Gynecology_Novak

Gynecology_Novak. Another study compared the effectiveness of artificial sphincter with dynamic graciloplasty (144). Two surgeons each performed four consecutive operations with each technique to minimize the learning curve of a new operation. Each started with a different procedure to avoid discrepancies in the time of follow-up. This prospective cohort study involved eight patients in each group who had similar demographic variables. Length of follow-up was 44 months in the artificial sphincter group and 39 months in the dynamic graciloplasty group. Early postoperative complications were similar in each group at 50%, as were late complications, with both groups reporting a high reoperation rate of 63%. There were six (75%) late complications in the artificial sphincter group, of which three (38%) were nonreversible and required explantation. Postoperative continence scores were significantly lower with the artificial sphincter than with graciloplasty. The authors conclude that artificial sphincter


Gynecology_Novak

Gynecology_Novak. nonreversible and required explantation. Postoperative continence scores were significantly lower with the artificial sphincter than with graciloplasty. The authors conclude that artificial sphincter has better efficacy and similar morbidity compared with dynamic graciloplasty. The rate of late complications for the artificial sphincter exceeded that reported in the literature, which may indicate poor long-term durability. Postoperative continence scores reﬂect those reported for artificial sphincter but are far worse than those for dynamic graciloplasty. The authors feel that the learning curve with the artificial sphincter is less important than that with graciloplasty.


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Gynecology_Novak. Sacral neuromodulation (InterStim®, Medtronic, Minneapolis, Minnesota) was approved by the FDA for treatment of urinary urge incontinence in 1997 and for nonobstructive urinary retention and urgency in 1999. It has been employed experimentally for the treatment of fecal incontinence and is currently undergoing FDA approval for this intervention. In Europe, it was approved for treatment of both urinary and fecal incontinence in 1994. The exact mechanism of action has not been fully elucidated. The goal of sacral nerve stimulation is to recruit residual function of the continence mechanism through electrical stimulation of its peripheral nerve supply. Initially, indications were confined to patients with deficient EAS and levator ani function without gross morphologic defects and intact neuromuscular connections. More recently, the acceptable indications have expanded to include deficiency of the IAS, limited structural defects, and functional deficits of the internal and external anal


Gynecology_Novak

Gynecology_Novak. connections. More recently, the acceptable indications have expanded to include deficiency of the IAS, limited structural defects, and functional deficits of the internal and external anal sphincter.


Gynecology_Novak

Gynecology_Novak. The device is instilled exactly the same way as for treatment of urinary incontinence. Current application is performed as a two-stage outpatient surgical procedure. The first stage involves instillation of the electrodes. The electrode is placed through the S2-4 foramen using minimally invasive surgical technique. During the test phase, multiple electrodes can be employed either bilaterally or at different levels to determine the site with the best response. Proper location is confirmed intraoperatively using ﬂuoroscopy as well as visualization of an appropriate pelvic ﬂoor muscle response (bellows) with minimal plantar ﬂexion of the first and second toes, which usually corresponds to S3 stimulation. An interval testing phase utilizes an external pulse generator that typically lasts 1 to 2 weeks. Those with a good response (decrease in fecal incontinence episodes of at least 50% documented by bowel-habit diary) will proceed to the second stage, implantation of the permanent pulse


Gynecology_Novak

Gynecology_Novak. to 2 weeks. Those with a good response (decrease in fecal incontinence episodes of at least 50% documented by bowel-habit diary) will proceed to the second stage, implantation of the permanent pulse generator (IPG). Typically only one electrode is left in place at the end of the second stage. Once the permanent pulse generator is implanted, all adjustments are made using telemetry. The patient has a basic remote control that enables her to turn the device on or off and adjust the amplitude of the stimulation.


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Gynecology_Novak. By the end of 2003, sacral nerve stimulation had been used to treat more than 1,300 patients with fecal incontinence (145). Despite this large number, the analysis of the results was limited to several small case series. In all studies, significant improvements in continence scores lasting up to 99 months occurred. Most patients experienced at least a 75% improvement in continence scores, and improvement also occurred in the frequency of incontinence episodes, the ability to postpone defecation, and bowel emptying. Intent-to-treat analysis revealed 80% to 100% therapeutic success. There also were significant improvements in quality-of-life measures using validated measurement scales. Complications occurred in 0% to 50% of patients, with the most common complications consisting of pain at the electrode or IPG site, electrode migration, infection, or worsening of bowel symptoms. No permanent sequelae occurred, however. Effects of anorectal physiology varied among the published studies,


Gynecology_Novak

Gynecology_Novak. the electrode or IPG site, electrode migration, infection, or worsening of bowel symptoms. No permanent sequelae occurred, however. Effects of anorectal physiology varied among the published studies, highlighting the fact that the precise mechanism of action remains unclear.


Gynecology_Novak

Gynecology_Novak. A Cochrane review of three crossover trials concluded that the limited data suggest improvement in both fecal incontinence and constipation with sacral nerve stimulation (146). Large multi-center trials have been conducted to evaluate the efficacy of sacral nerve stimulation for fecal incontinence. Wexner et al. prospectively followed 120 patients (110 female, 10 male) for a mean of 28 (2-70) months (147,148). Participants completed validated quality-of-life measures and bowel diaries. Success, defined as a 50% or greater improvement and reduction in fecal incontinence episodes per week, was achieved in 83% at 1 year and 85% at 2 years. Forty-one percent achieved total continence at 1 year, and mean incontinent episodes decreased from 9.4 to 1.9 per week. The same group reported an overall 10.8% infection rate (13/120), with nine occurring within the first month and four occurring after 1 year. Among the early infections, five responded to antibiotics, one resolved spontaneously, and


Gynecology_Novak

Gynecology_Novak. 10.8% infection rate (13/120), with nine occurring within the first month and four occurring after 1 year. Among the early infections, five responded to antibiotics, one resolved spontaneously, and three were treated surgically. For the late infections, all four had to be removed. Another large multicenter study of 200 patients revealed decreased severity scores and improved quality of life with sacral nerve stimulation (149). Loose stool consistency and low stimulation intensity were predictive of successful outcomes on multivariate analysis. Ultrasound findings, manometry, age and gender did not impact outcomes. Tjandra et al. performed a randomized controlled trial of 120 participants with 1-year follow-up comparing sacral nerve stimulation to best supportive therapy consisting of pelvic ﬂoor exercises, bulking agent, and dietary manipulation (150). Fecal incontinence outcomes improved dramatically in the stimulation group, with 47% achieving complete continence. In contrast, there


Gynecology_Novak

Gynecology_Novak. ﬂoor exercises, bulking agent, and dietary manipulation (150). Fecal incontinence outcomes improved dramatically in the stimulation group, with 47% achieving complete continence. In contrast, there were no significant improvements observed in the supportive therapy group. Thus, sacral nerve stimulation appears to be a promising new treatment for fecal incontinence with relatively limited complications. FDA approval for fecal incontinence seems likely in the near future, and the minimally invasive nature of this procedure makes it a desirable first-line surgical option.


