The pelvic floor and genital prolapse : a clinical, physiological and radiological study

Abstract

Objective: To determine the frequency of concomitant colorectal disorders in patients with rectocele, and to assess any such association with rectocele; to investigate if paradoxical sphincter reaction (PSR) is influenced by the rectal filling volume; to investigate if surface electromyography (EMG) is a reliable method for diagnosing PSR; to evaluate the use of defeco-peritoneography (DP) in patients with an unexplained widening of the rectovaginal space at defecography; to study the long-term results after rectocele repair and to evaluate parameters that might influence the outcome; to evaluate pre- and postoperative findings at cysto-defeco-peritoneography (CDP) in patients with genital prolapse.

Methods: EMG of the anal sphincter muscles was carried out and PSR was diagnosed using needle, wire and/or surface electrodes. Defecography was used and further developed with contrast medium intraperitoneally (DP) and in the urinary bladder (CDP). Clinical examination was performed and anorectal manometry, colon transit time and questionnaires were used.

Results: The frequency of PSR in patients with rectocele at defecography was higher (60%) than in patients without rectocele but having other abnormal findings at defecography (24%) (p<0.001). All 18 patients investigated had PSR at EMG in the lying position with an empty rectum. In the sitting position with a rectal balloon filled with 150 ml water, the EMG no longer showed PSR in 7 patients (39%) (p<0.05). In 65 of 71 patients (92%) EMG showed the same result during straining using surface electrodes compared to needle electrodes. In 20/22 patients with an unexplained widening seen at defecography, DP demonstrated that the widening was completely or partly due to a peritoneocele, of which 9 contained bowel (i.e. an enterocele). Long-term follow-up was performed in 24/25 patients 5.1 years after rectocele repair. 75% of patients with preoperative symptoms of pelvic heaviness reported relief of these symptoms. 91 % of patients with preoperative symptoms of rectal emptying difficulties had improved, 48% reported no symptoms at all. All 5 patients with preoperative pathological transit study reported various degrees of rectal emptying difficulties. 3 of 5 patients with preoperative PSR at EMG reported improvement of symptoms of rectal emptying difficulties at long-term follow-up. CDP was performed in 27 patients. At preoperative CDP a rectocele was diagnosed in 23 patients, a cystocele in 24, and a peritoneocele in 11 patients of which 6 contained bowel (i.e. an enterocele). At clinical examination a rectocele was diagnosed in 26 patients, a cystocele in 7 and an enterocele in 2 patients preoperatively. Postoperatively anatomical alterations or correction of anatomical defects were visualized at CDP.

Conclusions: The data support an association between rectocele and PSR. PSR is influenced by the rectal filling volume in some patients. The conventional EMG technique, with the patient in the lying position and with an empty rectum, might therefore overdiagnose this condition. The use of surface electrodes at EMG is a reliable method in diagnosing PSR. DP allows visualization of peritoneoceles in the middle and posterior compartments of the pelvis. Surgery for rectocele is associated with improved symptoms in a majority of patients and improvement is usually sustained long term. Patients with pathological transit study may have a less favorable symptomatic outcome. The clinical significance of PSR needs further studies. CDP is useful as a complement to the clinical assessment of patients with genital prolapse and in the evaluation of surgical outcome.