Chapter Outline
Pelvic floor dysfunction including pelvic organ prolapse and urinary or fecal incontinence affects one in four community-dwelling women. Our population is aging. Over the next 40 years, the population of women 65 years and older will more than double (from 38.6 million to 88.5 million) and the population of women 85 years and older will dramatically increase (from 5.4 million to 19 million). As women age, dysfunction of the pelvic floor becomes progressively more common. In fact, one-half of all women over the age of 80 years have at least one form of pelvic floor dysfunction. The development of pelvic floor dysfunction may have a dramatic effect on a woman’s quality of life. In fact, urinary and fecal incontinence are common indications for nursing home placement.
Annually, approximately 225,000 women in the United States undergo prolapse surgery, with direct costs estimated at $1 billion per year. One-third to one-half of all prolapse surgeries involve the posterior vaginal wall. Although rectocele repair has been commonly performed for over a century, the long-term functional and anatomic outcomes and ideal procedure have not been determined. This chapter will review the anatomy, pathophysiology, evaluation techniques, and surgical management of rectoceles and perineal body defects.
Anatomy and Pathophysiology
The gynecologist, searching for a means of holding up and maintaining sagging structures and organs, has placed reliance on a mythical support of his own creation.
The terminology of the anatomic tissue that is present under the vaginal epithelium has been the subject of debate for most of the past century. The term fascia was introduced by . The histology of the apical portion of the posterior vaginal wall consists of mucosa (which includes the epithelium of the posterior wall and the lamina propria), a superficial and deep muscularis layer, and adventitia. This fibromuscularis has been named rectovaginal fascia and perirectal fascia , perhaps giving the surgeon an illusion of more sturdy tissue than is actually present. Comparisons of the histology of women with and without prolapse have shown that the smooth muscle content of the posterior vaginal wall of women with prolapse is disorganized and significantly reduced in comparison to women without prolapse.
Prolapse of the posterior vaginal wall may be secondary to the presence of an enterocele, sigmoidocele, or rectocele, or a combination of these entities. A rectocele is an anterior protrusion of the rectal wall to the posterior vaginal wall. The rectovaginal space exists between the vaginal tube and the rectum. This potential space, occupied by areolar tissue, allows the vagina and rectum to function independent of each other. Support of the posterior vaginal wall is provided by a complex interaction of the integrity of the vaginal tube, the connective tissue support, and muscular support of the pelvic floor. divided the connective tissue support of the vagina into three levels. All three levels of support should be evaluated and addressed during surgical management of the posterior vaginal wall.
At level I, the apical portion of the posterior vaginal wall is suspended and supported primarily by the cardinal–uterosacral ligaments. This mesentery of support originates at the sacrum and the pelvic sidewalls and inserts onto the posterior cervix and upper vagina. With normal support, the apical posterior wall of the vagina is dorsally directed to lie upon the rectum in a horizontal fashion overlying the levator ani muscles. With increases in abdominal pressure, the vaginal tube is closed top to bottom and supported by the pelvic floor muscles.
Level II includes the support for the middle half of the vagina. This support is provided by the endopelvic fascia attaching the lateral posterior vaginal wall to the aponeurosis of the levator ani on the pelvic sidewall. Most of the fibers of the endopelvic fascia connect the lateral edge of the vaginal tube to the pelvic sidewall. Very few of the fibers actually run like a sheet from sidewall to sidewall. The sidewall attachment of the apical half of the posterior vaginal wall is convergent with the anterior vaginal wall at the arcus tendineus fasciae pelvis, giving the vagina a flat profile. The distal sidewall attachment of the posterior vaginal wall, the arcus tendineus fasciae rectovaginalis , deviates dorsally from the anterior vaginal wall, giving the vagina an H appearance at the introitus ( Fig. 24.1 ).
The role of the perineal body is to resist caudally directed forces by the rectum and to provide a physical barrier between the vagina and rectum. The perineal body is thicker (approximately 3 cm in length) and more defined in women. It includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter. reconstructed the perineal body into three distinct regions (superficial, mid, and deep) with three-dimensional analysis of thin-slice magnetic resonance (MR) imaging. The superficial region of the perineal body is at the level of the vestibular bulb. The bulbospongiosus muscle inserts into the lateral margins of the perineal body, while caudally, the transverse perineus muscle and external anal sphincter comprise the bulk of the superficial component. The perineal body extends cranially in the posterior wall of the vagina to approximately 2 to 3 cm proximal to the hymenal ring. The puborectalis loops around the rectum and lateral vagina but does not send fibers to the perineal body. Laterally, the perineal body is attached to the ischiopubic rami through the transverse perineus muscles and the perineal membrane. The perineal membrane spans the anterior half of the pelvic outlet and is comprised of dense fibromuscularis. This dense, fused level of support represents level III. Interruption in the support of the perineal body allows the posterior vaginal wall, perineal body, and the distal portion of the anterior rectal wall to descend with increased rectal pressure (allowing for perineal body hypermobility).
