = 0.24), and rectoanal pressure differential (Youden index = 0.21) in the MRW group. CONCLUSIONS: Compared to the HFI group, the ROC curve of the 3D HRAM parameters suggests that age, urge to defecate, and rectoanal pressure differential in the MRW group have a significant diagnostic value. Because the Youden index is lower, 3D HRAM cannot be considered the gold standard method for diagnosing MRW.

[Imaging of the pelvic floor (MR defecography) : The surgeon's perspective]. / Bildgebung des Beckenbodens (MR-Defäkographie) : Die Sicht der Chirurgie.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD. OBJECTIVES: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches. MATERIALS AND METHODS: A comprehensive literature search was conducted, including current consensus guidelines. RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis. CONCLUSION: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.

Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size.

PURPOSE: This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). METHODS: Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. RESULTS: Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047). CONCLUSION: The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

A possible physiological mechanism of rectocele formation in women.

BACKGROUND: We aimed to determine the anorectal physiological factors associated with rectocele formation. METHODS: Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected. RESULTS: Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011). CONCLUSION: Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.

Rectocele: Correlation Between Defecography and Physical Examination.

IMPORTANCE: There is a lack of consensus regarding the clinical applicability of fluoroscopic defecography in evaluation of pelvic organ prolapse. OBJECTIVES: The aim was to evaluate the association between rectocele on defecography and posterior vaginal wall prolapse (PVWP) on physical examination. The secondary objective was to describe radiologic and clinical predictors of surgical intervention and outcomes. STUDY DESIGN: This was a retrospective review of patients enrolled in a large health maintenance organization who underwent defecography and were examined by a urogynecologist within 12 months. The electronic medical record was reviewed for demographic and clinical variables, including pelvic organ prolapse and defecatory symptoms, physical examination, and surgical intervention through 12 months after initial urogynecologic examination or 12 months after surgery if applicable. RESULTS: One hundred eighty-six patients met inclusion criteria. Of those, 168 (90.3%) had a rectocele on defecography and 31 (16.6%) had PVWP at or beyond the hymen. Rectocele size on defecography was poorly correlated with PVWP stage (spearman ρ = 0.18). Forty patients underwent surgical intervention. Symptoms of splinting, digitation, and stool trapping were associated with surgical intervention (odds ratio, 4.24; 95% confidence interval, 1.59-11.34; P < 0.01) as was advanced PVWP stage ( P < 0.01), while rectocele presence and size on defecography were not. Large rectocele size on defecography was correlated with persistent postoperative defecatory symptoms ( P = 0.02). CONCLUSIONS: We demonstrated a poor correlation between rectocele size on defecography and PVWP stage. Defecatory symptoms (splinting, digitation, stool trapping) and higher PVWP stage were associated with surgical intervention, while rectocele on defecography was not.

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE: It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. METHODS: This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. RESULTS: Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). CONCLUSION: In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Rectoceles: Is There a Correlation Between Presence of Vaginal Prolapse and Radiographic Findings in Symptomatic Women?

