POSTERIOR
COMPARTMENT
PROLAPSE:
WHEN TO DO
WHAT?
Dr EW Henn
SASOG May 2014
T: +27(0)51 401 9111 | [email protected] | www.ufs.ac.za
CONTENTS
•
•
•
•
•
•
•
Introduction
How much
Fundamentals
Roots
Line of attack
What to do
What transpires
T: +27(0)51 401 9111 | [email protected] | www.ufs.ac.za
INTRODUCTION
• Posterior vaginal wall disorders:
Enterocele
Rectocele
Perineal descent/hernia
Intussusception
Rectal prolapse
• Anatomy/function
• Trans-disciplinary
INTRODUCTION:
POSTERIOR PELVIC ORGAN PROLAPSE (POP)
• Gynaecological literature
Definition
Outcomes
• Colorectal literature
Definition
Outcomes
EPIDEMIOLOGY
• Pelvic floor disorders are increasing Luber,KM 2011
• Parous women:
40% asymptomatic Walters, MD 1993
• Nulliparous women:
80% asymptomatic (defecogram) Shorvon, PJ 1999
12% asymptomatic (ultrasound) Dietz, HP 2005
• Females: Males = 10:1
Males mostly after prostatectomy
Halverson, AL 2001
EPIDEMIOLOGY
• Advanced posterior POP mostly not isolated
 Enterocele 60% Ortega, M 2011
• POP repairs general: ≥ 50% posterior Wu, JM 2011
• Surgery:
 Isolated rectoceles uncommon (7%) Olsen, AL 1997
 Cystocele:rectocele = 60:40 (stage ≥ 3) de Tayrac, R 2008
BASIC SCIENCE
• Normal support multifaceted:
Pelvic diaphragm
Endopelvic fascia
Rectovaginal septum
Perineum
BASIC SCIENCE: PELVIC DIAPHRAGM
• Pelvic diaphragm:
 Levator ani & coccygeus
Primal pictures
BASIC SCIENCE: PELVIC DIAPHRAGM
• Levator plate:
 Posterior insertion (midline raphe)
 Tonic state
 Elevation achieved
 Levator hiatus
• Balancing of forces
BASIC SCIENCES: ENDOPELVIC FASCIA
• Levels of support (DeLancey)
 Level I
 Level II
 Level III
• Condensations
BASIC SCIENCES: RECTOVAGINAL SEPTUM
PERINEAL MEMBRANE
PATHOGENESIS
• Often combinations
 Reflected in epidemiological data
• Posterior vaginal supports: Distal, mid, proximal
 Distal vagina: perineal membrane
DeLancey, JO 1999
PATHOGENESIS
 Midvagina: endopelvic fascia and rectovaginal septum
PATHOGENESIS
 Midvagina: levator ani (injury/dysfunction)
• Levator plate
• Levator hiatus
• Genital hiatus
• Level II displacement
PATHOGENESIS
 Proximal vagina: level I support defects
• Apex (culdocele co-exist) Nichols, DH 1996
• Paracolpium defects
 Rectal defects: circular muscle fibers
• Anterior rectal wall
• Separation
• Pressure effect
Brunenieks,I 2013
CLINICAL APPROACH
• Symptomatic evaluation
 Management must be individualised
 General pelvic floor dysfunction
Bulge
Bladder
Bowel
Dyspareunia
Daily activities
• Validated questionnaires
CLINICAL SYMPTOMS
• Rectocele:
 Majority asymptomatic (80%) for bulge Kelvin, FM 1994
 Co-existing constipation 75% Mollen, RG 1996
• Descent:
 Apical/perineal = 10 marker bulge symptoms
CLINICAL SYMPTOMS
• Typical symptoms:
o Chronic constipation
o Incomplete bowel emptying
o ODS
o Defecatory pain
o Anal incontinence
Pescatori, M 2011
CLINICAL SYMPTOMS
• Relationship between size and symptoms?
 General POP symptoms leading edge hymen Swift, SE 2003
 Rectocele
Most literature = weak correlation
depth defect & bowel dysfunction
• Strongest correlating symptom = ODS
 Especially if Bp ≥ 0 Saks, EK 2010
 Especially if perineal descent present D’Amico DF, 2000
CLINICAL APPROACH: OBSTRUCTED DEFECATION
• ODS: Rule out
 Proximal cancer
 Intussusception
 Slow transit constipation
 IBS
 Anismus
CLINICAL SYMPTOMS: BLADDER
• Often seen in posterior POP (urge-obstruct)
• Not supported in urodynamic literature
• Universitas:
o Review 119 repairs
o Follow up median 17 months
o OAB resolved in 65%
• Possible mechanism:
 Obstructed micturition
CLINICAL EVALUATION
• Visual inspection
 Rest
 Cough
 Valsalva
• Hymenal ring
• Perineal descent
• Rectal prolapse
CLINICAL EVALUATION
• Remember:
o 3 compartments
o 3 levels
• Rectovaginal examination
 Enterocele?