Gynecology_Novak

Gynecology_Novak. Therapeutic Approach to Constipation As with fecal incontinence, it is imperative to attempt conservative management of constipation and defecatory dysfunction before performing surgery. Initial evaluation should focus on identifying any underlying systemic conditions (Table 28.1) associated with disordered defecation and optimizing treatment for these conditions. In the absence of systemic etiologies, it is reasonable to proceed with empiric, nonsurgical management, such as diet, fiber supplementation, and toileting behavior changes. Biofeedback and laxatives can be used in more severe cases. Initially, disimpaction with regular enemas or laxatives is essential if the patient


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Gynecology_Novak. Colonic Transit Time Anorectal Manometry Defecography Anorectal Manometry Psychological Profile Esophageal, gastric and small intestinal studies to evaluate for gastrointestinal pseudoobstruction Infrequent Defecation Normal Defecatory Straining Normal Outlet Delay Colonic Inertia Normal Hirschsprung Disease Anatomical Abnormalities Abnormal Expulsion Define Complaint Figure 28.7 Diagnostic Algorithm for Idiopathic Constipation. (From Ellerkmann MR, Kaufman H. Defecatory dysfunction. In: Bent AE, Ostergard DR, Cundiff GW, et al., eds. Ostergard’s urogynecology and pelvic ﬂoor dysfunction. 5th ed. Philadelphia,


Gynecology_Novak

Gynecology_Novak. Bent AE, Ostergard DR, Cundiff GW, et al., eds. Ostergard’s urogynecology and pelvic ﬂoor dysfunction. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002:358, with permission.) has fecal impaction. Symptoms that persist despite a trial of conservative management indicate the need for further evaluation of colonic and anorectal function. A diagnostic algorithm for idiopathic (nonsystemic) constipation is given in Figure 28.7. Treatment should then be tailored to the underlying cause. Some conditions associated with disordered defecation are best treated using nonsurgical techniques, whereas others may benefit from surgery once conservative management has failed. As with fecal incontinence, the lack of consistent outcome measures in the published literature makes it difficult to compare efficacy among treatments.


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Gynecology_Novak. in adults with constipation (156). This study lacked baseline data collection resulting in recall bias, and the use of mineral water containing magnesium may confound the results because of its mild laxative effect. Overall, the existing data do not support increased ﬂuid intake to treat constipation unless there is evidence of dehydration (151). The addition of fiber may decrease constipation through several mechanisms. Fiber acts as a stool bulking agent and improves stool consistency through water absorption. It can also act as a substrate for bacterial proliferation and gas production. These mechanisms of action are believed to result in increased colonic motility, decreased transit time, and increased stool frequency.


Gynecology_Novak

Gynecology_Novak. Fiber therapy appears to have a beneficial effect in the treatment of diverticular disease, constipation of pregnancy, and possibly IBS (19,157,158). Its efficacy for idiopathic (nonsystemic) constipation remains uncertain. Dietary fiber intake for patients with constipation was similar to that of controls in several studies (152,153). A meta-analysis of 36 randomized trials using laxatives or fiber therapy for the treatment of constipation showed that the use of fiber or laxatives resulted in increased stool frequency and improved symptoms without the presence of severe side effects (159). Conversely, another meta-analysis showed an inability to restore transit time and stool weight in constipated patients using dietary fiber (158). Approximately half of the patients in another study responded to fiber treatment, but a much better response occurred in patients without an identifiable structural or motility disorder (160). Consequently, a low-fiber diet may be a contributing factor in


Gynecology_Novak

Gynecology_Novak. to fiber treatment, but a much better response occurred in patients without an identifiable structural or motility disorder (160). Consequently, a low-fiber diet may be a contributing factor in chronic constipation, and an empiric trial of fiber therapy can be expected to help some patients. Side effects of increased gas production may limit compliance with treatment, so doses should be slowly titrated. Fiber therapy should be avoided in patients with impaction, megacolon or megarectum, or obstructive gastrointestinal lesions. Fiber therapy should also be used with caution in patients with cognitive dysfunction (dementia), difficulty with ambulation, and underlying neurogenic disease for fear of worsening the condition. There is no evidence to substantiate the recommendation for extra water intake with fiber supplements (161).


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Gynecology_Novak. Laxatives are commonly used to treat constipation and disordered defecation. Many classes of laxatives are available over the counter. Bulk-Forming Laxatives These come in natural forms (psyllium) as well as synthetic form (Metamucil, Konsyl, Citrucel) and are felt to be the safest laxatives. They have mechanisms of action and side effects similar to that of fiber (162). Hyperosmolar Laxatives These consist of poorly absorbed substances that increase intraluminal osmolarity and water absorption. This action results in greater stool volume with decreased consistency. Examples include nonabsorbable sugars (lactulose and sorbitol), glycerin, and polyethylene glycol (GoLytely, MiraLAX). Polyethylene glycol is a common preoperative bowel preparation. Side effects are diarrhea, increased ﬂatus, and abdominal cramping (162).


Gynecology_Novak

Gynecology_Novak. Emollient Laxatives These agents are divided into two subsets: docusate salts and mineral oil. The docusate salts have hydrophilic and hydrophobic properties similar to detergents. They soften stool and decrease surface tension by increasing stool water and lipid content. Examples include docusate calcium (Surfak), docusate potassium (Dialose, Kasof), and docusate sodium (Colace, Comfolax). They also improve the absorption of other laxatives and are combined in preparations with stimulant laxatives such as Correctol, Peri-Colace, and Feen-a-Mint. The limited absorption of mineral oil allows it to penetrate and soften the stool. It can be used orally or rectally. Prolonged daily use can lead to decreased absorption of the fat-soluble vitamins A, D, E, and K. Use of mineral oil should be avoided in elderly and debilitated patients, as well as in those with esophageal motility disorders because of the potential for aspiration pneumonia. Side effects include diarrhea, anal leakage, and


Gynecology_Novak

Gynecology_Novak. avoided in elderly and debilitated patients, as well as in those with esophageal motility disorders because of the potential for aspiration pneumonia. Side effects include diarrhea, anal leakage, and pruritus ani (162–164).


Gynecology_Novak

Gynecology_Novak. Saline Laxatives These usually contain magnesium cations and phosphate anions that are relatively nonabsorbable and produce an osmotic gradient with increased water absorption. They also stimulate intestinal motility by increasing cholecystokinin release. Fast-acting effects can be seen with both oral (2–6 hours) and rectal (15 minutes) preparations. Examples include magnesium citrate, magnesium hydroxide (Milk of Magnesia), magnesium sulfate, sodium phosphate, and biphosphate (Phospho-soda, Fleet enema). Although generally well tolerated, electrolyte abnormalities can occur. These side effects should be avoided in patients with renal insufficiency because of the potential for magnesium toxicity (162–164).