BACKGROUND: Constipation is highly prevalent. Women with constipation are evaluated for the presence of vaginal prolapse that may contribute to obstructed defecation syndrome. Defecography can identify anatomic causes of obstructed defecation syndrome (rectocele, intussusception, and enterocele). OBJECTIVE: This study aimed to assess the characteristics of women with obstructed defecation syndrome and radiographic rectoceles with and without posterior vaginal wall prolapse and to characterize the relationship between anatomical abnormalities and dysfunction. DESIGN: This is a retrospective case-control study of women with obstructed defecation syndrome who had radiographic rectoceles on defecography. SETTINGS: Women who presented to a Pelvic Floor Disorders Center were included. PATIENTS: Cases were defined as constipated women with radiographic rectoceles and at least stage II posterior vaginal wall prolapse on examination. Controls were patients with radiographic rectoceles but without posterior vaginal wall prolapse on examination. MAIN OUTCOME MEASURES: Patient characteristics, anorectal testing results, and validated questionnaires were compared between groups. RESULTS: A total of 106 women met inclusion criteria. Women with posterior vaginal wall prolapse (48 (45.3%)) had larger rectoceles on defecography than women without it on examination (3.4 cm vs 3.0 cm, p < 0.01). Women with posterior vaginal wall prolapse on examination were more likely to splint during defecation than women without vaginal wall prolapse (63.8% vs 27.3%, p < 0.01). All other defecatory symptoms, anorectal manometry parameters, and questionnaire responses were similar between groups. LIMITATIONS: This study was limited by its retrospective study design. Our data were taken from a single institution within a center specializing in the treatment of pelvic floor disorders, potentially limiting generalizability. CONCLUSIONS: Patients with constipation, radiographic rectoceles, and vaginal prolapse may differ from those without evidence of prolapse. Patients with vaginal prolapse were more likely to splint to aide evacuation and demonstrated larger rectoceles on defecography. Further studies are needed to determine whether constipation causes progression along this continuum or whether progression of prolapse is a cause of worsening defecatory dysfunction. See Video Abstract at http://links.lww.com/DCR/B626. RECTOCELES EXISTE UNA CORRELACIN ENTRE LA PRESENCIA DE PROLAPSO VAGINAL Y LOS HALLAZGOS RADIOLGICOS EN MUJERES SINTOMTICAS: ANTECEDENTES:El estreñimiento es una enfermedad muy prevalente. Las mujeres con estreñimiento se evalúan para detectar la presencia de prolapso vaginal que pueda contribuir al síndrome de defecación obstructiva. La defecografía puede identificar las causas anatómicas del síndrome de defecación obstructiva (rectocele, invaginación intestinal (intususcepción) y enterocele).OBJETIVO:Este estudio tiene como objetivo evaluar las características de las mujeres con síndrome de defecación obstructiva y la presencia de rectocele como hallazgo radiológico, con y sin prolapso de la pared vaginal posterior, y caracterizar la relación entre las anomalías anatómicas y la presencia de disfunción.DISEÑO:Este es un estudio retrospectivo de casos y controles, de mujeres con síndrome de defecación obstructiva, que tenían rectocele como hallazgo radiológico en una defecografía.MARCO:Mujeres que acudieron a un Centro de Trastornos del Piso Pélvico.PACIENTES:Los casos fueron definidos como mujeres con estreñimiento con hallazgos radiológicos de rectocele, con al menos un prolapso estadio II de la pared vaginal posterio, en el examen físico. Los controles fueron pacientes con solo rectocele por hallazgos radiológicos, sin prolapso de la pared vaginal posterior en el examen físico.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon entre los grupos: las características de las pacientes, los resultados de las pruebas diagnósticas anorrectales y los cuestionarios validados.RESULTADOS:Un total de 106 mujeres cumplieron los criterios de inclusión. Las mujeres con prolapso de la pared vaginal posterior 48 (45,3%) tenían rectoceles de mayor tamaño en la defecografía en comparación con las mujeres sin rectocele en el examen físico (3,4 cm versus 3,0 cm, p <0,01). Las mujeres con prolapso de la pared vaginal posterior en el examen, tenían una mayor probabilidad de que les fuera necesario ejercer una maniobra de presión manual o digital del periné durante la defecación, comparado con las mujeres sin rectocele clínico (63,8% versus 27,3%, p <0,01). Todos los demás síntomas defecatorios, los parámetros de la manometría anorrectal, y las respuestas al cuestionario fueron similares entre los grupos.LIMITACIONES:Estudio retrospectivo. Los datos fueron obtenidos de la base de datos de un centro especializado en el tratamiento de los trastornos del piso pélvico lo que potencialmente limita generalizar.CONCLUSIONES:Las pacientes con estreñimiento, rectocele como hallazgo radiológico, y prolapso vaginal pueden ser diferentes de aquellas sin evidencia de prolapso. Las pacientes con prolapso vaginal, tenían una mayor probabilidad de que les fuera necesario ejercer maniobras manuales o digitales de presión a nivel del periné para ayudar a la evacuación, y tenían rectoceles de mayor tamaño en la defecografía. Se necesitan más estudios para determinar si el estreñimiento causa que el rectocele aumente progresivamente de tamaño, empeorando la disfunción defecatoria. Consulte Video Resumen en http://links.lww.com/DCR/B626.

X-ray video defaecography is superior to magnetic resonance defaecography in the imaging of defaecation disorders.