The pelvic floor muscles, of which the levator ani muscles are a major contributor, provide substantial support of the pelvic organs. In a woman with an intact pelvic floor, the puborectalis (and remaining levator ani muscles) are in a chronic state of contraction. This contraction closes the vaginal canal and the anterior and posterior vaginal walls are in direct apposition. With defecation, the increased pressure placed on the posterior vaginal wall is equilibrated by the opposing anterior vaginal wall, and there is minimal stress placed on the endopelvic fascial attachments ( Fig. 24.2 A ). The puborectalis also provides a sling of support for the vaginal tube. This sling leads to an angulation of the mid-posterior wall of approximately 45° from vertical. The proximal portion of the vagina lies upon (and is supported by) the pubococcygeus and iliococcygeus muscles. The puborectalis helps to close the potential space of the vagina and close the levator hiatus. With a healthy pelvic floor, there is little stress and strain placed on the connective tissue support system.
The levator hiatus has been shown to be larger in women with prolapse than in women with normal support. If there is muscular and/or neurologic damage to the puborectalis, the levator hiatus widens and the vaginal canal opens. The increased rectal pressure and distension associated with defecation places strain on the endopelvic fascial attachments and the fibromuscularis of the posterior vaginal wall and can result in rectocele and perineal descent ( Fig. 24.2 B and C ).
A description and understanding of normal anatomy guides us in identifying areas of loss of support and challenges us to return the vagina to its “normal position” during prolapse surgery. However, static anatomy does not give us insight into the complexities of the pathophysiology of posterior vaginal wall prolapse. compared the MR images at rest and maximal Valsalva between women with predominant rectocele and those without prolapse (controls). As the women with posterior vaginal wall prolapse strained, all 10 experienced descent of the apical two-thirds of posterior vaginal wall resulting in a folding “kneeling fashion,” obstructing the rectum in the process. A proportion (but not all) of the women with a rectocele also had widening of the genital hiatus and descent of the distal posterior wall and perineal body. Therefore, identifying and repairing apical posterior wall support is critical to restoring normal anatomy.
A dynamic and complex interplay of the bony pelvis and connective tissue support with the tonically and actively contracted pelvic floor muscles allow the vagina to maintain its anatomic position. Disruption of support leading to herniation of the vagina and surrounding organs (pelvic organ prolapse) can impact urinary, defecatory, and sexual function. Prolapse is most likely due to an accumulation of injuries. Risk factors for the development of prolapse may begin at conception and continue to accrue until death. Table 24.1 shows various risk factors for development of posterior vaginal wall prolapse. performed a meta-analysis of the family history of prolapse and concluded that there is strong evidence that women with at least one family member with pelvic organ prolapse have a significantly higher risk of developing prolapse than those without a family history of prolapse. In families with many members affected by pelvic organ prolapse, chromosomal linkage analysis has identified an area on the long arm of chromosome 9 (9q21) that is associated with the development of prolapse. This area of chromosome 9 houses genes involved with the development of connective tissue and muscle in the pelvic floor. It is apparent that abnormalities of connective tissue development (e.g., Ehlers–Danlos syndrome and Marfan’s syndrome) are related to early development of pelvic organ prolapse. Women with less pronounced connective tissue disorders often have hyperextensible skin and joints. Women with joint hypermobility are more likely to have defecatory evacuation disorders and develop a rectocele.
| Inheritable | Trauma | Promotional |
|---|---|---|
| Genetic | Vaginal delivery | Chronic disease |
| Pelvic surgery | Defecatory dysfunction | |
| Obesity | ||
| Occupational exposures | ||
| Smoking | ||
| Aging |
Given the genetic link to pelvic organ prolapse, it is not surprising that demonstrated a high concordance of prolapse between 101 pairs of nulliparous and parous postmenopausal sisters. While genetics predisposed sisters to prolapse development, inciting factors were also important. The vast majority (88-100%) of cases of discordance between sisters showed more advanced prolapse in the parous sister.
