POSTERIOR COMPARTMENT PROLAPSE: WHEN TO DO WHAT? … · INTRODUCTION • Posterior vaginal wall...

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POSTERIOR

COMPARTMENT

PROLAPSE:

WHEN TO DO

WHAT? Dr EW Henn

SASOG May 2014


CONTENTS

• Introduction

• How much

• Fundamentals

• Roots

• Line of attack

• What to do

• What transpires

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


• 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


• 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


• Pessaries:

Relief of bulge

Improvement all domains Abdool,Z 2011

Success at 1 month = long term predictor Lone,F 2011

Unsuccessful fitting:

oYounger women

oDiscomfort

o Large genital hiatus-short vagina Geoffrion,R 2013


• Biofeedback:

Conflicting results

Likely benefit:

oDyssenergic 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)


Indication for surgery:

• Literature:

Very debateable

Disciplinary variation

Criteria:

Size, emptying failure, digitation

• Universitas:

Symptomatic rectocele (bulge, ODS, OAB)

Failed conservative management


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)


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 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


Post-op dyspareunia 15%

• Sacrocolpopexy-rectopexy:

Universitas


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


• Rectocele plication outcomes:

o Case series retrospective

o N=67

o Mean follow up 21 months



o ODS 11%

o OAB treated 65%

SUMMARY: WHEN TO DO WHAT?

• Appreciate anatomy and epidemiology

• Assessment holistic

Patient & Pelvic floor

Optimal outcome

Individualise

management

Goal directed

management


Thank You

Dankie

POSTERIOR COMPARTMENT PROLAPSE: WHEN TO DO WHAT? … · INTRODUCTION • Posterior vaginal wall...

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Transcript of POSTERIOR COMPARTMENT PROLAPSE: WHEN TO DO WHAT? … · INTRODUCTION • Posterior vaginal wall...