Hypothesis / aims of study
Rectoceles are present in 30-50% of women over 50 years of age and may cause bulge symptoms, defecatory dysfunction, dyspareunia, and fecal incontinence. Fecal incontinence (FI) is prevalent in 20% of women with symptomatic rectocele. The anorectal function of women with rectocele is underexplored, thus the mechanism of FI in the presence of rectocele is unknown. It is plausible that the anal sphincter complex is attenuated by shortened perineal body with prolonged and or advanced posterior compartment prolapse. Further, stool trapping in the distal rectal vault may create opportunity for ‘overflow’ incontinence as the pressure inside of the rectum increases above that of the attenuated perineal body. Consequently, we hypothesized that rectocele repair would significantly reduce FI symptoms. We aimed to observe the rate of resolution or improvement of FI symptoms following rectocele repair in patients with posterior compartment prolapse and FI symptoms. Secondarily, we aimed to explore preoperative predictors for FI resolution.
Study design, materials and methods
We present a retrospective cohort study including female patients who underwent transvaginal rectocele repair with diagnosis of fecal incontinence at a single academic institution between 1/1/2016 and 1/1/2022. Subjects were identified by an EMR search which included patients with any ICD-10 diagnosis of fecal incontinence as well as any associated CPT codes for anterior and posterior repair with or without enterocele, posterior repair alone, or repair of rectocele (57260, 57265, 57250, 45560). Subjects with or without concomitant anal sphincteroplasty were included. Subjects who did not have the diagnosis of fecal incontinence prior to surgery were excluded, as well as subjects who had the diagnosis of flatal incontinence or fecal urgency alone. Subjects with rectocele repair without anal sphincteroplasty were grouped together for comparison against those with rectocele and concomitant anal sphincteroplasty, which formed the comparator group anticipated to have resolution of FI symptoms post-operatively. Two researchers abstracted key demographic and clinical data from the electronic medical record. An audit of data collection was performed on 10 charts prior to data analysis by an independent study team member. Fecal incontinence symptoms were determined at baseline interview and six week post-operative evaluation through a single question, “Do you have bowel accidents?”. The absolute resolution of FI symptoms at six weeks post-operatively was the primary outcome. Secondarily, improvement in FI symptoms and anorectal manometry characteristics were examined. Primary and secondary outcomes were compared based on the presence of anal sphincteroplasty. Univariate and bivariate analysis were performed based on outcomes between groups. Statistical analysis was performed using R (RStudio, PBC, Boston, MA).
Results
A total of 179 subjects were identified as those who underwent transvaginal rectocele repair and had FI symptoms pre-operatively. Of those, 91 had rectocele alone while 88 subjects had rectocele with anal sphincter defects and had concomitant anal sphincteroplasty. Demographic and clinical characteristics were similar between groups. The mean age was 61± 13 years, and mean BMI was 28.1± 7.4 kg/m2. 91% percent of our cohort were white and 8.9% were black. The median stage of pelvic organ prolapse was Stage II for both groups. Fecal incontinence symptoms resolved with similar rates in both groups. Overall, 143 (79.89%) subjects did not report any fecal incontinence by their 6-week postoperative visit. An additional 28 (15.64%) reported improvement in FI symptoms. Among subjects who underwent rectocele repair alone, 83.5% had complete resolution of their FI compared to 76.1% in subjects with rectocele repair with concomitant sphincteroplasty (p=0.62). Improvement in FI symptoms was demonstrated in 12.1% of subjects with rectocele alone and in 19.3% of subjects with rectocele and anal sphincteroplasty (p=0.62)
71 subjects underwent anorectal manometry preoperatively. There were no significant differences observed between groups regarding anorectal measures. For the overall cohort, the mean average resting pressure was 53.8 ± 22 mmHg and the mean maximum squeeze pressure was 81.7 ± 37 mmHg. The mean average resting pressure and mean maximum squeeze pressure in the rectocele repair alone group was 51.5 ± 22 mmHg and 74.8 ± 32 mmHg respectively (p=0.45), as compared to 55.3 ± 22 mmHg and 86.9 ± 41 mmHg in the rectocele with sphincteroplasty group (p = 0.16).
Interpretation of results
Rectocele repair resulted in resolution or significant improvement of FI symptoms within the initial post-operative period. This observed decrease in FI symptoms was similar to the decrease observed in women undergoing rectocele repair with anal sphincteroplasty. Anal sphincter functional pressures of subjects with rectocele and FI symptoms were similar to those of subjects with anal sphincter defects. Thus, the mechanism for FI symptoms in women with rectocele may be independent of the anal sphincter complex.