AIM: The aim of this work was to study the technical success and diagnostic capability of magnetic resonance defaecography (MRD) compared with video defaecography (VD). METHOD: Sixty four women with defaecation disorders underwent both MRD and x-ray VD over 1 year. The assessment by two radiologists in consensus was retrospective and blinded. The technical success of straining and evacuation was evaluated subjectively. The presence of enterocele, intussusception, rectocele and dyssynergic defaecation was analysed according to established criteria, with VD as the standard of reference. RESULTS: It was found that 62/64 (96.9%) VD studies were technically fully diagnostic compared with 29/64 (45.3%) for MRD. The number of partially diagnostic studies was 1/64 (1.6%) for VD versus 21/64 (32.8%) for MRD, with 1/64 (1.6%) (VD) and 14/64 (21.9%) (MRD) being nondiagnostic. Thirty enteroceles were observed by VD compared with seven in MRD with moderate agreement (κ = 0.41). Altogether 53 intussusceptions were observed by VD compared with 27 by MRD with poor agreement (κ = -0.10 and κ = 0.02 in recto-rectal and recto-anal intussusception, respectively). Moderate agreement (κ = 0.47) was observed in diagnosing rectocele, with 47 cases by VD and 29 by MRD. Dyssynergic defaecation was observed in three patients by VD and in 11 patients by MRD, with slight agreement (κ = 0.14). CONCLUSION: The technical success and diagnostic capabilities of VD are better than those of MRD. VD remains the method of choice in the imaging of defaecation disorders.

Rectal-vaginal pressure gradient in patients with pelvic organ prolapse and symptomatic rectocele.

OBJECTIVE: The aim of this study is to examine the relationship between rectal-vaginal pressure and symptomatic rectocele in patients with pelvic organ prolapse (POP). METHOD: Patients with posterior vaginal prolapse staged III or IV in accordance with the POP Quantitation classification method who were scheduled for pelvic floor reconstructive surgery in the years 2016-2019 were included in the study. Rectocele was diagnosed using translabial ultrasound, and obstructed defecation (OD) was diagnosed in accordance with the Roma IV diagnostic criteria. Both rectal and vaginal pressure were measured using peritron manometers at maximum Vasalva. To ensure stability, the test was performed three times with each patient. RESULTS: A total of 217 patients were enrolled in this study. True rectocele was diagnosed in 68 patients at a main rectal ampulla depth of 19 mm. Furthermore, 36 patients were diagnosed with OD. Symptomatic rectocele was significantly associated with older age (p < 0.01), a higher OD symptom score (p < 0.001), and a lower grade of apical prolapse (p < 0.001). The rectal-vaginal pressure gradient was higher in patients with symptomatic rectocele (37.4 ± 11.7 cm H2O) compared with patients with asymptomatic rectocele (16.9 ± 8.4 cm H2O, p < 0.001), and patients without rectocele (17.1 ± 9.2 cm H2O, p < 0.001). CONCLUSION: The rectal-vaginal pressure gradient was found to be a risk factor for symptomatic rectocele in patients with POP. A rectal-vaginal pressure gradient of > 27.5 cm H2O was suggested as the cut-off point of the elevated pressure gradient.

Is perineal hypermobility an independent predictor of obstructive defecation?

INTRODUCTION AND HYPOTHESIS: Symptoms of obstructed defecation (OD) and anatomical abnormalities of the posterior compartment are prevalent in urogynecological patients. The aim of this study was to determine whether perineal hypermobility is an independent predictor of OD, as is the case for rectocele, enterocele and rectal intussusception. METHODS: This is a retrospective study of 2447 women attending a tertiary urodynamic center between September 2011 and December 2016. The assessment included a structured interview, urodynamic testing, a clinical examination and 4D transperineal ultrasound. After exclusion of previous pelvic floor surgery and defined anatomical abnormalities of the anorectum, 796 patients were left for analysis. Perineal hypermobility was defined as rectal descent ≥ 15 mm below the symphysis pubis, determined in stored ultrasound volume datasets offline, using proprietary software, blinded to all other data. Any association between perineal hypermobility and symptoms of obstructed defecation was tested for by chi-square (X2) test. RESULTS: For the 796 patients analyzed, median age was 52 (range, 16-88) years with a mean BMI of 27 (range, 15-64) kg/m2. Average vaginal parity was two (range, 0-8). Reported OD symptoms in this group included sensation of incomplete emptying in 335 (42%), straining at stool in 300 (37%) and digitation in 83 (10%). At least one of those symptoms was reported by 424 (53%) women; 153 showed perineal hypermobility. There was no significant association between perineal hypermobility and OD symptoms on univariate testing. CONCLUSIONS: We found no evidence of an independent association between perineal hypermobility and obstructed defecation.

Does the presence of a true radiological rectocele increase the likelihood of symptoms of prolapse?

