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Posterior vaginal compartment prolapse and defecatory dysfunction: are they related?

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Abstract

While posterior vaginal compartment prolapse and defecatory dysfunction are highly prevalent conditions in women with pelvic floor disorders, the relationship between anatomy and symptoms, specifically obstructed defecation, is incompletely understood. This review discusses the anatomy of the posterior vaginal compartment and definitions of defecatory dysfunction and obstructed defecation. A clinically useful classification system for defecatory dysfunction is highlighted. Available tools for the measurement of symptoms, physical findings, and imaging in women with posterior compartment prolapse are discussed. Based on a critical review of the literature, we investigate and summarize whether posterior compartment anatomy correlates with function. Definitions of obstructed defecation and significant posterior compartment prolapse are proposed for future exploration.

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References

  1. Handa VL, Cundiff G, Chang HH, Helzlsouer KJ (2008) Female sexual function and pelvic floor disorders. Obstet Gynecol 111:1045–1052

    Article  PubMed  Google Scholar 

  2. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE (2001) Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 185:1332–1337, discussion 1337-8

    Article  PubMed  CAS  Google Scholar 

  3. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A (2002) Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 186:1160–1166

    Article  PubMed  Google Scholar 

  4. Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW (1989) Defecography in normal volunteers: results and implications. Gut 30:1737–1749

    Article  PubMed  CAS  Google Scholar 

  5. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–506

    Article  PubMed  CAS  Google Scholar 

  6. Erekson EA, Kassis NC, Washington BB, Myers DL (2010) The association between stage II or greater posterior prolapse and bothersome obstructive bowel symptoms. Female Pelvic Med Reconstr Surg 16:59–64

    Article  PubMed  Google Scholar 

  7. Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P, Talley NJ (2005) Systematic review on the management of chronic constipation in North America. Am J Gastroenterol 100(Suppl 1):S5–S21

    Article  PubMed  Google Scholar 

  8. Varma MG, Hart SL, Brown JS, Creasman JM, Van Den Eeden SK, Thom DH (2008) Obstructive defecation in middle-aged women. Dig Dis Sci 53:2702–2709

    Article  PubMed  Google Scholar 

  9. Whitcomb EL, Lukacz ES, Lawrence JM, Nager CW, Luber KM (2009) Prevalence of defecatory dysfunction in women with and without pelvic floor disorders. Female Pelvic Med Reconstr Surg 15:179–187. doi:10.1097/SPV.0b013e3181b12e01

    Google Scholar 

  10. Stewart WF, Liberman JN, Sandler RS et al (1999) Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features. Am J Gastroenterol 94:3530–3540

    Article  PubMed  CAS  Google Scholar 

  11. Bradley CS, Brown MB, Cundiff GW et al (2006) Bowel symptoms in women planning surgery for pelvic organ prolapse. Am J Obstet Gynecol 195:1814–1819

    Article  PubMed  Google Scholar 

  12. Bradley CS, Nygaard IE (2005) Vaginal wall descensus and pelvic floor symptoms in older women. Obstet Gynecol 106:759–766

    Article  PubMed  Google Scholar 

  13. Tan JS, Lukacz ES, Menefee SA, Powell CR, Nager CW (2005) Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct 16:203–209, discussion 209

    Article  PubMed  Google Scholar 

  14. Gutman RE, Ford DE, Quiroz LH, Shippey SH, Handa VL (2008) Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms? Am J Obstet Gynecol 199:683.e1–683.e7. doi:10.1016/j.ajog.2008.07.028

    Article  Google Scholar 

  15. Swift SE, Tate SB, Nicholas J (2003) Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 189:372–377, discussion 377-9

    Article  PubMed  Google Scholar 

  16. Barber MD, Brubaker L, Nygaard I et al (2009) Defining success after surgery for pelvic organ prolapse. Obstet Gynecol 114:600–609

    Article  PubMed  Google Scholar 

  17. Abramov Y, Gandhi S, Goldberg RP, Botros SM, Kwon C, Sand PK (2005) Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 105:314–318