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Gynecology_Novak. Stimulant Laxatives These are found in three basic types: castor oil, anthraquinones, and diphenylmethanes. A metabolite of castor oil, ricinoleic acid, increases intestinal motility and secretion. Anthraquinones (cascara sagrada, senna [Senokot], casanthranol [aloe], and danthron) are absorbed by the small intestine and stimulate motility by increasing intraluminal ﬂuid and electrolyte content. Diphenylmethanes (phenolphthaleins [Feen-a-Mint, Correctol] and bisacodyl [Dulcolax]) have a mechanism of action similar to anthraquinones. These agents are potent and are intended for short-term use in cases refractory to bulk or osmotic laxatives. It has been a long-standing belief that prolonged use can lead to a dilated atonic colon known as cathartic colon syndrome, melanosis coli, or neuronal degeneration. A recent article refutes the theory that stimulant laxatives damage the autonomic nervous system when used at recommended doses (151). Other side effects include cramping, nausea, and


Gynecology_Novak

Gynecology_Novak. degeneration. A recent article refutes the theory that stimulant laxatives damage the autonomic nervous system when used at recommended doses (151). Other side effects include cramping, nausea, and abdominal pain (162–164).


Gynecology_Novak

Gynecology_Novak. Medications that stimulate gastrointestinal motility primarily through neuromodulation of acetycholine levels include metoclopramide, cisapride, cholinergic agonists (bethanechol), cholinesterase inhibitors (neostigmine), and serotonin agonists. Their efficacy in the treatment of chronic idiopathic constipation is uncertain. Metoclopramide is better for upper gastrointestinal motility disorders, whereas cisapride appears to exert its effect at the level of the colon (162–164).


Gynecology_Novak

Gynecology_Novak. Behavioral Approaches Behavioral techniques such as biofeedback and bowel regimens may have a role in certain conditions associated with constipation and defecatory dysfunction. Overall, these approaches have far less application to disordered defecation than to fecal incontinence. Biofeedback is important in the treatment of dyssynergic defecation. Relaxation techniques and behavioral modification may be helpful for IBS. Bowel regimens in conjunction with laxatives, suppositories, and enemas can facilitate emptying by optimizing the gastrocolic reﬂex and increased peristaltic activity. Efficacy of Nonsurgical Treatment Irritable Bowel Syndrome


Gynecology_Novak

Gynecology_Novak. The most commonly used first-line treatment for the constipation variant of IBS is fiber supplementation and osmotic laxatives. The efficacy of bulking agents for this condition is controversial, and many studies, including meta-analyses, exhibit an effect similar to placebo. There may be benefit to the use of fiber because of the high placebo effect with IBS treatment and lack of serious adverse events associated with its use. However, patients may experience exacerbation of bloating and abdominal discomfort with fiber therapy. Randomized trials and meta-analysis revealed a beneficial effect of polyethylene glycol (MiraLAX) over placebo for the treatment of chronic constipation. In addition, polyethylene glycol was better than tegaserod and lactulose for chronic constipation (165–167). They can be useful as adjunctive treatment options, but can also exacerbate abdominal pain and discomfort. A newer class of drugs, serotonin 5HT4 agonist tegaserod (Zelnorm), stimulates peristalsis,


Gynecology_Novak

Gynecology_Novak. They can be useful as adjunctive treatment options, but can also exacerbate abdominal pain and discomfort. A newer class of drugs, serotonin 5HT4 agonist tegaserod (Zelnorm), stimulates peristalsis, increases colonic motility, decreases intestinal transit times, and reduces visceral hypersensitivity. The recommended dose is 6 mg twice daily. Randomized trials have consistently shown an approximately 10% greater improvement in global IBS symptoms when compared with placebo. Improvement in the bloating and pain symptoms also occurred. No episodes of ischemic colitis or cardiac toxicity have been reported with the use of this medication, and the most common side effects are diarrhea and headache. Cisapride, a 5HT4 agonist with partial 5HT3 antagonist actions, has been withdrawn from use secondary to rare cardiac toxicity. Additional 5HT4 agonists, 5HT3 agonists, and cholecystokinin antagonists are in development (95,96).


Gynecology_Novak

Gynecology_Novak. Patients with slow-transit constipation tend to respond poorly to fiber supplementation, although most have already tried an empiric trial of fiber before testing to confirm the diagnosis (160). Some patients may benefit from regular toileting, either in the morning or after meals when there is increased colonic motor activity. Biofeedback may have modest short-term benefits, but the long-term effect is questionable (168). Enemas and suppositories can be used in conjunction with bowel regimens. It is also reasonable to attempt a trial of any of the laxatives listed in Table 28.10. Stimulant laxatives are commonly used, but questions remain about the development Table 28.10 Laxatives for the Treatment of Disordered Defecation PO, by mouth; PR, per rectum. From Wald A. Approach to the patient with constipation. In: Yamada T, ed. Textbook of gastroenterology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999:921, with permission.


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Gynecology_Novak. of neuronal degeneration with prolonged usage. It is imperative that patients adhere to and not exceed the recommended dosages. Data regarding laxative use for this condition have failed to show a significantly better response than placebo. Prokinetic agents are intuitively the ideal choice to stimulate colonic motility. Currently there is only one available prokinetic agent, tegaserod, approved for the treatment of constipation that improves colonic transit. Its data are almost entirely based on treatment of IBS, and there is a lack of information for its use in slow-transit constipation. Other prokinetic agents in various stages of testing include bethanechol, neostigmine, cholecystokinin antagonists, misoprostol, colchicine, neurotrophin-3, and other 5HT4 agonists such as prucalopride and mosapride (49).


Gynecology_Novak

Gynecology_Novak. As with slow-transit constipation, initial management using bowel regimens, laxatives, enemas, suppositories, and fiber supplementation is appropriate for patients with dyssynergic defecation, yet many will have already tried conservative management before undergoing testing to confirm the diagnosis. These treatments are relatively well tolerated with few serious side effects. They have not been shown to have greater efficacy when compared with placebo, and their role in the treatment of dyssynergic defecation remains uncertain. Specific treatment for this condition tends to focus on biofeedback because of studies indicating that this is an acquired behavioral disorder of defecation. Modalities such as diaphragmatic muscle training, simulated defecation, and manometric or electromyography-guided anal sphincter and pelvic muscle relaxation have been employed independently or combined with other techniques. These techniques have yielded symptomatic improvement in approximately 60% to


Gynecology_Novak

Gynecology_Novak. anal sphincter and pelvic muscle relaxation have been employed independently or combined with other techniques. These techniques have yielded symptomatic improvement in approximately 60% to 80% of patients. Many patients with dyssynergic defecation also have abnormal rectal sensation, so rectal sensory conditioning may provide additional benefit (33,49,169,170). Others have tried botulinum toxin injections to paralyze the puborectalis and anal sphincter muscle. Small case series have shown modest early improvement, but the results do not appear to be long lasting (171,172). A recent randomized trial of 48 participants comparing botulinum toxin to biofeedback retraining found better initial improvement with the botulinum toxin (70% vs. 50%) but no difference at 1 year (33% vs. 25%) (173).