INTRODUCTION AND HYPOTHESIS: Posterior compartment prolapse is commonly due to a 'true' rectocele, i.e., a diverticulum of the rectal ampulla. This condition is associated with symptoms of obstructed defecation and may contribute to prolapse symptoms. We tested the hypothesis: 'A true rectocele is an independent predictor of symptoms of prolapse.' METHODS: This was a retrospective cohort study of patients presenting to a urogynecology unit for symptoms of pelvic floor dysfunction between September 2011 and June 2016. Assessment included a structured interview, POP-Q examination and 4D TLUS. Ultrasound volume data were acquired on Valsalva. Offline measurements were performed by analysis of stored volume data sets at a later date, blinded to all clinical data. RESULTS: One hundred six patients were excluded because of incomplete data. Of the remainder, Bp was the most distal point on POP-Q in 348. Statistical analysis was performed on this cohort. Mean age was 60 (33-86) years and mean BMI 31 (18-55) kg/m². One hundred fifty-three patients (44%) presented with symptoms of prolapse; 272 were diagnosed with a true rectocele on TLUS. Bp on POP-Q and true rectocele on TLUS were both significantly associated with prolapse symptoms; however, on multivariate analysis the latter became nonsignificant (p = 0.059). Receiver-operating characteristic (ROC) analysis confirmed that the presence of a true rectocele on TLUS did not contribute significantly to symptoms of prolapse (AUC 0.66 for model with rectocele, AUC 0.65 without). CONCLUSIONS: The presence of a true rectocele on TLUS does not seem to contribute substantially to the manifestation of clinical symptoms of prolapse.

Three years prospective clinical and radiologic follow-up of laparoscopic sacrocolpoperineopexy.

BACKGROUND: When Rectocele is part of a complex pelvic organ prolapse, a full repair is recommended. The aim of this study was to evaluate the clinical and radiological results after laparoscopic surgery in patients with symptomatic rectocele and III/IV stage vaginal vault prolapse METHODS: This is a prospective cohort study of women with symptomatic rectoceles and middle compartment prolapse operated on between 2013 and 2015, who underwent a laparoscopic sacrocolpoperineopexy with synthetic Y mesh attached to puborectalis muscles, the anterior and posterior vagina wall and the sacrum. The clinical outcomes measured were symptoms of prolapse, obstructive defecation syndrome and quality of life. Radiological outcomes were distance of the vaginal vault below pubococcigeal line and depth of rectovaginal wall protrusion in dynamic pelvic resonance. RESULTS: 33 patients were included. 32 of them remained asymptomatic after a three years follow-up. Significant differences were shown in the obstructed defecation score and quality of life after 6, 12 and 36 months compared to preoperatively. No differences were identified when the postoperative results were compared. Significant differences were shown in preoperative vaginal vault prolapse (3.2 cms ± 0.8 SD below the pubococcigeal Line) and rectocele size, compared with 1 and 3 years after surgery. There were no significant differences in vaginal vault prolapse when compared after 1 and 3 years. When rectocele size after 1 and 3 years was compared, significant differences were shown, but only one clinical recurrence (3%) was identified after a mean follow-up of 47 months. CONCLUSIONS: Laparoscopic sacrocolpoperineopexy in patients with symptomatic rectocele and III/IV vaginal vault prolapse solves the constipation and obstructed defecation with an excellent quality of life and low clinical recurrences. Radiological deterioration, especially in rectocele size, was identified in the mid-term follow-up without clinical significance.

Is there any association between symptoms and findings on imaging in pelvic floor defaecatory dysfunction? A prospective study.

AIM: To compare features on imaging (integrated total pelvic floor ultrasound (transperineal, transvaginal) and defaecation proctography) with bowel, bladder and vaginal symptoms in pelvic floor defaecatory dysfunction. METHOD: A prospective observational case series of 216 symptomatic women who underwent symptom severity scoring (bowel, bladder and vaginal), integrated total pelvic floor ultrasound and defaecation proctography. Anatomical (rectocele, intussusception, enterocele, cystocele) and functional (co-ordination, evacuation) features were examined. RESULTS: Irrespective of imaging modality, patients with a rectocele had higher International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) scores than patients without. On integrated total pelvic floor ultrasound, ICIQ-VS quality of life scores were higher in those with a rectocele. There was a higher International Consultation on Incontinence Modular Questionnaire - Bowel Symptoms (ICIQ-BS) bowel pattern score in those with a rectocele, and a lower ICIQ-BS bowel pattern and sexual impact score in those with intussusception. Poor co-ordination was associated with increased ICIQ-BS bowel control scores and obstructed defaecation symptom scores. On defaecation proctography, ICIQ-VS symptom scores were lower in patients with poor co-ordination. CONCLUSION: Patients with a rectocele on either imaging modality may have qualitative vaginal symptoms on assessment. In patients with bowel symptoms but no vaginal symptoms, it is not possible to predict which anatomical abnormalities will be present on imaging.