Vaginal delivery, particularly in the occiput-posterior position, is associated with an increased risk for posterior vaginal wall and perineal body trauma and is one of the greatest risk factors for pelvic organ prolapse development. Magnetic resonance images in the postpartum period show changes in intensity within the levator ani muscle. These changes likely reflect the recovery process following neurologic or muscular damage related to childbirth. Additionally, aging may impact the levator ani muscles leading to muscle atrophy and devascularization. Vaginal delivery, age, and size of the genital hiatus (more than 2 cm often associated with levator injury) have been associated with the development and progression of prolapse in parous women.
Chronic strain and constipation are often found in women with rectocele, perineal descent, and fecal incontinence. It is suggested that with chronic straining, there is a stretch placed on the pudendal nerve and the nerve to the levator ani muscle; this stretch is amplified in the setting of rectocele and perineal body descent. found that fecal incontinence was more prevalent in women with a rectocele that extended beyond the hymen (31%) than in women with prolapse inside the hymenal ring (19%). Increasing body mass index has been strongly associated with incident rectocele but not with prolapse of other areas of the vagina (anterior or apical vaginal wall).
Pelvic surgery can predispose a woman to develop prolapse. Alterations of the connective tissue support and injury to the innervation and vascularization to the pelvic floor muscles occur with pelvic surgery. However, the indication for the pelvic surgery contributes to the risk of subsequent prolapse surgery. In a large case–control study, found the primary risk factor for development of prolapse after hysterectomy was the degree of prolapse before the hysterectomy. The risk of subsequent prolapse repair in a woman with prolapse to the hymen at the time of hysterectomy was eight times that of women without prolapse, regardless of the route of surgery. The performance of a hysterectomy outside of the setting of prolapse is a risk for prolapse development. retrospectively evaluated women who presented with primary prolapse. When matched for age and parity, women who underwent a prior hysterectomy were more likely to present with stage 2 or greater posterior vaginal wall prolapse as compared to women without prior hysterectomy (46.5% versus 25.3%, respectively, P = 0.01). Additionally, surgical procedures in the pelvis may alter the axis of the vagina, increasing the forces placed on the connective tissue supports. Overelevation of the anterior vaginal wall, as with anterior vaginal mesh or retropubic urethropexy, alters the distribution of force on the vaginal walls and can open the posterior wall to the development of an enterocele or rectocele.
Evaluation
History
Many women with a rectocele or a perineal body defect are asymptomatic or unaware of the loss of support. However, most women electing to undergo surgical management of a rectocele report a sense of bulging and/or symptoms relating to sexual, defecatory, or urinary function.
Women with prolapse often describe bulging of the vagina and pressure (particularly if the prolapse extends beyond the hymen), which worsens by the end of the day and improves when she is lying down. Sexual function is multifaceted in women. Sexual dysfunction may occur in the setting of prolapse through discomfort, loss of sensation, alteration in body image, or incontinence. Women with a perineal body defect, which leads to a widened genital hiatus, may describe loss of sensation for her and her partner during intercourse. If stool is trapped in the rectocele, intercourse may lead to fecal incontinence or instill the fear of fecal incontinence, leading to the avoidance of sex.
Defecatory dysfunction is common in women with a symptomatic rectocele. described in a prospective evaluation of 160 women undergoing rectocele repair that preoperatively, 87% had bowel symptoms. The most common symptom was incomplete evacuation (85%), followed by straining (74%), sensation of obstructed defecation (66%), anal incontinence (63%), and manual splinting (56%). Defecatory function is common in women with and without posterior wall prolapse and may be resolved by increasing fiber and water in a woman’s diet. It also may be impacted by a multitude of medical factors (see Table 24.2 ). Infrequent defecation is not likely related to a rectocele and may require additional evaluation. Women with a large rectocele may trap stool within this rectal pocket leading to feeling of incomplete emptying, which can result in soiling. Splinting, or placing manual pressure in the vagina, rectum, or on the perineum to reduce the prolapse and facilitate emptying of the rectum, is commonly described.
| Systemic Illness | Mechanical Bowel Obstruction | Medications (Common Culprits) | Psychiatric Conditions |
|---|---|---|---|
| Diabetes mellitus Metabolic disorders Thyroid disorders Neuromuscular disorders | Hirshsprung disease Malignancy Inflammatory bowel disease Rectal intussusception Pelvic organ prolapse | Aluminum antacids Anticholinergics Antidepressants Anti-inflammatory medications Beta-blockers Calcium channel blockers Iron sulfate Opiates | Abuse (psychologic, physical, and sexual)Eating disordersPelvic pain |
Anal incontinence is commonly seen in patients with posterior wall and perineal body defects. Many women are reluctant to initiate the conversation about anal incontinence due to embarrassment, so it is crucial to ask about accidental loss of solid or liquid stool.