Gynecology_Novak

Gynecology_Novak. Pessary for Treatment of Pelvic Organ Prolapse


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Gynecology_Novak. Pessaries of various shapes and sizes have been used for centuries to treat pelvic organ prolapse (174). They are a safe alternative to surgery, with the most common complications being increased vaginal discharge and erosion or ulceration of the vaginal wall. Although pessaries represent a common therapeutic modality, there are limited data regarding fitting and management (175). Even less is known about which type of pessary is better for enteroceles and rectoceles, although the site of prolapse does not appear to affect the ability to retain a pessary (176). Pessaries can be divided into subtypes of supportive and space occupying (177). Some of the space-occupying pessaries, such as the Gellhorn and cube, use a suction mechanism to maintain vaginal retention, whereas others, like the donut, do not. In theory, space-occupying pessaries and those that exert forces against the posterior wall and vaginal apex (donut, inverted Gehrung) should aid in treatment of rectoceles and


Gynecology_Novak

Gynecology_Novak. the donut, do not. In theory, space-occupying pessaries and those that exert forces against the posterior wall and vaginal apex (donut, inverted Gehrung) should aid in treatment of rectoceles and enteroceles. However, there are few data regarding the efficacy of pessaries for relieving symptoms of disordered defecation. One prospective study found that stage III or IV posterior vaginal wall prolapse was an independent predictor for discontinuation of pessary use in favor of surgical repair (178). The only randomized crossover trial comparing different types of pessaries (ring and Gelhorn) found improvement in quality-of-life measures with each pessary that did not differ. Protrusion and voiding dysfunction symptoms were most improved (179). More research is needed to determine the role of pessaries for treatment of rectoceles and enteroceles as well as symptoms that are likely to be improved using a pessary.


Gynecology_Novak

Gynecology_Novak. Surgical Treatment Following is a review of the efficacy of various surgical treatments for specific conditions associated with constipation and disordered defecation.


Gynecology_Novak

Gynecology_Novak. Subtotal colectomy with ileosigmoid or ileorectal anastomosis is considered by many to be the surgical treatment of choice for slow-transit constipation refractory to medical management. Most surgeons restrict the use of this surgical procedure to the most extreme cases and typically operate on fewer than 10% of patients. Strict criteria for surgery include the following: chronic, severe, disabling symptoms unresponsive to medical therapy; slow transit in the proximal colon; no evidence of pseudo-obstruction; and normal anorectal function (162). Success rates are variable and depend on several factors. An extensive review of colectomy for slow-transit constipation analyzed 32 studies from 1981 to 1988 and found satisfaction rates ranged from 39% to 100% (180). Higher success rates occurred in studies in the United States (n = 11, median 94%, range 75%–100%) and prospective studies (n = 16, median 90%, range 50%–100%). Superior outcomes occurred in those who had a complete physiologic


Gynecology_Novak

Gynecology_Novak. in studies in the United States (n = 11, median 94%, range 75%–100%) and prospective studies (n = 16, median 90%, range 50%–100%). Superior outcomes occurred in those who had a complete physiologic evaluation and proven slow-transit constipation. Patients with anismus had higher rates of recurrent symptoms and lower satisfaction levels (181). Poorer outcomes occurred with ileosigmoid and cecorectal anastomosis than with ileorectal anastomosis. Those with segmental resection (hemicolectomy) had the worst outcome. None of the studies had a comparison group, and outcomes were variable and lacking validated measures. Morbidity associated with the operation included small bowel obstruction (median 18%, range 2%–71%), need for reoperation (median 14%, range 0%–50%), diarrhea (median 14%, range 0%–46%), fecal incontinence (median 14%, range 0%–52%), recurrent constipation (median 9%, range 0%–33%), persistent abdominal pain (median 41%, range 0%–90%), and permanent ileostomy (median 5%,


Gynecology_Novak

Gynecology_Novak. 0%–46%), fecal incontinence (median 14%, range 0%–52%), recurrent constipation (median 9%, range 0%–33%), persistent abdominal pain (median 41%, range 0%–90%), and permanent ileostomy (median 5%, range 0%–28%). Mortality ranged from 0%–6% (182). A quality-of-life study revealed that the score correlated poorly with frequency of bowel movements. However, a lower score was seen in those patients who had persistent abdominal pain, diarrhea, fecal incontinence, and permanent ileostomies. Overall satisfaction with the procedure was very high and correlated with the quality-of-life score (183).


Gynecology_Novak

Gynecology_Novak. Surgical alternatives to subtotal colectomy include ileostomy, cecostomy with antegrade continence enemas, and sacral nerve stimulation. Subtotal colectomy has never been directly compared with ileostomy, but those who had a permanent diversion after subtotal colectomy had lower quality-of-life scores. Patients undergoing cecostomy with antegrade continence enemas can expect to have satisfactory function approximately half of the time, with most requiring additional revision procedures secondary to stomal complications (184). Although sacral nerve stimulation has primarily been used for fecal incontinence, the results of a few small studies evoke optimism for its use in chronic constipation and slow-transit constipation (146,185–187).


Gynecology_Novak

Gynecology_Novak. Pelvic Organ Prolapse The variety of surgical treatment techniques for the repair of rectocele include posterior colporrhaphy, defect-directed repair, posterior fascial replacement, transanal repair, and abdominal repair with sacral colpopexy. When an enterocele is present, a culdoplasty is usually performed. In cases of perineal descent, abdominal sacral colpoperineopexy is the procedure of choice. Suture rectopexy can be performed in conjunction with sacral colpoperineopexy if rectal prolapse is present. Despite the routine use of these procedures, data are limited regarding symptomatic improvement of disordered defecation. Greater detail regarding the specific techniques for many of these procedures is provided in Chapter 27 This section will focus on surgical outcomes, including anatomic cure of prolapse, improvement of defecatory dysfunction symptoms, and morbidity associated with the procedure.


Gynecology_Novak

Gynecology_Novak. Posterior Colporrhaphy Posterior colporrhaphy has been the surgical procedure for rectocele repair preferred by gynecologic surgeons for more than 100 years. Traditional posterior colporrhaphy narrows the vaginal caliber through plication of the rectovaginal septum and usually includes a perineorrhaphy, which narrows the introitus. Despite it broad use, there are few data regarding long-term anatomic success, symptomatic improvement, and sexual function following the procedure. The outcomes of several studies are summarized in Table 28.11 (189–207). Anatomic cure and relief of vaginal bulge occurred in 76% to 96% of patients. In these studies, the procedure was ineffective at treating constipation, vaginal digitations (splinting), and fecal incontinence. Dyspareunia developed in 8% to 26% of patients with and without levator plication (188–192,207). As early as 1961, high rates of dyspareunia have been reported with this procedure in as many as 50% of patients (208).


