Pelvic Organ Prolapse and Urinary Incontinence in Women With Surgically Managed Rectal Prolapse: A Population-Based Case-Control Study D. Altman, M.D., Ph.D.,1 J. Zetterstrom, M.D., Ph.D.,1 I. Schultz, M.D., Ph.D.,2 J. Nordenstam, M.D.,2 F. Hjern, M.D.,2 A. Lopez, M.D., Ph.D.,1 A. Mellgren, M.D., Ph.D.3 1 2 3
Division of Obstetrics and Gynecology, Pelvic Floor Center, Stockholm, Sweden Division of Surgery, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden Division of Colon and Rectal Surgery, University of Minnesota, St. Paul, Minnesota genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment. [Key words: Genital; Incontinence; Rectal; Prevalance; Prolapse]
PURPOSE: This study aimed to investigate the prevalence of genital prolapse surgery and urinary incontinence in female patients operated on for rectal prolapse compared with a matched control group without rectal prolapse. METHODS: Fifty-two patients with a history of abdominal rectal prolapse surgery and 200 randomly selected agematched and gender-matched control subjects without rectal prolapse received an extensive health care history survey. RESULTS: Response rate in the patient group was 48 of 52 (92 percent) and 165 of 200 (82 percent) in the control group. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (odds ratio = 3.1; 95 percent confidence interval = 1.4–6.9) and vaginal wall prolapse (odds ratio = 3.2; 95 percent confidence interval = 1.3–7.8). Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (P < 0.01). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (P < 0.05). There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence. CONCLUSION: Our results indicate a strong association between rectal and
R
ectal prolapse (RP) is a benign condition of unknown etiology, resulting in a protrusion of the rectum through the anal verge. RP is most commonly found in elderly women, although it may also afflict young and nulliparous women, children, and men.1 Except for the prolapse itself, patients frequently have associated symptoms including anal incontinence, constipation, mucus discharge, and soiling.2 The incidence of RP in the general population is unknown although it is less common than genital prolapse. Concomitant pelvic floor disorders has been reported in 8 to 27 percent of patients with RP.3,4 Some of the risk factors presumably predisposing for RP, such as chronic straining at defecation, previous pelvic surgery, elevated intra-abdominal pressure, and increasing age, are often associated with genital prolapse as well.5,6 An association between rectal and genital prolapse is biologically plausible since both conditions involve laxity of pelvic organ supportive tissues. However, few of these patients are offered a multidisciplinary pelvic floor evaluation at the time of surgical treatment for RP.
Read at the meeting of The European Association of ColoProctology, Barcelona, Spain, September 18 to 20, 2003. Correspondence to: Daniel Altman, M.D., Ph.D., Department of Obstetrics and Gynecology, Danderyd Hospital, 182 88, Stockholm, Sweden, e-mail:
[email protected] Dis Colon Rectum 2005; 49: 28–35 DOI: 10.1007/s10350-005-0217-3 * The American Society of Colon and Rectal Surgeons Published online: 08 November 2005
28
Vol. 49, No. 1
GENITAL AND RECTAL PROLAPSE ARE ASSOCIATED
The present study was undertaken to study the prevalence of genital prolapse surgery and urinary incontinence (UI) in female patients operated for RP to determine if these patients are at increased risk of undergoing additional pelvic floor surgery compared with a matched control group without RP.
29
were nulliparous. Mean age at menopause was 49.8 (range, 34–59) years. Eight patients (17 percent) were smokers with a mean of 23.8 years of smoking. Twenty-seven patients (56 percent) had undergone other surgical procedures (Table 1).
Control Group PATIENTS AND METHODS Study Group Between 1980 and 2000, 73 female patients who had RP underwent a modified Ripstein rectopexy at the Department of Surgery, Danderyd Hospital, Stockholm, Sweden. Some of these patients and the surgical procedure have been described previously regarding other aspects of RP pathology and treatment.7,8 Through the national registrar’s office, 52 of these patients were identified as alive at the time of the study and were asked to complete a questionnaire regarding previous medical and surgical history. Patients were all Caucasians from the same geographic area in Stockholm, Sweden. Subjects not answering the questionnaire were considered nonresponders after a reminding letter. Forty-eight of the 52 women (92 percent) answered the questionnaire. Mean age at follow-up was 69.0 (range, 32–90) years, mean age at the time of rectopexy was 56.2 (range, 26–75) years, mean time from surgery to follow-up was 13.8 (range, 3–23) years, and median follow-up time was 14.3 years. Median parity was 2.0 (range, 0–4) and six patients
Survey
Table 1. Abdominal Surgical Procedures Surgical Procedures Performed
Study Group (n = 48)
Control Group (n = 165)
Cholecystectomy Hysterectomy (indications other than prolapse) Salpingectomy and ovarian surgery Appendectomy Bowel obstruction Tubal surgery Cesarean section Colon resection Inguinal hernia Vaginal fistula Extrauterine pregnancy Gastric surgery
10
3
3
21
5 6 3 2 2 2 2 1 0 0
23 4 2 2 2 2 1 1 1 1
Figures are number of patients.