    Article  PubMed  Google Scholar 

  18. Cundiff GW, Fenner D (2004) Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 104:1403–1421

    Article  PubMed  Google Scholar 

  19. Kleeman SD, Westermann C, Karram MM (2005) Rectoceles and the anatomy of the posterior vaginal wall: revisited. Am J Obstet Gynecol 193:2050–2055

    Article  PubMed  Google Scholar 

  20. Kleeman SD, Karram M (2008) Posterior pelvic floor prolapse and a review of the anatomy, preoperative testing and surgical management. Minerva Ginecol 60:165–182

    PubMed  CAS  Google Scholar 

  21. Leffler KS, Thompson JR, Cundiff GW et al (2001) Attachment of the rectovaginal septum to the pelvic sidewall. Am J Obstet Gynecol 185:41–43

    Article  PubMed  CAS  Google Scholar 

  22. DeLancey JO (1999) Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol 180:815–823

    Article  PubMed  CAS  Google Scholar 

  23. Abendstein B, Petros PE, Richardson PA, Goeschen K, Dodero D (2008) The surgical anatomy of rectocele and anterior rectal wall intussusception. Int Urogynecol J Pelvic Floor Dysfunct 19:705–710

    Article  PubMed  CAS  Google Scholar 

  24. Richardson AC (1996) Female pelvic floor support defects. Int Urogynecol J Pelvic Floor Dysfunct 7:241

    Article  PubMed  CAS  Google Scholar 

  25. Nichols DH (1996) Vaginal surgery. Lippincott Williams & Wilkins, Philadelphia

    Google Scholar 

  26. Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 36:976–983

    Article  PubMed  CAS  Google Scholar 

  27. Bump RC, Mattiasson A, Bo K et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17

    Article  PubMed  CAS  Google Scholar 

  28. Mellgren A (1995) Diagnosis and treatment of constipation. Eur J Surg 161:623–634

    PubMed  CAS  Google Scholar 

  29. Ternent CA, Bastawrous AL, Morin NA, Ellis CN, Hyman NH, Buie WD (2007) Practice parameters for the evaluation and management of constipation. Dis Colon Rectum 50:2013–2022

    Article  PubMed  Google Scholar 

  30. Bharucha AE, Wald A, Enck P, Rao S (2006) Functional anorectal disorders. Gastroenterology 130:1510–1518

    Article  PubMed  Google Scholar 

  31. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006) Functional bowel disorders. Gastroenterology 130:1480–1491

    Article  PubMed  Google Scholar 

  32. Haylen BT, de Ridder D, Freeman RM et al (2010) An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 29:4–20

    PubMed  Google Scholar 

  33. Davis K, Kumar D (2005) Posterior pelvic floor compartment disorders. Best Pract Res Clin Obstet Gynaecol 19:941–958

    Article  PubMed  Google Scholar 

  34. American College of Gastroenterology Chronic Constipation Task Force (2005) An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 100(Suppl 1):S1–S4

    Article  Google Scholar 

  35. Gutman RE, Cundiff GW (2007) Chapter 25: anorectal dysfunction. In: Berek J (ed) Novak's gynecology, 14th edn. Lippincott Williams & Wilkins, Philadelphia

    Google Scholar 

  36. Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 32:920–924

    Article  PubMed  CAS  Google Scholar 

  37. Saad RJ, Rao SS, Koch KL et al (2010) Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol 105:403–411

    Article  PubMed  Google Scholar 

  38. Altomare DF, Spazzafumo L, Rinaldi M, Dodi G, Ghiselli R, Piloni V (2008) Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome. Colorectal Dis 10:84–88. doi:10.1111/j.1463-1318.2007.01262.x

    PubMed  CAS  Google Scholar 

  39. Barber MD, Kuchibhatla MN, Pieper CF, Bump RC (2001) Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol 185:1388–1395

    Article  PubMed  CAS  Google Scholar 

  40. Barber MD, Walters MD, Bump RC (2005) Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 193:103–113

    Article  PubMed  CAS  Google Scholar 

  41. Jelovsek JE, Markland AD, Brubaker L et al (2010) Minimum important differences for scales assessing symptom severity and quality of life in patients with fecal incontinence (abstract). Female Pelvic Med Reconstr Surg 16:S66

