Objective
We sought to evaluate changes in bowel symptoms after rectocele repair and identify risk factors for persistent symptoms.
Study Design
We conducted ancillary analysis of a randomized surgical trial for rectocele repair. Subjects underwent examinations and completed questionnaires for bowel symptoms at baseline and 12 months postoperatively. Outcomes included resolution, persistence, or de novo bowel symptoms. We used multiple logistic regression to identify risk factors for bowel symptom persistence.
Results
A total of 160 women enrolled: 139 had baseline bowel symptoms and 85% had 12-month data. The prevalence of bowel symptoms decreased after rectocele repair (56% vs 23% splinting, 74% vs 37% straining, 85% vs 19% incomplete evacuation, 66% vs 14% obstructive defecation; P < .001 for all). On multiple logistic regression, a longer history of splinting was a risk factor for persistent postoperative splinting (adjusted odds ratio, 2.25; 95% confidence interval, 1.02–4.93).
Conclusion
Bowel symptoms may improve after rectocele repair, but almost half of women will have persistent symptoms.
Bowel symptoms and defecatory dysfunction are common in women with pelvic floor disorders. The term “defecatory dysfunction” broadly includes the need for excessive straining, manual manipulation, the sensation of incomplete evacuation, and the sensation of obstructed defecation. Pelvic organ prolapse has been reported to be a risk factor for bowel symptoms and it is estimated that 67-80% of women with pelvic organ prolapse also report defecatory symptoms.
The underlying cause of defecatory symptoms may include structural disorders (eg, rectocele, rectal prolapse), functional disorders (eg, dyssynergic defecation, metabolic disorders), or even a “normal” range of bowel habits. On clinical examination, patients with these bowel symptoms may have posterior vaginal wall prolapse or rectocele. However, many studies have not confirmed an association between the severity of posterior vaginal prolapse and increasing bowel symptom prevalence or severity. In addition, surgery for rectocele does not always lead to resolution of the bowel symptoms. A study by Gustilo-Ashby et al concluded that resolution or improvement in bowel symptoms can be expected after rectocele repair; however, up to 35% of their patients reported persistent or worsening bowel symptoms postoperatively. We previously found that up to 45% of women who participated in a randomized trial of graft-augmented vs native tissue rectocele repair also reported persistent defecatory symptoms. Therefore, more information on the effect of rectocele repair on bowel symptoms and predictors are needed to most appropriately counsel women regarding expectations after rectocele repair.
The primary objective of this study was to describe changes in bowel symptoms 1 year after rectocele repair. Our secondary objective was to identify risk factors for persistent and/or worsening bowel symptoms.
Materials and Methods
We performed a planned ancillary analysis of 160 women enrolled in a randomized, double-masked controlled trial of porcine subintestinal submucosal graft-augmented rectocele repair vs native tissue repair. The details and methods for this trial have been previously published. This ancillary analysis includes the subset of women who reported baseline bowel symptoms. The study was conducted at 2 sites: Women and Infants Hospital of Rhode Island in Providence, and Hartford Hospital in Connecticut, and the protocol was approved by both institutional review boards. Patients and outcome assessors were masked to randomization assignment. All women provided written informed consent. No funding or support was provided by the manufacturer of the graft for any portion of the study.
As previously described, women with symptomatic stage II rectocele electing surgical repair were eligible. Other concomitant vaginal prolapse repairs and antiincontinence procedures were allowed. Women <18 years of age; undergoing concomitant sacrocolpopexy or colorectal procedures; with a history of porcine allergy, connective tissue disease, pelvic malignancy, or pelvic radiation; or who did not speak English were excluded.
All women underwent a complete history and physical examination, including the Pelvic Organ Prolapse Quantification examination in a 30-degree supine lithotomy position at baseline and 12 months postoperatively. All women also completed a self-administered symptom questionnaire at baseline and 12 months postoperatively, which included relevant items from the Pelvic Floor Distress Inventory (PFDI)-20. Although “abnormal” bowel behavior can encompass a wide range of symptoms, the American College of Gastroenterology defines constipation as “unsatisfactory defecation characterized by infrequent bowel movement, difficult stool passage, or both, with difficult stool passage including straining, sense of incomplete evacuation, hard/lumpy stool, prolonged time to defecate, or need for manual maneuvers.” Therefore, we included bowel symptoms of splinting (PFDI item #4), straining (PFDI item #7), incomplete evacuation (PFDI item #8), and obstructed defecation (sensation that “stool gets trapped”). We also measured anal incontinence (inability to control gas and/or stool). Women with affirmative responses were asked additional detailed questions regarding bowel symptom characteristics including the severity of bother, the frequency of occurrence of each bowel symptom (every day, >once/wk, once/wk, once/mo, <once/mo), and duration of symptoms prior to surgery (<12 months, 1-2 years, >2 years).