A control group consisting of four matched women to each patient with RP was obtained using the national registrar’s office database. The control group was randomly selected primarily to match date of birth and gender by an administrator not involved in the study. The control subjects were all Caucasians from the same residential area as the patients, forming the population base of the hospital, consisting of approximately 220,000 women in all age groups. One hundred sixty-five of the 200 control subjects (82.5 percent) answered the questionnaire. Mean age at the time of the study was 67.7 (range, 30–91) years. Mean parity was 2.1 (range, 0–5) and 16 patients were nulliparous. Mean age at menopause was 51.4 (range, 41–58) years. Eleven patients (6.7 percent) were smokers with a mean of 24.6 years of smoking. Fifty-two patients (31 percent) had undergone other surgical procedures (Table 1). Of the subjects not answering the questionnaire, seven subjects could not provide reliable information (reportedly because of memory loss or dementia), four declined participation, and the remaining 24 subjects were nonresponders after a reminding letter. Mean age in nonresponders was 65.3 (range, 30–72) years.
Patients with surgically managed RP were identified by searching hospital records using International Classification of Disease (ICD) 8-10 diagnosis nomenclature, with the discharge diagnosis of abdominal rectopexy as a key search variable. Preoperative diagnosis of RP was confirmed at clinical examination, rectoscopy, and defecography.9 At defecography RP was defined as a circumferential descent of the entire thickness of the rectal wall, extending through the anal verge.10 An identical, self-administered questionnaire was sent out to all 52 living patients and to the 200 subjects in the control group. Detailed questions regarding previous medical and surgical history, including treatment of genital prolapse, UI, and other gynecologic surgeries were included. Because of the
ALTMAN ET AL
30
long follow-up period, questions on pelvic floor disease were directed toward the diagnosis of disease by a physician rather than current symptoms.
Statistical Analysis and Ethical Considerations A power analysis was performed with genital prolapse surgery as the primary outcome variable and was based on the assumption that the lifetime risk of undergoing pelvic floor surgery is 13 percent.11 To detect a 20 percent difference between the cohorts, a sample size of 46 patients, with a patientto-control ratio of at least 1:3, was required to provide 80 percent power with an a level of 0.05.12 Risk factors in health care history were analyzed using a univariate logistic regression computer model (Statistica\, Statsoft Inc., Tulsa, OK). Multivariate logistic regression was performed on risk factors demonstrating significant associations in the univariate logistic regression. Nonparametric statistics was used to compare continuous and ordinal data. P < 0.05 was considered significant for all analyses. Participation in the study was voluntary and all patients gave their informed consent to participate. The study was approved by the Local Ethics Committee at Karolinska Hospital, Karolinska Institutet, Stockholm.
RESULTS There were no significant differences in age at follow-up, parity, and age at menopause when comparing the study and control group.
Genital Prolapse Diagnosis of genital prolapse, regardless of treatment, had been made in a total of 23 of 48 patients (48 percent) and 33 of 165 controls (20 percent) at the time of the study (P < 0.01). Surgical treatment of
Dis Colon Rectum, January 2006
uterine prolapse and vaginal wall prolapse was significantly more common in the study group compared with the control group (Table 2). Uterine prolapse was reported by 16 of 48 patients (33 percent); of these 16, 15 patients had undergone hysterectomy and one patient was treated conservatively with a pessary. Uterine prolapse was reported by 21 of 165 controls (13 percent), 18 controls had undergone hysterectomy and three controls were treated conservatively with a pessary. Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (P < 0.01). Vaginal wall prolapse (including cystocele, rectocele, enterocele, and vaginal vault prolapse) surgical repair was reported by 10 of 48 patients (21 percent), and 15 of 165 controls (9 percent). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (P < 0.05). At multiple regression analysis of the combined study cohorts, first-degree familial incidence of genital prolapse (mother or sister with genital prolapse), previous abdominal surgery, and postmenopausal status were independently associated with an increased risk of uterine prolapse surgery (Table 3). Previous abdominal surgery, hysterectomy, and two vaginal deliveries or more were independently associated with an increased risk of vaginal wall prolapse surgery (Table 3).
Urinary Incontinence There was no statistical difference in prevalence of UI when comparing the study group with the control group (Table 2). A total of 15 of 48 patients (31 percent) and 43 of 165 controls (24 percent) reported UI. Urge UI was reported by 7 of 48 patients (15 percent) and 17 of 165 controls (10 percent) and stress UI was reported by 8 of 48 patients (17 percent) and 26 of 165 controls (16 percent). Ten patients and one control subject
Table 2. Comparison Between Study and Control Groups at Logistic Regression Analysis Control Group (n = 165)a Hysterectomy-uterine prolapse Vaginal wall prolapse surgery SUI UUI a
21 15 26 17
(13) (9) (16) (10)
Study Group (n = 48)a 16 10 8 7
(33) (21) (17) (15)
Adjusted OR (95% CI) 3.1 3.2 1.0 1.5
(1.4–6.9) (1.3–7.8) (0.4–2.4) (0.6–3.8)
P P P P
= = = =
0.001 0.002 0.9 0.4
Values are number of patients and percent in parenthesis. OR = odds ratio; CI = confidence interval; SUI = stress urinary incontinence; UUI = urge urinary incontinence.