    Google Scholar 

  42. Grimes CL, Lieschen H, Gutman RE, Shippey S, Cundiff GW, Handa VL (2010) Long-term impact of abdominal sacral colpoperineopexy on symptoms of obstructed defecation. Female Pelvic Med Reconstr Surg 16:234–237

    Article  PubMed  Google Scholar 

  43. Burrows LJ, Sewell C, Leffler KS, Cundiff GW (2003) The accuracy of clinical evaluation of posterior vaginal wall defects. Int Urogynecol J Pelvic Floor Dysfunct 14:160–163, discussion 163

    Article  PubMed  Google Scholar 

  44. Hall AF, Theofrastous JP, Cundiff GW et al (1996) Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol 175:1467–1470, discussion 1470-1

    Article  PubMed  CAS  Google Scholar 

  45. Shull BL (1993) Clinical evaluation of women with pelvic support defects. Clin Obstet Gynecol 36:939–951

    Article  PubMed  CAS  Google Scholar 

  46. Baessler K, Schuessler B (2006) Anatomy of the sigmoid colon, rectum, and the rectovaginal pouch in women with enterocele and anterior rectal wall procidentia. Clin Anat 19:125–129

    Article  PubMed  Google Scholar 

  47. Heslop JH (1987) Piles and rectoceles. Aust N Z J Surg 57:935–938

    Article  PubMed  CAS  Google Scholar 

  48. Groenendijk AG, Birnie E, de Blok S et al (2009) Clinical-decision taking in primary pelvic organ prolapse; the effects of diagnostic tests on treatment selection in comparison with a consensus meeting. Int Urogynecol J Pelvic Floor Dysfunct 20:711–719

    Article  PubMed  Google Scholar 

  49. Groenendijk AG, van der Hulst VP, Birnie E, Bonsel GJ (2008) Correlation between posterior vaginal wall defects assessed by clinical examination and by defecography. Int Urogynecol J Pelvic Floor Dysfunct 19:1291–1297

    Article  PubMed  Google Scholar 

  50. Altman D, Lopez A, Kierkegaard J et al (2005) Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography. Int Urogynecol J Pelvic Floor Dysfunct 16:96–103, discussion 103

    Article  PubMed  Google Scholar 

  51. Kenton K, Shott S, Brubaker L (1999) The anatomic and functional variability of rectoceles in women. Int Urogynecol J Pelvic Floor Dysfunct 10:96–99

    Article  PubMed  CAS  Google Scholar 

  52. Broekhuis SR, Futterer JJ, Barentsz JO, Vierhout ME, Kluivers KB (2009) A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: the use of reference lines and anatomical landmarks. Int Urogynecol J Pelvic Floor Dysfunct 20:721–729

    Article  PubMed  Google Scholar 

  53. Broekhuis SR, Kluivers KB, Hendriks JC, Futterer JJ, Barentsz JO, Vierhout ME (2009) POP-Q, dynamic MR imaging, and perineal ultrasonography: do they agree in the quantification of female pelvic organ prolapse? Int Urogynecol J Pelvic Floor Dysfunct. doi:10.1007/s00192-009-0821-1

  54. Weber AM, Walters MD, Ballard LA, Booher DL, Piedmonte MR (1998) Posterior vaginal prolapse and bowel function. Am J Obstet Gynecol 179:1446–1449, discussion 1449-50

    Article  PubMed  CAS  Google Scholar 

  55. Jelovsek JE, Barber MD, Paraiso MF, Walters MD (2005) Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence. Am J Obstet Gynecol 193:2105–2111

    Article  PubMed  Google Scholar 

  56. da Silva GM, Gurland B, Sleemi A, Levy G (2006) Posterior vaginal wall prolapse does not correlate with fecal symptoms or objective measures of anorectal function. Am J Obstet Gynecol 195:1742–1747

    Article  PubMed  Google Scholar 

  57. Barber MD, Walters M, Bump R (2003) Association of magnitude of pelvic organ prolapse and presentation and severity of symptoms (abstract). J Pelvic Med Surg 208

