Obstetrics & Gynecology 2001;98:265-268
© 2001 by The American College of Obstetricians and Gynecologists
Functional and Anatomic Follow-up of Enterocele Repairs
Paul K. Tulikangas, MD,
Marion R. Piedmonte, MA and
Anne M. Weber, MD
From the Departments of Gynecology and Obstetrics and Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
Address reprint requests to: Paul Tulikangas, MD, Department of Gynecology and Obstetrics, The Cleveland Clinic Foundation, A81, 9500 Euclid Avenue, Cleveland, OH 44195; E-mail: tulikap{at}ccf.org.
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ABSTRACT
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OBJECTIVE: To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair.
METHODS: Fifty-four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms.
RESULTS: Fifty-four women had enterocele repairs as part of their surgery. Mean follow-up time was 16 months (range 6–29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty-three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow-up.
CONCLUSION: Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.
Symptoms attributed to enteroceles include pelvic pressure, low back ache, and defecatory dysfunction. 1 Occasionally, severe complications such as small bowel evisceration can occur in women with enteroceles.2 Surgical repair of enteroceles has been well described; however, there are few reports evaluating the outcomes of those repairs.1 We performed a prospective observational study evaluating the functional and anatomic outcomes of enterocele repair.
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MATERIALS AND METHODS
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Our Institutional Review Board approved this study, and each subject provided written informed consent. Women who had surgery for pelvic organ prolapse and urinary incontinence between June 1996 and January 1998 were asked to participate. The study population consisted of 54 women who had enterocele repair and completed follow up at least 6 months after surgery. Preoperative and postoperative examinations were done by a research nurse. Pelvic examinations using the International Continence Society staging system were done preoperatively and at 6 months, 1 year, and 2 years postoperatively.3 Women were examined in the supine lithotomy position in stirrups on a standard gynecologic table. Vaginal examinations were performed with Sims speculums. The maximum descent of prolapse was demonstrated by Valsalva maneuver or cough and confirmed by the patient to be the most severe protrusion that occurred. In the staging system, the location of vaginal points is measured in centimeters relative to the hymen. Negative numbers represent positions above the hymen and positive numbers represent positions beyond the hymen. Point C refers to the most distal edge of the cervix or the leading edge of the vaginal cuff after hysterectomy. Point Bp refers to the most distal extent of posterior vaginal prolapse. At each evaluation, subjects completed standardized questionnaires about bowel function, sexual function, and prolapse symptoms. Women were asked to rate how much their bowel function and prolapse symptoms bothered them by using a visual analog scale of 1 to 10 (1 being "not at all," 10 being "extremely").
Enterocele repair was done in all women who had intraoperative identification of enteroceles. The peritoneal sac was identified and sharply dissected free from the rectum and the bladder. Bowel within the sac was retracted with gauze packing or a retractor. A permanent, monofilament purse string suture was used to close the peritoneum as high as possible without injuring the ureters. In most cases, a second purse string suture was placed caudad to the first. Excess peritoneum was excised or incorporated into the vaginal repair, depending on the surgeon’s preference.
Statistical analyses used measurements of vaginal sites. Data from the visual analog scale were analyzed as continuous data. Symptoms of straining and manual evacuation were considered to be absent for responses of "never or rarely," and present otherwise. Dyspareunia was considered absent for responses of "never or rarely" or "sometimes," and present otherwise. Abnormal frequency of bowel movements was defined as less often than twice per week. Optimal anatomic outcome ("cure") was defined as point Bp and C at stage 0 (-3 cm). Satisfactory anatomic outcome ("improvement") was defined as point Bp and C at stage I (-2 cm). Unsatisfactory anatomic outcome (persistence or recurrence, failed treatment) was defined as point Bp or C at stage II or worse (Bp at -1 cm or lower), or no change or worsening from pretreatment stage. These definitions were determined before data review and analysis and are consistent with recommendations from the National Institutes of Health Terminology Workshop for Researchers in Female Pelvic Floor Dysfunction.
Symptomatic and anatomic evaluation of patients was based on assessments done preoperatively and at the most recent follow-up examination. Duration of anatomic success was estimated using the method of Kaplan and Meier. Changes between baseline and follow-up measures were assessed with McNemar tests for dichotomous factors and sign-rank tests for ordinal or continuous factors. Ordinal and continuous data are reported as median (minimum, maximum). Numbers do not always add up to the total sample size because of missing data. All statistical tests were two-tailed, and, to adjust for the many comparisons, we considered only P < .01 or lower to be statistically significant. The sample size for this observational study was not selected to test specific hypotheses; therefore, negative results do not imply conclusively that no differences existed.