Women reporting any bowel symptom at baseline with 12-month data were included in this analysis. We assessed changes in bowel symptoms between baseline and 12 months postoperatively. We use the following definitions: resolution of symptoms (symptoms present at baseline that had completely resolved at 12 months); persistence of symptoms (symptoms that were present at baseline and either stayed the same or worsened in severity of bother at 12 months); improvement of symptoms (symptoms that were present at baseline and improved in severity of bother at 12 months); and de novo symptoms (bowel symptoms that were absent at baseline but present postoperatively). Student t tests were used to compare means between groups. We used χ 2 for categorical variables. We compared baseline and 12-month changes in bowel symptoms using McNemar test or Cochran-Mantel-Haenszel test to account for within-person comparisons. For women reporting any degree of bowel symptoms postoperatively, we also evaluated in detail changes in frequency of occurrence and severity of bother after rectocele repair. We used multiple logistic regression to identify risk factors for persistent bowel symptoms at 12 months, constructing separate models for straining, splinting, incomplete evacuation, and obstructed defecation. Variables based on the literature and those that statistically changed our effect estimates were included in our models. P < .05 was considered statistically significant. Statistical analyses were performed using software (SAS 8.2; SAS Institute, Cary, NC).
Results
A total of 160 women were randomized in this trial. All women received a rectocele repair: 81 received native tissue repair and 79 received graft-augmented rectocele repair. There was a high prevalence of at least 1 bowel symptom. Of the 160 women randomized, 139 (87%) had bowel symptoms at baseline and 117 (85%) of these had 12-month data and were included in this analysis. At baseline, the mean age of women with bowel symptoms was 56.2 years (SD 11), the majority (99%) were Caucasian, 27% had undergone a prior urogynecologic procedure, and 80% had stage II and 21% had stage III rectocele on baseline Pelvic Organ Prolapse Quantification. Of women, 94% underwent concomitant procedures, including 13% who underwent vaginal hysterectomy and vault suspension. Table 1 presents additional clinical characteristics of the study population.
| Variable | |
|---|---|
| Mean age, y (SD) | 56.2 (10.9) |
| Preoperative rectocele stage, n (%) | |
| II | 93 (79.5) |
| III | 24 (20.5) |
| IV | 0 |
| Median preoperative POP-Q measurements, cm (range) | |
| Point AP | 0.0 (−1.0 to 4.0) |
| Point BP | 0.0 (−1.0 to 4.0) |
| GH | 4.0 (2.0–6.5) |
| PB | 3.5 (0.0–6.0) |
| Postoperative rectocele stage, n (%) | |
| 0 | 69 (61.1) |
| I | 32 (28.3) |
| II | 10 (8.9) |
| III | 2 (1.8) |
| IV | 0 |
| Median postoperative POP-Q measurements, cm (range) | |
| Point AP | −3.0 (−3.0 to 3.0) |
| Point BP | −3.0 (−3.0 to 3.0) |
| GH | 3.0 (0–5.0) |
| PB | 4.0 (0–6.0) |
At baseline, 56% of women reported manual splinting; 74%, straining; 85%, incomplete evacuation; 66%, sensation of obstructed defecation; and 63%, anal incontinence. Of women, 15% reported having only 1 bowel symptom; 14%, 2 bowel symptoms; 24%, 3 bowel symptoms; 23%, 4 bowel symptoms; and 25%, all 5 bowel symptoms.