Gynecology_Novak

Gynecology_Novak. Many feel that the successful anatomic support obtained with this procedure is offset by the modest relief of functional symptoms and high rate of de novo dyspareunia. However, a recent prospective case series of 38 women undergoing posterior colporrhaphy along with concomitant procedures for rectocele and obstructed defecation revealed markedly different results (209). Fascial plication was performed without levator plication, and perineal body reconstruction rather than routine perineorrhaphy was employed when indicated. Anatomic cure rate was 87% at 12 months and 79% at 24 months. Subjective cure rate was 97% at 12 months and 89% at 24 months. There was significant improvement in preoperative and postoperative symptoms for constipation (76% vs. 24%), digitations (100% vs. 16%), awareness of prolapse (100% vs. 5%), obstructed defecation (100% vs. 13%), and dyspareunia (37% vs. 5%). There was no difference in fecal incontinence and only one case of de novo dyspareunia. The authors


Gynecology_Novak

Gynecology_Novak. of prolapse (100% vs. 5%), obstructed defecation (100% vs. 13%), and dyspareunia (37% vs. 5%). There was no difference in fecal incontinence and only one case of de novo dyspareunia. The authors attribute their improved anatomic and functional outcomes and combined improvement in dyspareunia to exclusion of levator plication, perineorrhaphy, and excision of vaginal epithelium. An additional benefit may be derived during mobilization of the vaginal epithelium, when scar tissue from prior episiotomy or surgery is divided. They also found that preoperative defecating proctography was


Gynecology_Novak

Gynecology_Novak. Table 28.11 Rectocele Repairs Table 28.11 (Continued ) aProspective.bIn sexually active patients. cCombined transanal and transvaginal repair. of limited value and have stopped its routine use as part of the preoperative evaluation for women with symptomatic rectoceles and obstructive defecation.


Gynecology_Novak

Gynecology_Novak. Defect-Directed Repair The goal of a defect-directed repair or site-specific repair is to restore normal anatomy (36). This procedure can be combined with a perineal body reconstruction, if necessary, but usually does not routinely involve perineorrhaphy. Table 28.11 lists the anatomic and functional outcomes for this type of repair. Anatomic cure rates range from 82% to 100%, which are similar to those for posterior colporrhaphy. This procedure also resulted in modest improvement for symptoms of difficult evacuation, vaginal bulge, and vaginal digitations, which appear to be slightly better than for posterior colporrhaphy (193–197,207). Constipation symptoms significantly decreased in only one study (193). All studies reported low rates of de novo dyspareunia with good functional and anatomic outcomes, but the long-term durability of the procedure is unknown. All but one of these studies included concomitant prolapse and urinary incontinence procedures.


Gynecology_Novak

Gynecology_Novak. A randomized clinical trial of 106 women with stage II or greater posterior vaginal wall prolapse compared posterior colporrhaphy, defect-directed rectocele repair, and defect-directed repair augmented with a porcine small intestinal submucosal (210). Participants completed validated pelvic ﬂoor instruments at baseline and 6 months, 1 year, and 2 years after surgery. Anatomic failure was defined as POP-Q system point Bp greater than or equal to −2 at 1 year. There was a significant improvement in prolapse and colorectal scales in all groups with no differences between groups. The proportion of subjects with functional failures was 15% overall and not significantly different between groups. Posterior colporrhaphy and defect-directed repairs resulted in similar anatomic and functional outcomes, although the addition of a porcine-derived graft did not improve anatomic outcomes. On average, all bowel symptoms evaluated were significantly improved 1 year after surgery, with no differences


Gynecology_Novak

Gynecology_Novak. although the addition of a porcine-derived graft did not improve anatomic outcomes. On average, all bowel symptoms evaluated were significantly improved 1 year after surgery, with no differences between treatment groups. The development of new “bothersome” bowel symptoms after surgery was uncommon (11%). After controlling for age, treatment group, comorbidities, and preoperative bowel symptoms, corrected postoperative vaginal support (stage 0 or I) was associated with a reduced risk of postoperative straining (adjusted OR 0.17; 95% CI, 0.03–0.9) and feeling of incomplete emptying (adjusted OR 0.1; 95% CI, 0.01–0.52). This led the authors to conclude that resolution or improvement in bowel symptoms can be expected in the majority of women after rectocele repair (211).


Gynecology_Novak

Gynecology_Novak. Transanal repair involves repair of the rectocele through a transanal incision with excision of redundant rectal mucosa and plication of the rectovaginal septum and rectal wall. The procedure was developed and is primarily used by colorectal surgeons to treat constipation or obstructed defecation associated with “low” or distal rectoceles. The advantages of this approach include excision of redundant rectal mucosa and the ability to treat other anorectal pathology, such as hemorrhoids or anterior rectal wall prolapse (212). Disadvantages include the inability to repair higher rectoceles, enteroceles, cystoceles, uterine prolapse, and defects in the perineal body or anal sphincter (213). Major complications of infection (6%) and rectovaginal fistula (3%) are relatively rare (203). Most studies did not require vaginal bulging or protrusion symptoms as a prerequisite for surgery. The results of several studies are summarized in Table 28.11. The anatomic cure rate was 70% to 98%, and


Gynecology_Novak

Gynecology_Novak. studies did not require vaginal bulging or protrusion symptoms as a prerequisite for surgery. The results of several studies are summarized in Table 28.11. The anatomic cure rate was 70% to 98%, and symptoms of constipation, difficult evacuation, and vaginal digitations appear to improve (202–207).


Gynecology_Novak

Gynecology_Novak. Recent reviews have compared transanal with transvaginal rectocele repair using the results of two small, randomized control trials (214–217). Women with compromised sphincter function and other symptomatic prolapse were excluded. The results for transvaginal repair were superior to those for transanal repair with respect to subjective failure rate (relative risk [RR] 0.36; 95% CI, 0.13–1.0) and objective failure rate (RR 0.24; 95% CI, 0.09–0.64) (214). In one study, a significant decrease occurred in the depth of rectocele on postoperative defecography for the transvaginal group compared with the transanal group (2.73 vs. 4.13 cm, respectively) (217). The transvaginal group had fewer problems with bowel evacuation, but this finding was not statistically significant. In one study, researchers discovered that 38% of patients developed fecal incontinence following transanal repair (188). In the two randomized trials, no significant differences were seen in the rate of fecal incontinence


Gynecology_Novak

Gynecology_Novak. discovered that 38% of patients developed fecal incontinence following transanal repair (188). In the two randomized trials, no significant differences were seen in the rate of fecal incontinence or dyspareunia, but the studies were underpowered to detect a difference (216,217). Although a vaginal approach has been considered superior to a transanal approach for rectocele repair, studies are retrospective and impossible to compare because the indications for transanal repairs are generally different from those for transvaginal repairs. A prospective, randomized trial with adequate power to evaluate symptomatic outcomes of bowel and sexual function along with anatomic cure is warranted.


