posterior compartment prolapse: when to do what? … · introduction • posterior vaginal wall...
TRANSCRIPT
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T: +27(0)51 401 9111 | [email protected] | www.ufs.ac.za
POSTERIOR
COMPARTMENT
PROLAPSE:
WHEN TO DO
WHAT? Dr EW Henn
SASOG May 2014
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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
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INTRODUCTION
• Posterior vaginal wall disorders:
Enterocele
Rectocele
Perineal descent/hernia
Intussusception
Rectal prolapse
• Anatomy/function
• Trans-disciplinary
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INTRODUCTION:
POSTERIOR PELVIC ORGAN PROLAPSE (POP)
• Gynaecological literature
Definition
Outcomes
• Colorectal literature
Definition
Outcomes
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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
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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
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BASIC SCIENCE
• Normal support multifaceted:
Pelvic diaphragm
Endopelvic fascia
Rectovaginal septum
Perineum
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BASIC SCIENCE: PELVIC DIAPHRAGM
• Pelvic diaphragm:
Levator ani & coccygeus
Primal pictures
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BASIC SCIENCE: PELVIC DIAPHRAGM
• Levator plate:
Posterior insertion (midline raphe)
Tonic state
Elevation achieved
Levator hiatus
• Balancing of forces
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BASIC SCIENCES: ENDOPELVIC FASCIA
• Levels of support (DeLancey)
Level I
Level II
Level III
• Condensations
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BASIC SCIENCES: RECTOVAGINAL SEPTUM
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PERINEAL MEMBRANE
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PATHOGENESIS
• Often combinations
Reflected in epidemiological data
• Posterior vaginal supports: Distal, mid, proximal
Distal vagina: perineal membrane
DeLancey, JO 1999
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PATHOGENESIS
Midvagina: endopelvic fascia and rectovaginal septum
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PATHOGENESIS
Midvagina: levator ani (injury/dysfunction)
• Levator plate
• Levator hiatus
• Genital hiatus
• Level II displacement
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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
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CLINICAL APPROACH
• Symptomatic evaluation
Management must be individualised
General pelvic floor dysfunction
Bulge
Bladder
Bowel
Dyspareunia
Daily activities
• Validated questionnaires
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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
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CLINICAL SYMPTOMS
• Typical symptoms:
o Chronic constipation
o Incomplete bowel emptying
o ODS
o Defecatory pain
o Anal incontinence
Pescatori, M 2011
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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
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CLINICAL APPROACH: OBSTRUCTED DEFECATION
• ODS: Rule out
Proximal cancer
Intussusception
Slow transit constipation
IBS
Anismus
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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
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CLINICAL EVALUATION
• Visual inspection
Rest
Cough
Valsalva
• Hymenal ring
• Perineal descent
• Rectal prolapse
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CLINICAL EVALUATION
• Remember:
o 3 compartments
o 3 levels
• Rectovaginal examination
Enterocele?
• Rectal examination
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SPECIAL INVESTIGATIONS: IMAGING
• Defecography:
Conventional
MRI
• Ultrasound:
Perineal
Endovaginal
Endoanal
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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
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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
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SPECIAL INVESTIGATIONS
• Consider:
Anal manometry
EMG
Nerve conduction studies
Colonic transit time
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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
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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
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POSTERIOR PROLAPSE: CONSERVATIVE
• Lifestyle
• Underlying co-morbidities and Rx
• Diet
• Stool management
• Exercise
• Multidisciplinary
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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:
oYounger women
oDiscomfort
o Large genital hiatus-short vagina Geoffrion,R 2013
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POSTERIOR PROLAPSE: CONSERVATIVE
• Biofeedback:
Conflicting results
Likely benefit:
oDyssenergic defecation
(anismus)
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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)
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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
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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)
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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
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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
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TRANSVAGINAL REPAIRS
• Posterior colporrhaphy:
o Anatomic success 83%
o Post-op dyspareunia 18%
o ODS (digitation) 26%
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TRANSVAGINAL REPAIRS
• Defect-specific repair:
o Anatomic success 83%
o Post-op dyspareunia 18%
o ODS (digitation) 18%
Karram, Maher 2013
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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
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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%
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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
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POSTERIOR PROLAPSE: UNIVERSITAS
• Rectocele plication
– Often combined with perineal repair
– Technique
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POSTERIOR PROLAPSE: UNIVERSITAS
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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%
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SUMMARY: WHEN TO DO WHAT?
• Appreciate anatomy and epidemiology
• Assessment holistic
Patient & Pelvic floor
Optimal outcome
Individualise
management
Goal directed
management