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RESULTS
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Fifty-four women had enterocele repairs as part of their surgery for pelvic organ prolapse and completed follow up; their characteristics are summarized in Table 1
. Other procedures were done as indicated (Table 2). Mean follow-up time was 16 months (range 6–29 months). Vaginal length decreased a median of 2.5 cm (range -8 to +1 cm) (P < .001). Introital caliber decreased a median of 2.5 cm (range -6.5 to +5 cm) (P < .001).
Figure 1 depicts the duration of satisfactory posterior and apical pelvic support after surgery, based on 49 women (five had fluctuation in their stage of pelvic organ prolapse over time so they were excluded from this analysis). At the time of the last observation, 33 women had a satisfactory anatomic surgical outcome. Sixteen had stage II prolapse, and none had stage III or IV prolapse. Of the 16 women with stage II prolapse, 12 had prolapse at point Bp and three had prolapse at point C. One woman had stage II prolapse at both points Bp and C. To our knowledge no woman has had subsequent surgery for prolapse repair or used a pessary.
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Figure 1. Duration of satisfactory posterior and apical pelvic support.
Tulikangas. Enterocele Follow-up. Obstet Gynecol 2001.
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Table 3 shows the postoperative change in prolapse and bowel symptoms and functional outcomes based on anatomic outcome. Severity of bowel symptoms and prolapse symptoms improved equally in women with and without anatomic cures. Five women (11%) had new bowel symptoms or had worsening bowel function after surgery.
There was no significant change in the frequency of bowel movements after surgery (median change 0.0, range -3.5 to +3.5) In the 23 women who were sexually active, there was no significant change in the frequency of sexual activity (median change 0.0, range -1.0 to +1.0), rate of dyspareunia (one [5%] resolved, two [10%] new onset, 18 [85%] no change) or in satisfaction with their sexual relationship (median change 0.0, range -9.0 to + 4.0).
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DISCUSSION
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The goal of reconstructive pelvic surgery is to restore normal anatomy and function to the pelvic floor. Women with enteroceles pose a particular challenge because they present with more advanced prolapse than those without enteroceles.4 The most important finding of this study is that functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall.
It has been noted that after enterocele correction, the vagina may be shortened.1,5 There is likely a threshold vaginal length (7–11 cm) and introital caliber (10–12 cm) below which there might be impaired sexual function resulting from restricted vaginal dimensions.7 The sexually active women in this study had adequate postoperative vaginal length and caliber.
There was no change in the frequency of bowel movements, the frequency of sexual activity, the rate of dyspareunia, or satisfaction with their sexual relationship. There are many factors that affect those variables. In this series, reconstructive pelvic surgery with enterocele repair had no adverse or beneficial effect on these outcomes. When counseling patients preoperatively, women should be aware that surgery might not resolve their bowel or sexual function symptoms.
Using a survival analysis model, we estimated that about half of the women in this study would have an unsatisfactory surgical outcome (stage II prolapse). It is reassuring that none of the 16 women who had stage II prolapse required follow-up surgery for prolapse or, to our knowledge, a pessary. Although our series is small, functional results do not appear to be worse in the women with stage II prolapse. One limitation in this analysis is that the time of surgical failure might not be the time that the symptom follow-up questions were completed. For example, a woman could develop a stage II prolapse at 6 months postoperatively but the anatomic and functional outcomes used in this analysis might occur at 2 years postoperatively (the last date of follow-up). Because of this limitation, no statistical attempt has been made to show a cause and effect relationship.
Objective evaluation of functional outcomes with validated questionnaires on sexual function, urinary function, bowel function, and prolapse symptoms are crucial for evaluating surgical success. Many women in this study who had an unsatisfactory anatomic outcome have improved bowel function and relief of prolapse symptoms. Many of those women would consider their surgery a success. Unfortunately, some women with optimal and satisfactory anatomic outcomes have persistent or new functional deficits. In their view, surgery has not helped them although they would be considered cured by a strictly anatomic definition. Further research is needed to develop definitions of outcomes based on a combination of functional and anatomic measures.
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Footnotes
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PII S0029-7844(01)01407-7
Received December 6, 2000.
Received in revised form March 12, 2001.
Accepted March 23, 2001.
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REFERENCES
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1. Nichols DH, Randall CL, eds. Vaginal surgery. 4th ed. Baltimore: Williams & Wilkins, 1996;336–50.
2. Holley RL. Enterocele: A review. Obstet Gynecol Surv 1994;49:284–93.[Medline]
3. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.[Medline]
4. Chou QA, Weber AM, Piedmonte MR. Clinical presentation of enterocele. Obstet Gynecol 2000;96:599–603.[Abstract/Free Full Text]
5. McCall ML. Posterior culdoplasty. Obstet Gynecol 1957; 10:595–602.[Free Full Text]
6. Weber AM, Walters MD, Piedmont MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000;182:1610–5.[Medline]
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ABSTRACT
MATERIALS AND METHODS