An important part of the history to obtain from your patient is an understanding of what her management desires are. If the patient requires and is willing to undergo surgical management, having her verbally express her expectations of surgery can be illuminating.
Physical Examination
The patient is typically examined in the dorsal lithotomy or semirecumbent position. There is excellent correlation in the evaluation of prolapse between the supine and standing positions in women performing maximal Valsalva maneuver. If the prolapse observed in the lithotomy position does not recreate the degree of prolapse that the patient described, a standing examination should be performed. However, it is physically more difficult to perform measurements of the prolapse in this position.
To stage the severity of prolapse, the posterior vaginal wall is visualized with the posterior blade of a bivalve speculum or a Sim’s speculum. The retractor elevates the anterior wall and reduces any uterine or apical prolapse. The patient is asked to increase abdominal pressure with a Valsalva maneuver or cough. The Pelvic Organ Prolapse Quantification (POPQ) system is a standardized, validated tool for measuring and staging pelvic organ prolapse and is described in detail in Chapter 8 . Measurements of the posterior vaginal wall are documented at maximal strain, 3 cm proximal to the hymen (Ap), at the most dependent portion of the posterior vaginal wall proximal to this mark (Bp), and at the vaginal cuff (C) or cul-de-sac, if the uterus is present (D). The genital hiatus (gh) and perineal body (pb) are measured with the patient straining. Evaluation for and staging of concurrent anterior wall and apical prolapse should be performed.
A rectovaginal examination can facilitate evaluation of the support and descent of the perineal body as well as evaluate the protrusion of the anterior rectum into the posterior vaginal wall. Palpation of loops of small bowel or sigmoid colon in the rectovaginal space confirms an enterocele or sigmoidocele, respectively. Performing a rectovaginal examination in the standing position may increase the detection of an enterocele by allowing the bowel to enter the rectovaginal space. Pressure on the posterior wall of the vagina, directed downward toward the rectum, may facilitate identification of rectal prolapse or intussusception. If you suspect rectal prolapse, allowing a woman to Valsalva in privacy with a handheld mirror to guide her may allow you to see what she is describing.
The perineal body should be evaluated for length (POPQ measurement of pb), strength (including anal sphincter), and descent. It may be difficult to measure perineal descent, but documentation of its presence or absence can be helpful in planning your surgery. Descent of the perineal body occurs with a lack of continuity of the suspensory support at the apex (level I) to the perineal body (level III). It may occur also due to a mass effect of the rectum or small bowel herniating into the perineal body, a perineocele. Perineal descent also has been associated with fecal incontinence, possibly related to stretch and damage to the innervation to the anal sphincter.
Because anal incontinence commonly occurs with rectocele, assessment of the anal sphincter should be performed. This includes evaluation of anal tone, squeeze, and symmetry. If a symptomatic woman is found (or suspected) to have a disrupted anal sphincter on examination, further testing is indicated.
A focused neurologic examination includes evaluation of sensation, motor function, and reflexes of sacral nerves 2 to 4. The patient is asked to discriminate between sharp and dull on the perineum. Pelvic floor muscle strength can be assessed by asking the patient to contract and relax the pelvic floor muscles around the examiner’s fingers. Reflex testing includes the bulbocavernosus reflex and anal wink.
Diagnostic Tests
A woman with defecatory dysfunction and rectocele may benefit from further testing. Defecography provides a two-dimensional view of the efficiency of rectal emptying and quantification of rectal parameters. Evaluation includes rest, squeeze, strain, and evacuation. Contrast in the small and large bowel may also reveal the presence of an enterocele, sigmoidocele, or perineocele. Rectocele, enterocele, and rectal intussusception can be graded based on anatomic evaluation obtained with defecography (see Table 24.3 ). Rectal intussusception, perineal descent, and spastic pelvic floor (pelvic floor dyssynergia) may be apparent during strain. The dynamic nature of the study allows for insight into the defecation process. Retention of more than 10% of the barium following defecation is referred to as barium trapping . It should be recognized that this examination is done in an artificial environment, which may make the patient more prone to incomplete emptying.