Changes in bowel symptoms are presented in Table 2 . At 12 months postsurgery, the prevalence of all bowel symptoms significantly decreased; however, 23% of patients reported persistent splinting; 37%, persistent straining; and 19%, persistent incomplete evacuation ( P < .001 for all). The prevalence of obstructed defecation also improved (14%) as did anal incontinence (26%) ( P < .001 for both). The total number of bowel symptoms reported postoperatively per patient also significantly decreased with 29% now reporting 0 symptoms; 21%, 1 symptom; 23%, 2 symptoms; 16%, 3 symptoms; 10%, 4 symptoms; and <1%, 5 bowel symptoms ( P < .0001, data not shown).
| Bowel symptom | Baseline, n (%) | 12 mo postoperative, n (%) a | |
|---|---|---|---|
| Splinting | 66 (57) | Persistent | 15 (22.7) b |
| Resolved | 40 (60.6) | ||
| Improved | 11 (16.7) | ||
| De novo | 0 | ||
| Straining | 80 (69) | Persistent | 32 (36.8) b |
| Resolved | 35 (40.2) | ||
| Improved | 13 (14.9) | ||
| De novo | 7 (8.1) | ||
| Incomplete evacuation | 92 (80) | Persistent | 19 (19.0) b |
| Resolved | 50 (50.0) | ||
| Improved | 23 (23.0) | ||
| De novo | 8 (8.0) | ||
| Obstructed defecation | 73 (66) | Persistent | 11 (14.3) b |
| Resolved | 53 (68.8) | ||
| Improved | 9 (11.7) | ||
| De novo | 4 (5.2) | ||
a Resolved = symptom present at baseline, absent postoperatively; persistent = symptom present at baseline, same or worse bother postoperatively; improved = symptom present at baseline and postoperatively, but improved bother severity; de novo = symptom absent at baseline, present postoperatively;
b P < .001 for comparison of baseline vs persistent postoperative symptoms.
Table 3 presents additional details regarding bowel symptom characteristics for the women reporting unresolved bowel symptoms at 12 months (includes those reporting symptoms improved, same, or worse). The frequency of experiencing each symptom daily, weekly, or monthly significantly improved only for the symptom of incomplete evacuation, although there were trends of improvement in frequency for all other bowel symptoms as well. Overall the severity of bother improved for splinting, straining, incomplete evacuation, and obstructed defecation.
| Bowel symptom and characteristic | Baseline | 12 mo postoperative | P value |
|---|---|---|---|
| Splinting (n = 26) | |||
| Frequency | |||
| Every day | 8 (30.8) | 4 (16.0) | |
| Once/wk to once/mo | 15 (57.7) | 13 (52.0) | |
| <Once/mo | 3 (11.5) | 8 (32.0) | .06 |
| Severity of bother | |||
| Very | 16 (61.5) | 7 (26.9) | |
| Somewhat/moderate | 7 (26.9) | 11 (42.3) | |
| Not at all | 3 (11.5) | 8 (30.8) | .01 |
| Straining (n = 45) | |||
| Frequency | |||
| Every day | 8 (17.8) | 8 (18.2) | |
| Once/wk to once/mo | 30 (66.7) | 25 (56.8) | |
| <Once/mo | 7 (15.6) | 11 (25.0) | .3 |
| Severity of bother | |||
| Very | 22 (48.9) | 12 (26.7) | |
| Somewhat/moderate | 21 (46.7) | 31 (68.9) | |
| Not at all | 2 (4.4) | 2 (4.4) | .03 |
| Incomplete evacuation (n = 42) | |||
| Frequency | |||
| Every day | 14 (33.3) | 6 (14.6) | |
| Once/wk to once/mo | 26 (61.9) | 30 (73.2) | |
| <Once/mo | 2 (4.8) | 5 (12.5) | .08 |
| Severity of bother | |||
| Very | 26 (61.9) | 12 (28.6) | |
| Somewhat/moderate | 16 (38.1) | 20 (47.6) | |
| Not at all | 0 | 10 (23.8) | < .0001 |
| Obstructed defecation (n = 20) | |||
| Frequency | |||
| Every day | 7 (35.0) | 3 (15.0) | |
| Once/wk to once/mo | 13 (65.0) | 13 (65.0) | |
| <Once/mo | 0 | 4 (20.0) | .02 |
| Severity of bother | |||
| Very | 11 (55.0) | 7 (35.0) | |
| Somewhat/moderate | 9 (45.0) | 10 (5.0) | |
| Not at all | 0 | 3 (15.0) | .1 |
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