The relationship between obstructed defecation and true rectocele in patients with pelvic organ prolapse.

We aimed to investigate the prevalence of true rectocele and obstructed defecation (OD) in patients with pelvic organ prolapse (POP), to investigate the correlation between true rectocele and OD, and to understand the diagnostic value of translabial ultrasound (TLUS) in the diagnosis of true rectocele. The patients who scheduled for POP surgery were enrolled in this study. Patients who had previous reconstructive pelvic surgery or repair of rectocele were excluded. Birmingham Bowel and Urinary symptoms questionnaires and Longo's obstructed defecation syndrome scoring system were used to assess the bowel symptoms of patients. TLUS was used to evaluate anatomical defects. P value <0.05 was considered statistically significant, and confidence intervals were set at 95%. 279 patients were included into this study. The prevalence rate of OD was 43%, and the average value of ODS score was 6.67. 17% patients presented straining at stool, 33% presented incomplete emptying, 13% presented digitations, and 12% required laxatives or enema. The prevalence rate of true rectocele was 23%. Defecation symptoms were significantly correlated with age, levator-ani hiatus, levator-ani muscle injury and true rectocele. Logistic regression showed that true rectocele and increased levator-ani hiatus were independent risk factors of OD. True rectocele was significantly correlated with straining at stool, digitation, incomplete emptying and requirement of laxatives or enema.In POP patients, the prevalence rate of true rectocele and OD was 23% and 43%, respectively. True rectocele was related to OD. TLUS was a valuable approach in anatomical evaluation of POP.

Descent and hypermobility of the rectum in women with obstructed defecation symptoms.

INTRODUCTION AND HYPOTHESIS: Obstructed defecation symptoms (ODS) are common in women; however, the key underlying anatomic factors remain poorly understood. We investigated rectal mobility and support defects in women with and without ODS using pelvic floor ultrasound and MR defecography. METHODS: This prospective case-control study categorized subjects based on questions 7, 8 and 14 on the PFDI-20, which asks about obstructed defecation symptoms. All subjects underwent an interview, examination and pelvic floor ultrasound, and a subset of 16 subjects underwent MR defecography. The cul de sac-to-anorectal junction distance at rest and during maximum strain was measured on ultrasound and MRI images. The 'compression ratio' was calculated by dividing the change in rectovaginal septum length by its rest length to quantify rectal folding and hypermobility during dynamic imaging and to correlate with ODS. RESULTS: Sixty-two women were recruited, 32 cases and 30 controls. There were no statistically significant differences in age, parity, BMI or stage of rectocele between groups. A threshold analysis indicated the risk of ODS was 32 times greater (OR 32.5, 95% CI 4.8-217.1, p = 0.0003) among women with a high compression ratio (≥ 14) compared with those with a low compression ratio (< 14) after controlling for age, BMI, parity, stool type and BM frequency. CONCLUSIONS: Female ODS are associated with distinct alterations in rectal mobility and support that can be clearly observed on dynamic ultrasound. The defects in rectal support were quantifiable using a compression ratio metric, and these defects strongly predicted the likelihood of symptoms; interestingly, the presence or degree of rectocele defects played no role. These findings may provide new insight into the anatomic factors underlying female ODS.

Motion of the vaginal apex during strain and defecation.