Gynecology_Novak

Gynecology_Novak. Rectocele repair with graft augmentation is becoming more common, despite a paucity of supporting evidence indicating its benefits over standard procedures. The reason for its emergence is the theory that vaginal hernia repairs behave similar to abdominal hernia repairs, which have a documented decrease in recurrence when augmented with grafts. A variety of graft materials have been employed with posterior colporrhaphy and defect-directed repairs including autograft, allograft, xenograft, and synthetic mesh. There are no comparison data to aid in selecting the optimal graft. The purpose of the graft is debatable. It can either be intended to replace existing fascia as a permanent barrier or to provide an absorbable scaffold for collagen deposition, scar formation, and remodeling. The ideal material should have a low erosion rate, be relatively inexpensive, and decrease recurrence rates without causing bowel or sexual dysfunction. The outcomes for rectocele repair using graft materials


Gynecology_Novak

Gynecology_Novak. material should have a low erosion rate, be relatively inexpensive, and decrease recurrence rates without causing bowel or sexual dysfunction. The outcomes for rectocele repair using graft materials placed either vaginally or abdominally appear in Table 28.11. High anatomic cure rates of 89% to 100% occurred, and symptoms of constipation, difficult evacuation, and vaginal bulge also appeared to improve.


Gynecology_Novak

Gynecology_Novak. One randomized trial used absorbable vaginal mesh for rectocele repair (192). Patients were randomly assigned to fascial replacement with polyglactin 910 mesh at the time of anterior and posterior colporrhaphy. There were no differences in recurrence rates when comparing 70 women with a traditional colpoperineorrhaphy with 73 women having a traditional repair plus mesh: 10% versus 8%, respectively. This study did not describe changes in bowel or sexual function, and there were no mesh-related adverse events. As previously noted, the randomized controlled trial comparing posterior colporrhaphy, defect-directed repair, and defect-directed repair with porcine small intestine submucosal graft augmentation revealed higher anatomical failure rates in the graft-augmented group compared to the site-specific alone or the posterior colporrhaphy group (46% vs. 22% and 14%, respectively; P = .02), with no difference in symptom outcomes (210). Importantly, the risks of vaginal mesh erosion and


Gynecology_Novak

Gynecology_Novak. site-specific alone or the posterior colporrhaphy group (46% vs. 22% and 14%, respectively; P = .02), with no difference in symptom outcomes (210). Importantly, the risks of vaginal mesh erosion and severe complications may be relatively low but carry significant morbidity, including rectovaginal fistula, persistent vaginal bleeding and discharge, dyspareunia, and the need for additional surgery (199,207). Nonsynthetic grafts appear to be safer, with fewer erosions compared with synthetic grafts; however, there is no evidence to suggest that the addition of a graft to the posterior compartment improves outcomes (210,218,219).


Gynecology_Novak

Gynecology_Novak. The abdominal approach to rectocele repair may be of value when a superior defect in the rectovaginal fascia occurs in a patient with accompanying enterocele, uterine prolapse, or vault prolapse. If a patient is undergoing an abdominal or laparoscopic procedure such as a sacral colpopexy, the graft can be extended along the posterior vaginal wall to correct proximal defects in the rectovaginal septum (220). There are limited data regarding the efficacy of abdominal rectocele repair. The indication for this procedure, as well as the need for additional vaginal repair of distal defects, is often determined intraoperatively. An ancillary study from the Pelvic Floor Disorders Network evaluating bowel symptoms 1 year after sacrocolpopexy found that the majority of bothersome bowel symptoms resolve after this procedure. There was no difference in postoperative bowel symptoms among those who underwent a concomitant rectocele repair and those who did not. It is important to note that the


Gynecology_Novak

Gynecology_Novak. resolve after this procedure. There was no difference in postoperative bowel symptoms among those who underwent a concomitant rectocele repair and those who did not. It is important to note that the study was not developed to evaluate the impact of concomitant rectocele repair on bowel symptom resolution, and those who underwent a rectocele repair had more severe baseline bowel symptoms including worse obstructive symptom (221).


Gynecology_Novak

Gynecology_Novak. Sacral colpoperineopexy is a modification of sacral colpopexy aimed at correction of apical prolapse combined with rectocele and perineal descent (39). A continuous graft is placed from the anterior longitudinal ligament of the sacrum down to the perineal body. This procedure can be accomplished either through a total abdominal approach or a combined abdominal and vaginal procedure. If performing a total abdominal approach, the rectovaginal space is opened, and the rectum is dissected off the posterior vaginal wall and rectovaginal septum toward the perineal body. The graft is then sutured to the perineal body or as close to it as possible. A rectovaginal examination with the surgeon’s nondominant hand facilitates this attachment by supporting the perineal body. The graft is secured to additional points along the posterior vaginal wall and apex, and sacral colpopexy is completed in the usual fashion.


Gynecology_Novak

Gynecology_Novak. If performing a combined abdominal and vaginal approach, the graft is secured to the perineal body vaginally. The posterior vaginal wall is opened, and a defect-directed rectocele repair is performed. Sacral colpopexy is accomplished in the usual fashion except that the vaginal dissection is opened superiorly, creating a window to the abdominal dissection. The graft can then be passed down from the abdominal field to the vaginal field and anchored inferiorly to the perineal body and laterally to the arcus tendineus fascia rectovaginalis (Fig. 28.8).


Gynecology_Novak

Gynecology_Novak. Short-term outcomes for 19 patients who underwent sacral colpoperineopexy indicated good anatomic results for apical and posterior support as well as for perineal descent (39). Complete cessation of defecatory dysfunction symptoms was accomplished in 66% of patients. In a report of outcomes for a slightly different variation of the sacral colpoperineopexy, the authors’ technique involved attachment of Marlex mesh to the perineal body using a needle carrier (222). The failure rate was 25% and mesh erosion rate was 5% for 205 patients with up to 10-year follow-up. A study of Mersilene mesh erosion rates related to sacral colpopexy and sacral colpoperineopexy noted similar erosion rates between sacral colpopexy and colpoperineopexy when the vagina was not opened (3.2% vs. 4.5%, respectively) (223). However, the erosion rate was 16% with vaginal suture placement and 40% when the mesh was placed vaginally. The use of nonsynthetic grafts such as dermal allograft and xenograft may help


Gynecology_Novak

Gynecology_Novak. (223). However, the erosion rate was 16% with vaginal suture placement and 40% when the mesh was placed vaginally. The use of nonsynthetic grafts such as dermal allograft and xenograft may help prevent high erosion rates. In a case series of 11 patients, researchers performed sigmoid resection (if indicated) and suture rectopexy in conjunction with sacral colpoperineopexy using AlloDerm for women with coexistent rectal prolapse, perineal descent, and defecatory dysfunction. Early follow-up (12.5 ± 7.7 months) revealed excellent improvement of defecatory dysfunction symptoms and quality-of-life considerations, with an 82% cure of perineal descent (224). A recently published retrospective cohort of 38 women revealed high satisfaction following abdominal sacral colpoperineopexy, despite the persistence of obstructed defecation symptoms 5 years after surgery (225). Sacral colpoperineopexy may have value for a select group of patients, but larger prospective series with long-term anatomic


Gynecology_Novak

Gynecology_Novak. persistence of obstructed defecation symptoms 5 years after surgery (225). Sacral colpoperineopexy may have value for a select group of patients, but larger prospective series with long-term anatomic and symptomatic outcomes are necessary to evaluate the durability of this procedure.