• Rectal examination
SPECIAL INVESTIGATIONS: IMAGING
• Defecography:
 Conventional
 MRI
• Ultrasound:
 Perineal
 Endovaginal
 Endoanal
SPECIAL INVESTIGATIONS: IMAGING
• Ultrasound vs clinical:
o Moderate-good correlation Eisenberg,V 2011 ; Zhang, X 2013
• Defecogram vs clinical:
o Good correlation Konstantinovic,ML 2010
• MRI vs clinical:
o Good correlation Brocker,K 2010
• Imaging superior when array defects present
SPECIAL INVESTIGATIONS: IMAGING
• Clinical value of imaging (posterior)
 Under investigation
 Not routinely recommended Richardson,ML 2012
• Universitas:
o Perineal ultrasound: effect clinical management
o N=85
o RCT
o Management altered in 36%
o Most pronounced = posterior compartment
SPECIAL INVESTIGATIONS
• Consider:
 Anal manometry
 EMG
 Nerve conduction studies
 Colonic transit time
POSTERIOR PROLAPSE: MUCH ADO ABOUT NOTHING?
”ADVICE IS WHAT WE ASK FOR WHEN WE ALREADY
KNOW THE ANSWER BUT WISH WE DIDN'T. ”
— ERICA JONG
POSTERIOR PROLAPSE:
WHEN TO DO WHAT?
• Individualise:
 Symptoms not necessarily from specific compartment
 Often >1 compartment affected
 Cannot evaluate & manage in isolation
 Symptoms often co-exist in different compartments
 Multidisciplinary approach
 Surgery alone does not cure pelvic floor dysfunction in all
cases
• Define:
 Treatment goals
POSTERIOR PROLAPSE: CONSERVATIVE
• Lifestyle
• Underlying co-morbidities and Rx
• Diet
• Stool management
• Exercise
• Multidisciplinary
POSTERIOR PROLAPSE: CONSERVATIVE
• Pessaries:
 Relief of bulge
 Improvement all domains Abdool,Z 2011
 Success at 1 month = long term predictor Lone,F 2011
 Unsuccessful fitting:
o Younger women
o Discomfort
o Large genital hiatus-short vagina Geoffrion,R 2013
POSTERIOR PROLAPSE: CONSERVATIVE
• Biofeedback:
 Conflicting results
 Likely benefit:
o Dyssenergic defecation
(anismus)
POSTERIOR PROLAPSE: SURGERY
• When to do what?
 Clearly define surgical goals
 Patient = paramount
 Objective evidence (own)
 Avoid grey areas
 ACOG 2011
Only specific symptom = bulge
(level A)
POSTERIOR PROLAPSE: SURGERY
Indication for surgery:
• Literature:
 Very debateable
Disciplinary variation
 Criteria:
Size, emptying failure, digitation
• Universitas:
Symptomatic rectocele (bulge, ODS, OAB)
Failed conservative management
POSTERIOR PROLAPSE: SURGERY
Route of surgery:
• Surgeons = anal
 Focus: improve emptying & constipation symptoms
• Gynaecologists = vaginal
 Focus: improve pressure/bulge & sexual symptoms
• Options:
≥ 19 described procedures for rectocele
• Comparison = difficult (methodology)
POSTERIOR PROLAPSE: SURGERY
Route of surgery:
• No clear evidence which procedure is best
• Cochrane review 2013:
 Vaginal repair superior to anal
 No evidence to support mesh
• “Traditional” repair
TRANSANAL REPAIRS
• Techniques differ
Cundiff 2004
• Overall:
 Little uniformity
 Anatomic success 89%
 Dyspareunia 22% (1 study)
 ODS 9%
• STARR:
 No anatomic outcome
 Constipation and ODS scores
improved
 Morbidity 36% (overall)
European STARR registry
TRANSVAGINAL REPAIRS
• Posterior colporrhaphy:
o Anatomic success 83%
o Post-op dyspareunia 18%
o ODS (digitation) 26%
TRANSVAGINAL REPAIRS
• Defect-specific repair:
o Anatomic success 83%
o Post-op dyspareunia 18%
o ODS (digitation) 18%
Karram, Maher 2013
VAGINAL REPAIRS: TISSUE VS MESH
• Cochrane = not recommended
• NICE = not recommended
• Literature:
o RCTs Sand 2001, Paraiso 2006
o No benefit
o Associated risks
• Case series:
o Anatomic success 93-100%
o Short term FU
o Complication varies
ABDOMINAL REPAIRS
• Sacrocolpoperineopexy:
 Co-existing apical prolapse
 Anatomic success 86%
 Post-op dyspareunia 15%
• Sacrocolpopexy-rectopexy:
 Universitas
 Anatomic success 95%
 Rectocele recurrence beneath mesh 15%
POSTERIOR PROLAPSE IN SOUTH AFRICA
• Survey
 Gynaecologists & urologists
 21% response rate (n=106)
• Findings:
 Gynaecologists
• Tissue repairs 63%
• Mesh kits 17%
 Urologists
• Tissue repairs 30%
• Mesh kits 42%
Adam, A 2011
POSTERIOR PROLAPSE: UNIVERSITAS
• Rectocele plication
– Often combined with perineal repair
– Technique
POSTERIOR PROLAPSE: UNIVERSITAS
POSTERIOR PROLAPSE: UNIVERSITAS
• Rectocele plication outcomes:
o Case series retrospective
o N=67
o Mean follow up 21 months
o Anatomic success 90%
o Post-op dyspareunia 14%
o ODS 11%
o OAB treated 65%
SUMMARY: WHEN TO DO WHAT?
• Appreciate anatomy and epidemiology
• Assessment holistic
 Patient & Pelvic floor
Goal
directed
management
Individualise
management
Optimal
outcome
Thank You
Dankie
T: +27(0)51 401 9111 | [email protected] | www.ufs.ac.za