Prospective evaluation of paravaginal defect repair with and without apical suspension: a 6-month postoperative follow-up with MRI, clinical examination, and questionnaires.

INTRODUCTION AND HYPOTHESIS: Paravaginal defect (PVD) has been suggested as one of the main contributors to the development of prolapse in the anterior vaginal wall (AVW). We aimed to evaluate the descent of pelvic organs, presence of vaginal H configuration, and pubococcygeus (PC) muscle defect by pelvic magnetic resonance imaging (MRI), together with subjective symptoms of prolapse, before and 6 months after PVD repair. We also aimed to evaluate risk factors of recurrence. METHODS: Fifty women with PVD diagnosed by gynecological examination and scheduled for vaginal PVD repair were planned for enrollment. Preoperatively and 6 months postoperatively, subjective symptoms were evaluated using the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) together with MRI of the pelvis to evaluate defects in the PC muscle, vaginal shape, and pelvic organ descent. RESULTS: Forty-six women completed the study. Twenty had PVD repair alone, whereas 26 also had concomitant surgery performed. Prolapse grade, subjective symptoms, sexual problems, and quality of life (QoL) were significantly improved at follow-up. Missing vaginal H configuration was observed in 21 women before operation and was correlated with PC muscle defect. Recurrence rate was 39%, and significantly more women with recurrence had PC muscle defects and missing H configuration. CONCLUSION: Vaginal PVD repair alone or combined with concomitant surgery significantly reduces objective prolapse and subjective symptoms. We could not demonstrate MRI findings of missing H configuration to be a sign of PVD but, rather, a sign of defect in the PC muscle. Risk of recurrence is significantly higher in women with major PC muscle defects and missing H configuration.

Complete obstetric anal sphincter tear and risk of long-term fecal incontinence: a cohort study.

BACKGROUND: Women with anal sphincter injuries have an increased risk of developing fecal incontinence despite surgical intervention. OBJECTIVE: The aim of this study was to evaluate the long-term risk of fecal incontinence after primary anal sphincter reconstruction and its impact on quality of life. DESIGN: This was a cohort study. SETTINGS: This study was performed at Aarhus University Hospital. PATIENTS: Women with complete anal sphincter rupture (exposed) from 1976 to 1991 and a control group of parous women (nonexposed) were included. MAIN OUTCOME: The primary outcomes measured were fecal incontinence, Wexner score, St Mark incontinence score, and quality of life. RESULTS: A total of 363 women were included (125 exposed and 238 nonexposed). The mean age was 50.4 years (95%CI: 49.8-51.0), with 22.2 years (95% CI: 21.7-22.6) of follow-up. At the time of follow-up, 49% of exposed women and 74% of nonexposed women were continent. Complete anal sphincter tear increases the risk of fecal incontinence twofold (relative risk = 2.00; 95%CI: 1.52-2.63). No other risk factors were identified. The mean Wexner score was 1.7 (95%CI: 1.3-2.1) vs 1.1 (95%CI: 0.7-1.4) (p = 0.02), and the mean St Mark score was 2.8 (95% CI: 2.1-3.4) vs 1.4 (95%CI: 1.0-1.9) (p < 0.001) in the exposed and nonexposed groups. Severity of fecal incontinence had a significant impact on the quality of life independent of exposure. LIMITATION: The cohort is relatively young; a short postmenopausal period limits the assessment of hormonal status and the effect of postmenopausal hormone replacement therapy. CONCLUSION: Complete obstetric anal sphincter tear increases the long-term risk of fecal incontinence twofold. When present, the severity of the incontinence symptoms is minor and the risk of incontinence for solid stool is not increased in comparison with the general population. Anal sphincter rupture is the only independent risk factor for fecal incontinence. The severity of fecal incontinence had the same impact on quality of life in both groups.

Long-term outcome of delayed primary or early secondary reconstruction of the anal sphincter after obstetrical injury.

PURPOSE: Traditionally sphincter repair has not been performed during the puerperium. This prospective study was designed to determine the long-term outcome of delayed primary or early secondary sphincteroplasty in the puerperium. METHODS: Between 1991 and 2005, 22 females underwent delayed primary or early secondary repair after third-degree or fourth-degree anal sphincter rupture. Delayed primary reconstruction was performed more than 72 hours after delivery. Early secondary reconstruction was performed within 14 days postpartum. The reconstruction of the anal sphincter was performed without a covering stoma, in all cases. A control group of 19 age-matched and parity-matched females, without known anal sphincter injury after vaginal delivery, were included. Current degree of continence and associated quality of life were determined by a fecal incontinence severity questionnaire and a quality of life questionnaire. RESULTS: None of the females had complications postoperatively. Mean follow-up was 50 (range, 2-155) months in the case group and 60 (range, 12-132) months in the control group. At time of follow-up, the Wexner score was 4.1 (range, 0-13) in females with delayed primary or early secondary reconstruction and 1.1 (range, 0-8) in the control group (P<0.01). The inconvenience of incontinence after reconstruction was significantly higher (P<0.01) compared with the control group, but the quality of life was not significantly affected (P=0.75). CONCLUSIONS: It is safe to perform a delayed primary or early secondary reconstruction without a covering stoma in females who have sustained a third-degree or fourth-degree obstetric tear. The long-term functional outcome is acceptable.

Outcome of site-specific fascia repair for rectocele.

BACKGROUND: This article presents the anatomic and functional outcome of site-specific fascia repair for rectocele performed under local anesthesia. Methods. In this case series, 51 consecutive patients underwent site-specific rectocele repair under local anesthesia. Patients were subsequently reviewed in the outpatient clinic. RESULTS: The mean follow-up period was 26.7 months. Pelvic examination revealed recurrence of posterior vaginal wall prolapse in 31% (16/51). Improvement in emptying the rectum was achieved in 23% (7/30), and 23% (7/30) were relieved from constipation. One patient developed de novo dyspareunia. Some 92% of the patients (47/51) would recommend local anesthesia. CONCLUSIONS: Anatomic correction of posterior vaginal wall prolapse does not guarantee alleviation of all symptoms, especially those regarding defecation; however, postoperative dyspareunia levels are low. The use of local anesthesia is associated with high patient satisfaction. Patients should be informed that total recovery from accompanying subjective symptoms cannot be guaranteed.

Use of porcine small intestinal submucosa in the surgical treatment of recurrent rectocele in a patient with Ehlers-Danlos syndrome type III.

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders involving various organ systems. We report the case of a female patient with Ehlers-Danlos syndrome type III (EDS III) presenting with a recurrent rectocele in whom porcine small intestinal submucosa mesh was used successfully to correct the defect in the rectovaginal fascia.