Gynecology_Novak

Gynecology_Novak. Rectal Prolapse Numerous surgical procedures have been described for the treatment of rectal prolapse and are broadly categorized into perineal or abdominal approaches. Most surgeons prefer an abdominal procedure because of lower recurrence rates, reserving perineal procedures for more debilitated patients. Figure 28.8 Abdominal sacral colpoperineopexy with sigmoid resection and suture rectopexy. This sagittal view shows the posterior graft sutured to the rectovaginal fascia and perineal body after defect-directed rectocele repair. The anterior graft is sutured to the pubocervical fascia. Both sheets will be secured to the sacral periosteum to the right of the rectum. Rectopexy sutures (left) have not yet been tied and secured. (Courtesy of Geoffrey W. Cundiff, M.D.)


Gynecology_Novak

Gynecology_Novak. Abdominal procedures vary with respect to the extent of rectal mobilization, method of rectal fixation, and inclusion or exclusion of bowel resection. During abdominal rectopexy, the mesorectal plane is developed and the rectum mobilized down to the pelvic ﬂoor posteriorly, with care taken to identify and preserve the hypogastric nerves. Division of the lateral ligaments may or may not be performed. The concern is that division of the lateral ligaments will lead to rectal denervation and increased postoperative constipation. If performing a suture rectopexy, the fascia propria of the rectum is secured to the sacral periosteum from S-1 to S-3 (226). If performing a sigmoid resection with the rectopexy (Frykman-Goldberg resection rectopexy), the bowel resection is performed after mobilization and before suturing (227). The theoretical advantages of a rectosigmoid resection are creation of a dense area of fibrosis between the anastomotic suture line and the sacrum; removal of abundant


Gynecology_Novak

Gynecology_Novak. and before suturing (227). The theoretical advantages of a rectosigmoid resection are creation of a dense area of fibrosis between the anastomotic suture line and the sacrum; removal of abundant rectosigmoid, avoiding torsion or volvulus; additional fixation through straightening of the left colon and decreased mobility from the phrenocolic ligament; and relief of constipation in select patients. It is typically reserved for patients with a long redundant sigmoid colon, although specific criteria have not been proposed. Mesh rectopexies are usually avoided because of concern for increased complications and infections associated with placement of a foreign body at the time of bowel resection. There are two basic types of mesh rectopexy: posterior mesh rectopexy and anterior sling rectopexy (Rip-stein procedure) (228,229). A variety of materials have been used for this procedure, including absorbable and permanent mesh. The assumption is that placement of this material will provide


Gynecology_Novak

Gynecology_Novak. (Rip-stein procedure) (228,229). A variety of materials have been used for this procedure, including absorbable and permanent mesh. The assumption is that placement of this material will provide increased support through increased fibrous tissue formation. During the Ripstein procedure, an anterior sling of fascia lata or synthetic mesh is placed in front of the rectum and sutured to the sacrum. Most surgeons avoid this procedure because of fear of obstructed defecation. Modifications using a posterolateral wrap have been developed to resolve this problem.


Gynecology_Novak

Gynecology_Novak. In a series of more than 10 patients, there were five open series and five laparoscopic reports for suture rectopexy (230). The recurrence rates ranged between 0% and 9%. Most reports showed an improvement in fecal incontinence symptoms, but the results for constipation were variable. There were no mortalities noted and no difference between laparoscopic and open results. For posterior mesh rectopexy, there were 14 open series and five laparoscopic reports. The recurrence rates ranged between 0% and 6%. As with suture rectopexy, there was general improvement in fecal incontinence, mixed results for constipation, and no differences between laparoscopic and open outcomes. The mortality rate was between 0% and 3%, with increased rates of infection if resection rectopexy was performed. For anterior sling rectopexy (Ripstein procedure), there were eight studies with a recurrence rate between 0% and 12%. Again, there was a trend toward improvement of fecal incontinence and mixed response


Gynecology_Novak

Gynecology_Novak. anterior sling rectopexy (Ripstein procedure), there were eight studies with a recurrence rate between 0% and 12%. Again, there was a trend toward improvement of fecal incontinence and mixed response for constipation. Mortality ranged from 0% to 3%. For resection rectopexy (Frykman-Goldberg procedure), there were nine open series and three laparoscopic reports. Recurrence ranged between 0% and 5%. There was general improvement in continence as well as an overall reduction in constipation observed in most studies. Mortality rate was 0% for all studies but one, in which it was 6.7% (231). This study was a small, randomized trial comparing 15 patients undergoing resection rectopexy to 15 patients undergoing absorbable mesh rectopexy. The patient who died was in the resection group and had a myocardial infarction. The authors concluded that sigmoid resection did not seem to increase operative morbidity but tended to diminish postoperative constipation, possibly by causing less outlet


Gynecology_Novak

Gynecology_Novak. a myocardial infarction. The authors concluded that sigmoid resection did not seem to increase operative morbidity but tended to diminish postoperative constipation, possibly by causing less outlet obstruction. The study was underpowered to detect a difference in morbidity or mortality.


Gynecology_Novak

Gynecology_Novak. The laparoscopic series demonstrated similar safety and efficacy to the open techniques, and the effect on continence and constipation tended to mirror the type of rectopexy performed.


Gynecology_Novak

Gynecology_Novak. In a small, randomized trial, there were significant short-term benefits with laparoscopic rectopexy compared with open rectopexy, including earlier ambulation, more rapid return to normal diet, shorter hospital stay, and lower morbidity (232). Most surgeons believe that there are no differences in recurrence rates between suture and mesh rectopexy. Consequently, the role of mesh in these procedures is suspect. The role of division of the lateral ligaments is somewhat controversial. A Cochrane review performed in 2008 concluded that division of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation (233). The authors acknowledged the limitations of their review, which consisted of very few trials with small sample sizes and methodological weakness. A review of seven open and four laparoscopic series involving division of the lateral ligaments revealed a general improvement in fecal incontinence and either no change or worsening of


Gynecology_Novak

Gynecology_Novak. weakness. A review of seven open and four laparoscopic series involving division of the lateral ligaments revealed a general improvement in fecal incontinence and either no change or worsening of constipation (230). Conversely, there were 15 open and 4 laparoscopic series with preservation of the ligaments that displayed improved continence and a trend toward reduced constipation. This study suggests that preservation of the lateral ligaments is associated with an improvement in fecal incontinence and constipation symptoms.


Gynecology_Novak

Gynecology_Novak. Perineal procedures are more easily tolerated because they avoid laparotomy. Thus, they are ideal for patients at high risk for perioperative and postoperative morbidity and mortality. There are basically two perineal procedures: the Delorme procedure and perineal rectosigmoidectomy (Altemeier operation). Perianal encirclement procedures such as the Thiersch procedure are not recommended because of poor success rates, high recurrence rates, and fecal impaction.