| Grade 1 | Grade 2 | Grade 3 | |
|---|---|---|---|
| Rectocele | <2 cm | 2 to 4 cm | >4 cm |
| Enterocele | Proximal third of vagina | Middle third of vagina | Distal third of vagina |
| Intussusception | Above puborectalis | At puborectalis | In anal canal |
Defecation is effected through the coordination of relaxation of the levator ani and external anal sphincter, and contraction of the colon. If the puborectalis and/or external anal sphincter is paradoxically contracted during defecation, defecatory dysfunction with straining and incomplete emptying may result. A balloon expulsion test (BET) and manometry can indirectly measure the function of the pelvic floor muscles. A woman with a normally functioning pelvic floor should easily be able to expel a 60 mL balloon. Failure to expel the balloon suggests a functional abnormality. Physical therapy with biofeedback can promote coordinated defecation. Resolution of paroxysmal contraction of the pelvic floor muscles is imperative to address the woman’s symptoms and decrease the strain that would be placed on the surgically repaired posterior vaginal wall.
Rectoceles that retain contrast tend to be larger than those that do not. However, fluoroscopic evidence of barium trapping does not relate to patient symptoms. In the symptomatic, elderly population, found no association between the abnormalities demonstrated by defecography and symptoms. Defecography performed following surgical management of posterior wall prolapse generally has shown a reduction in the size of the rectocele and improvement in emptying. The limitations of defecography include the requirement of special equipment, radiation exposure of the patient, inability to show the rectum and adjacent soft tissue structures simultaneously, and that it is uncomfortable and poorly accepted by patients.
Dynamic MR imaging provides high quality images of the pelvic soft tissues and viscera. It is noninvasive and does not required ionizing radiation or significant patient preparation. However, there is poor correlation between MR grading of prolapse and clinical staging. Due to limited availability of open MR imaging facilities, most facilities perform dynamic MR imaging in the dorsal supine position with a woman’s legs together. Images are obtained resting and while performing a Valsalva maneuver and with evacuation. However, during a Valsalva maneuver in this position, the true extent of the prolapse may not be exhibited and may not simulate that woman’s ability to defecate. The limitations of this method of imaging include a lack of standardization of grading of prolapse, high cost, and limited availability of open MR imaging.
Translabial, perineal, and three-dimensional endoanal ultrasound have been used to evaluate the pelvic organs at rest and with contraction and Valsalva. Ultrasound compares favorably to defecography in identification of rectocele, enterocele, paroxysmal contraction of puborectalis, and rectal intussusception. An endoanal ultrasound provides anatomic detail of the integrity of the external and internal anal sphincters. The advantages of a dynamic ultrasound evaluation of the pelvic floor are avoidance of ionizing radiation, decreased expense, real-time visualization of dynamic maneuvers, and avoidance of asking a woman to defecate in public.
At this time there is a lack of a standardized method of establishing a radiologic diagnosis of a rectocele. Clinical examination has good sensitivity for the detection of a rectocele; therefore, radiologic confirmation of the presence or absence of a rectocele is not worthwhile. While defecatory dysfunction is common in women with prolapse, the extent of the prolapse does not necessarily correlate with the extent of bowel symptoms. If the woman’s primary complaint is defecatory dysfunction or fecal incontinence rather than a bulge, surgical correction of a rectocele or perineal body defect may not correct her symptoms. evaluated bowel symptoms before and 12 months after rectocele repair and found that while defecatory dysfunction improved in all categories (incomplete evacuation, straining, sensation of obstructed defecation, anal incontinence, and manual splinting), nearly one-half of women continued to have some defecatory complaint after surgery.
Thus, ancillary testing is pursued based on the woman’s complaints. Validated functional and quality of life questionnaires are available, and may be performed preoperatively and postoperatively to provide a standardized method of evaluating the surgical outcomes. The patient’s preoperative symptoms and surgical goals will guide the provider in selecting additional testing. A woman who describes life-long infrequent bowel movements (less than one per week) and an absence of a daily urge to defecate is unlikely to be cured of her constipation with a rectocele repair. A colon transit study may be helpful in identifying patients with slow-transit constipation. Dietary modifications including fiber and laxatives should be encouraged in any woman whose main complaint is constipation.
Urodynamic testing with prolapse reduction may be useful in women with stage III or stage IV posterior wall prolapse. With retraction of the posterior wall prolapse (simulating correction of the prolapse), women may “develop” stress incontinence or have an increase in leak volumes. If occult stress urinary incontinence or intrinsic sphincter deficiency is uncovered, then this observation should be factored into preoperative surgical recommendations and surgical planning.