INTRODUCTION AND HYPOTHESIS: Although the main function of the suspensory ligaments of the vaginal apex is to prevent its descent toward the vaginal introitus, there remains limited information regarding its normal physiological motion. This study was aimed at quantifying the motion of the non-prolapsed vaginal apex during strain and defecation maneuvers. METHODS: This study represents a sub-analysis of a parent study that was aimed at evaluating rectal mobility with regard to obstructed defecation symptoms. Patients with normal apical vaginal support who had undergone MR defecography were entered into the study. For each patient, midsagittal images at rest, maximum strain, and maximum evacuation were utilized. The location of the cervicovaginal junction, S4-S5 intervertebral disc, sacral promontory, and hymen were identified. Vectors were calculated from each of these landmarks to the vaginal apex to compare vector angles and magnitudes across subjects. RESULTS: Twelve patients were included in this study. At rest, the vagina extends from the hymen, which is inferior and posterior to the inferior symphysis pubis, to the vaginal apex at an angle of 45.2° ± 14.5° relative to the pubococcygeal line. This angle became more acute with strain and even more so during maximum evacuation (14.1° ± 9.0°, p < 0.001). Differences in the vector magnitude, although not statistically significant, showed a trend indicating shorter lengths with maximum evacuation. CONCLUSIONS: The vaginal apex is a highly mobile structure demonstrating significantly more mobility during defecation compared with strain. The data obtained contradict the general perception that the vaginal apex is relatively fixed within the pelvis of normally supported women.

Value of colpo-cysto-entero defecography to predict the post operative results in patients with obstructed defecation.

INTRODUCTION: The conventional video colpo-cysto entero defecography describing the morpho- functional imaging features, physiological and pathological of the recto-anal region and pelvic floor . It represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions. MATERIALS AND METHODS: Between January 2010 to January 2013 88 patients underwent STARR procedure for obstructed defecation syndrome (ODS) caused by single rectocele or internal rectal intussusception. We retrospectively analyzed the collected data,in particular we reviewed the defecography results before surgery. RESULTS: At defecography imaging , 30 patients (34 %) had an anal canal opening between 0 and 5 seconds, 44 (50 %) between 6 and 10 seconds and 14 patients (16 %) over 10 seconds at defecography imaging. The defecography showed an enterocele in 30 patients (34 %) The enterocele was functional in 25 (28,4 %) and stable in 5 (5,6 %) patients. 53 patients have a II° rectocele (60,2 %) and 35 patients a III° rectocele (39,7 %). The average preoperative ODS score was 14 . The average ODS score revaluated at 1 year was 3.1, 4.3 at 3 years an 6,4 after 5 years. The improvement of the ODS score was lower in the subgroup of patients presenting a slow opening of the anal canal (> 10 sec): 7.5 at one year, 9.1 at 3 years and 11 after 5 years follow-up. Also in the subgroup of patients with stable enterocele (5,6 %) the improvement was less evident: 6.7 at 1 year, 8 at 3 years and 9.7 after 5 years follow-up. DISCUSSION AND CONCLUSION: We have observed that a coexistence of a long opening time of the anal canal and / or the presence of a stable enterocele are factors that significantly reduce the effectiveness of the surgery leading over time to ODS score values close to those present before surgery. In the fisrt case we suggest a pre and post-operative perineal physiotherapy, in the second case a Dougla's platsy KEY WORDS: Defecography, Obstructed defecation syndrome, Rectocele, Recto-anal prolapse.

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

BACKGROUND: Obstructed 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. AIM: To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani's procedure with stapled posterior rectal wall resection. METHODS: A 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. RESULTS: In 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. CONCLUSION: Khubchandani's procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Long-term subjective, clinical and sonographic outcomes after native-tissue and mesh-augmented posterior colporrhaphy.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to describe long-term outcomes after posterior colporrhaphy with and without mesh augmentation. METHODS: This was a retrospective study including 93 patients after posterior colporrhaphy (native tissue in 39 and synthetic mesh augmented in 54). The indication was symptoms of prolapse with clinical posterior vaginal wall prolapse. Mesh augmentation and concomitant prolapse operations were performed at the surgeon's discretion. Patients underwent interview, clinical examination and 4D pelvic floor ultrasound. Imaging analysis was done with the reviewer blinded against all other data. Generalized linear modeling was used to compare groups with logistic regression for binary and linear regression for continuous outcomes. RESULTS: Patients were seen on average 5.3 years after surgery and described persistent symptoms of prolapse in 32% and of obstructed defecation in 33%. Clinical recurrence (Bp ≥ -1) was seen in 20%, while sonographic recurrence (rectal ampulla descent to ≥ 15 mm below the symphysis pubis) was noted in 12%. A true rectocele was diagnosed in 33% of patients. No major differences in outcomes were found between those who underwent native tissue and those who had a mesh-augmented repair. CONCLUSIONS: Mesh augmentation was not superior to native tissue posterior colporrhaphy, and both were only moderately effective in eliminating a true rectocele and symptoms of obstructed defecation 5 years after reconstructive surgery.