Gynecology_Novak

Gynecology_Novak. The Delorme procedure was first described in 1900 and involves separation of the rectal mucosa from the sphincter and muscularis propria, followed by resection of the rectal mucosa and plication of the distal rectal wall (muscularis propria) (234) (Fig. 28.9). A review of 10 series found a recurrence rate ranging between 4% and 38% and mortality rates of 0% to 4% (230).The low mortality rates are impressive considering the higher-risk population; however, the recurrence rates make it a less desirable procedure among healthy patients. There was a general improvement in fecal incontinence and constipation. Fecal incontinence (presumably indicating anal sphincter disruption or denervation), chronic diarrhea, and severe perineal descent are associated with failure of this procedure (235). The Delorme operation may be preferred in cases when the prolapsing segment is shorter than 3 to 4 cm or there is no circumferential full-thickness prolapse, making perineal rectosigmoidectomy difficult


Gynecology_Novak

Gynecology_Novak. Delorme operation may be preferred in cases when the prolapsing segment is shorter than 3 to 4 cm or there is no circumferential full-thickness prolapse, making perineal rectosigmoidectomy difficult to perform (230,236).


Gynecology_Novak

Gynecology_Novak. Figure 28.9 Delorme’s procedure. After mucosal stripping to the full extent of the prolapse, the circular smooth muscle or the rectum is plicated. A mucosa-to-mucosa anastomosis is then performed.


Gynecology_Novak

Gynecology_Novak. Perineal rectosigmoidectomy (Altemeier operation) has become the perineal procedure of choice (237). Among 12 studies, performance of full thickness excision of the rectosigmoid was associated with recurrence rates from 0% to 16% and mortality rates of 0% to 5%. Patients generally have minimal pain and a relatively uneventful postoperative course. Recurrent prolapse probably reﬂects inadequate resection. Incontinence results are modest at best but seem to improve substantially with the addition of levatorplasty. The addition of levatorplasty also appears to decrease the short-term recurrence rate, but there is no significant change in constipation with this procedure (238). Most agree that perineal rectosigmoidectomy with levatorplasty is the best procedure for very elderly patients and those with profound comorbidity. This is the preferred approach for patients with incarcerated, strangulated, or even gangrenous prolapsed rectal segment who are not candidates for abdominal rectopexy.


Gynecology_Novak

Gynecology_Novak. with profound comorbidity. This is the preferred approach for patients with incarcerated, strangulated, or even gangrenous prolapsed rectal segment who are not candidates for abdominal rectopexy. Although there is a general consensus that abdominal rectopexy is better than perineal rectosigmoidectomy, there is only one small, prospective, randomized controlled trial comparing these procedures. This study did not have the power to detect a difference in recurrence rates but found that patients undergoing abdominal resection rectopexy had less fecal incontinence and better physiological results than patients who had perineal rectosigmoidectomy (233,239).


Gynecology_Novak

Gynecology_Novak. 1. Barber MD, Bremer RE, Thor KB, et al. Innervation of the female levator ani muscles. Am J Obstet Gynecol 2002;187:64–71. 2. Harari D, Gurwitz JH, Avorn J, et al. How do older persons define constipation? Implications for therapeutic management. J Gen Intern Med 1997;12:63–66. 3. Glia A, Lindberg G. Quality of life in patients with different types of functional constipation. Scand J Gastroenterol 1997;32:1083–1089. 4. Cundiff GW, Nygaard I, Bland DR, et al. Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders. Am J Obstet Gynecol 2000;182:S1–S10. 5. Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 2004;99:750–759. 6. Sonnenberg A, Koch TR. Epidemiology of constipation in the U.S. Dis Colon Rectum 1989;32:1–8. 7.


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Gynecology_Novak. 6. Sonnenberg A, Koch TR. Epidemiology of constipation in the U.S. Dis Colon Rectum 1989;32:1–8. 7. Drossman DA, Li Z, Andruzzi E, et al. U.S. household survey of functional gastrointestinal disorders: prevalence, sociodemography and health impact. Dig Dis Sci 1993;38:1569–1580. 8. Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to 1986. Dig Dis Sci 1989;34:606–611. 9. Rantis PC Jr, Vernava AM III, Daniel GL, et al. Chronic constipation—is the work-up worth the cost? Dis Colon Rectum 1997;40:280–286. 10. Singh G, Lingala V, Wang H, et al. Use of health care resources and cost of care for adults with constipation. Clin Gastroenterol Hepatol 2007;5:1053–1058. 11. Irvine EJ, Ferrazzi S, Pare P, et al. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am J Gastroenterol 2002;97:1986–1993. 12. Nelson RL. Epidemiology of fecal incontinence. Gastroenterology 2004;126:S3–S7. 13.


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Gynecology_Novak. 35. Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006;130:1377–1390. 36. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976–982. 37. Tulikangas PK, Walters MD, Brainard JA, et al. Enterocele: is there a histologic defect? Obstet Gynecol 2001;98:634–637. 38. Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med 1966;59:477–482. 39. Henry MM, Parks AG, Swash M. The pelvic ﬂoor musculature in the descending perineum syndrome. Br J Surg 1982;69:470– 472. 40. Cundiff GW, Harris RL, Coates K, et al. Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse. Am J Obstet Gynecol 1997;177:1345–1355. 41.


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Gynecology_Novak. 41. Ihre T. Intussusception of the rectum and the solitary ulcer syndrome. Ann Med 1990;22:419–423. 42. Thompson JR, Chen AH, Pettit PD, et al. Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. Am J Obstet Gynecol 2002;187:1494–1500. 43. Freimanis MG, Wald A, Caruana B, et al. Evacuation proctography in normal volunteers. Invest Radiol 1991:26;581–585. 44. Mellgren A, Schultz I, Johansson C, et al. Internal rectal intussusception seldom develops into total rectal prolapse. Dis Colon Rectum 1997;40:817–820. 45. Bharucha AE, Wald, A, Enck P, et al. Functional anorectal disorders. Gastroenterology 2006;130:1510–1518. 46. Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. In: Drossman DA, Corazziari E, Talley NJ, et al., eds. Rome II: the functional gastrointestinal disorders. 2nd ed. McLean, VA: Degnon Associates, 2000:351–432. 47.


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Gynecology_Novak. 47. Vanner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol 1999;94:2912–2917. 48. Bassotti G, Imbimbo B, Betti C, et al. Impaired colonic motor response to eating in patients with slow-transit constipation. Am J Gastroenterol 1992;87:504–508. 49. Rao SS. Constipation: evaluation and treatment. Gastroenterol Clin North Am 2003;32:659–683. 50. Knowles CH, Martin JE. Slow transit constipation: a model of human gut dysmotility. Review of possible aetologies. Neurogastroenterol Motil 2000;12:181–196. 51. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98:225–230. 52. Fenner DE, Genberg B, Brahma P, et al. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003;189:1543–1550. 53.


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