Surgical Repair Techniques
The decision to undergo surgical correction of posterior wall prolapse is influenced by personal, cultural, and physician factors. The surgical experiences of a woman’s social network and her personal caregiving responsibilities also impact her decision. Typically, severity of prolapse, medical comorbidities, and socioeconomic status impact the physician and patient’s treatment plan. Older age often precludes consideration of a surgical approach in the minds of women, family members, and physicians. However, the surgical outcomes and complications are very similar to those found in younger women undergoing prolapse surgery. Over the next 40 years the elderly population will expand significantly. Age should not be the sole factor in determining surgical eligibility.
Current repair techniques address connective tissue defects. The dysfunctional levator ani, which widens the levator hiatus, increases the stress and strain on the connective tissue. This is likely a key contributor to the development of pelvic organ prolapse. Currently, pelvic floor muscle exercises (with or without biofeedback) are our primary method of strengthening the remaining innervated pelvic floor muscles but does not address denervated or damaged muscle.
The goals of rectocele repair are to provide anatomic correction, relieve prolapse symptoms, and restore normal bowel and sexual function without creating new symptoms. Understanding the patient’s goals of surgical correction and providing realistic expectations of outcomes is an essential component of preoperative management and counseling. Evaluation of prolapsed posterior vaginal wall in the operating room should include a careful inspection for an enterocele or sigmoidocele, and for associated apical support defects. It is difficult to compare various techniques for repair of posterior vaginal wall prolapse and anterior rectal wall prolapse because the indications for surgery and the standardized definitions of bowel function symptoms frequently are not reported. The definition of anatomic or functional cure also varies from study to study. There are few appropriately powered, prospective randomized studies comparing surgical procedures to correct posterior wall prolapse.
The gynecologist typically approaches repair of a rectocele through a transvaginal incision. The patient is placed in the dorsal lithotomy position with her legs in high leg holders. The colorectal surgeon often performs an endoanal repair of the rectocele with the patient in the prone position. Patients are given preoperative prophylactic antibiotics and anti-embolic prophylaxis. Mechanical bowel preparation is optional.
Posterior Colporrhaphy
The posterior colporrhaphy was introduced in the nineteenth century. The goals of this procedure were to narrow the vaginal tube and genital hiatus and to create a shelf of support. The posterior colpoperineorrhaphy was thought to be the key component of all prolapse surgery (including correction of anterior wall and uterine prolapse). It remains a commonly performed surgical procedure for posterior wall prolapse.
The traditional posterior colporrhaphy has an anatomic cure rate of 76% to 96% (see Table 24.4 ). The posterior colporrhaphy is a plication of the vaginal wall in the midline, decreasing the width of the posterior vaginal wall and increasing the fibromuscularis in the midline. Traditionally, a perineorrhaphy is included in this repair, purposely narrowing the vaginal tube. Estimation of adequate vaginal caliber is not standardized. It will vary depending upon physician training and experience, the patient’s current and future desire for sexual activity, and partner factors (e.g., men with erectile dysfunction may have a difficult time penetrating a smaller genital hiatus).
| Primary Author, Year | Patients at Follow-up/Initial Presentation | Mean Follow-up, Months | Anatomic Cure, % | Incomplete Evacuation Pre-op, % | Incomplete Evacuation Post-op, % | Sexual Dysfunction Pre-op, % | Sexual Dysfunction Post-op, % |
|---|---|---|---|---|---|---|---|
| 22/29 | 24 | 77 ∗ | 20 | NS | NS | 23 | |
| 243 | >24 | 94 | NS | NS | 9 | 50 | |
| 25 | 14 | 80 § | 88 | 0 | 6 | 19 | |
| 140 | 44 | 76 | 27 | 38 | 18 | 27 | |
| 70/80 | 12 | 90 † | NS | NS | NS | NS | |
| 25 | 9 | 83 § | 68 | 36 | 18 | 23 | |
| 38 | 12.5 | 87 | 100 | 16 | 37 | 5 | |
| 183 | 12 | 96 † | NS | NS | 8 | 17 | |
| 28/37 | 17.5 | 86 ¶ | 62 | 45 | 56 | 45 |
∗ Cure defined as “satisfied” on telephone interview.
† Cure defined as Bp ≤ 0 (hymen).
§ Cure defined as absence of rectocele on postoperative defecography.
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