  58. Fialkow MF, Gardella C, Melville J, Lentz GM, Fenner DE (2002) Posterior vaginal wall defects and their relation to measures of pelvic floor neuromuscular function and posterior compartment symptoms. Am J Obstet Gynecol 187:1443–1448, discussion 1448-9

    Article  PubMed  Google Scholar 

  59. Dietz HP, Korda A (2005) Which bowel symptoms are most strongly associated with a true rectocele? Aust N Z J Obstet Gynaecol 45:505–508

    Article  PubMed  Google Scholar 

  60. Burrows LJ, Meyn LA, Walters MD, Weber AM (2004) Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 104:982–988

    Article  PubMed  Google Scholar 

  61. Kahn MA, Breitkopf CR, Valley MT et al (2005) Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population. Am J Obstet Gynecol 192:1516–1522

    Article  PubMed  Google Scholar 

  62. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ et al (2009) The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct 20:1037–1045

    Article  PubMed  Google Scholar 

  63. Morgan DM, DeLancey JO, Guire KE, Fenner DE (2007) Symptoms of anal incontinence and difficult defecation among women with prolapse and a matched control cohort. Am J Obstet Gynecol 197(509):e1–e6. doi:10.1016/j.ajog.2007.03.074

    PubMed  Google Scholar 

  64. Saks EK, Harvie HS, Asfaw TS, Arya LA (2010) Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse. Int J Gynaecol Obstet 111:237–240

    Article  PubMed  Google Scholar 

  65. Digesu GA, Khullar V, Cardozo L, Robinson D, Salvatore S (2005) P-QOL: a validated questionnaire to assess the symptoms and quality of life of women with urogenital prolapse. Int Urogynecol J Pelvic Floor Dysfunct 16:176–181, discussion 181

    Article  PubMed  Google Scholar 

  66. Pescatori M, Spyrou M, Pulvirenti d'Urso A (2006) A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'. Colorectal Dis 8:785–789

    Article  PubMed  CAS  Google Scholar 

  67. Gustilo-Ashby AM, Paraiso MF, Jelovsek JE, Walters MD, Barber MD (2007) Bowel symptoms 1 year after surgery for prolapse: further analysis of a randomized trial of rectocele repair. Am J Obstet Gynecol 197:76.e1–76.e5. doi:10.1016/j.ajog.2007.02.045

    Article  Google Scholar 

  68. Bradley CS, Nygaard IE, Brown MB et al (2007) Bowel symptoms in women 1 year after sacrocolpopexy. Am J Obstet Gynecol 197:642.e1–642.e8. doi:10.1016/j.ajog.2007.08.023

    Article  Google Scholar 

  69. Miedel A, Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M (2008) Symptoms and pelvic support defects in specific compartments. Obstet Gynecol 112:851–858

    Article  PubMed  Google Scholar 

  70. Soligo M, Salvatore S, Emmanuel AV, De Ponti E, Zoccatelli M, Cortese M, Milani R (2006) Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights. Am J Obstet Gynecol 195:50–55

    Article  PubMed  Google Scholar 

  71. Bradley CS, Zimmerman MB, Wang Q, Nygaard IE, Women's Health I (2008) Vaginal descent and pelvic floor symptoms in postmenopausal women: a longitudinal study. Obstet Gynecol 111:1148–1153

    Article  PubMed  Google Scholar 

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Acknowledgement

Illustrations are made by Justin Marquis.

Conflicts of interest

Grimes has no conflict of interest. Lukacz is a consultant for Pfizer, a recipient of research funding from Renew Medical, and a recipient of an educational grant from Johnson and Johnson.

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  1. Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Reproductive Medicine, University of California, San Diego, La Jolla, CA, USA

    Cara L. Grimes & Emily S. Lukacz

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  1. Cara L. Grimes
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  2. Emily S. Lukacz
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Correspondence to Cara L. Grimes.

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Grimes, C.L., Lukacz, E.S. Posterior vaginal compartment prolapse and defecatory dysfunction: are they related?. Int Urogynecol J 23, 537–551 (2012). https://doi.org/10.1007/s00192-011-1629-3

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