Rectal Prolapse OR = odds ratio; CI = confidence interval; SUI = stress urinary incontinence; UUI = urge urinary incontinence. a Numbers are adjusted OR (95% CI).
(0.6–5.1) P = 0.3 (1.4–12.1) P = 0.01 (0.6–3.4) P = 0.7 (0.3–4.2) P = 0.8 1.7 4.1 1.4 1.1 = = = =
0.6 0.1 0.03 0.04
0.9 0.4 1.1 0.6
(0.4–2.6) (0.2–1.3) (0.5–2.3) (0.2–2.2)
P P P P
= = = =
0.6 0.1 0.6 0.4 P P P P (0.3–1.8) (0.1–1.3) (1.1–6.4) (1.2–4.6) 0.8 0.4 2.7 1.4 2.9 (1.4–6.7) P = 0.02 1.5 (0.2–3.7) P = 0.09 2.9 (1.2–7.0) P = 0.02 —
31
had had UI surgery performed and the remaining patients were treated conservatively. Mean age at onset of stress UI was 62.3 years in the study group compared with 60.6 years in the control group (NS). Mean age at onset of urge UI was 55.7 years in the study group compared with 61.5 years in the control group (NS). Rheumatic disease was the only factor associated with a significantly increased risk of UI at logistic regression analysis (Table 3). Smoking, steroid treatment, hypothyroidism, osteoporosis, and diabetes were not identified as risk factors for the development of genital prolapse or UI.
1.5 (0.7–3.3) P = 0.3 1.9 (0.7–5.3) P = 0.09 2.9 (1.5–5.7) P = 0.007 1.2 (0.4–3.5) P = 0.2
0.6 0.2 0.4 0.7 = = = = P P P P (0.6–2.5) (0.8–5.6) (0.8–1.5) (0.5–2.0) 1.2 2.1 1.1 0.9
Age at follow-up Vaginal delivery Vaginal deliveries (2 or more) Smoking Postmenopausal Menopause age < 52 Hereditary incidence Rheumatic disease Abdominal surgery Hysterectomy
= = = =
0.001 0.4 0.2 0.9
1.2 0.8 1.6 0.4
(0.2–6.4) (0.2–2.9) (0.5–5.1) (0.1–1.3)
P P P P
= = = =
0.8 0.7 0.1 0.9 P P P P (1.7–2.5) (0.1–2.3) (0.4–5.7) (0.5–1.8) 2.2 1.2 1.6 0.9 1.8 (0.4–2.1) P = 0.5 1.0 (0.3–3.1) P = 0.9 8.7 (1.1–11.7) P = 0.04 1.7 (0.5–5.2) P = 0.3
P P P P
= = = =
0.5 0.3 0.4 0.3 (0.6–3.5) (0.6–6.7) (0.4–8.8) (0.1–3.7) 1.4 2.0 1.9 1.4
1.0 (0.9–1.1) P = 0.1 1.8 (0.7–4.7) P = 0.2 1.0 (0.9–1.1) P = 0.06 1.9 (0.4–8.7) P = 0.9 1.1 (1.0–1.5) P = 0.9 2.7 (0.3–21.4) P = 0.5 1.5 (1.2–1.9) P = 0.03 1.3 (0.5–2.8) P = 0.2
1.0 (1.0–1.1) P = 0.06 1.2 (0.2–4.6) P = 0.9
SUI Hysterectomy for Uterine Prolapse
Vaginal Wall Prolapse Surgery
UUI
Rectal Prolapse
GENITAL AND RECTAL PROLAPSE ARE ASSOCIATED
Associated Factor
Multivariate Logistic Regressiona
Table 3. Outcome Variables Tested for Association With Pelvic Floor Dysfunction and Rectal Prolapse When Assessing the Entire Study Population
Vol. 49, No. 1
None of the patients with RP underwent concurrent genital prolapse surgery at the time of RP surgery. A history of abdominal surgical procedures was significantly more common in the study group than in the control group (odds ratio (OR) = 2.9; 95 percent confidence interval (CI) = 1.5–5.7; P = 0.007). Hysterectomy for reasons other than prolapse was not identified as a risk factor for genital prolapse surgery, rectopexy, or UI (Table 3). No risk factors, except other abdominal surgery, could be identified as specifically associated with RP when comparing the study group with the control group (Table 3).
DISCUSSION Our most important finding is the strong association between surgically managed RP and other pelvic organ prolapse surgery in Caucasian women. Patients with RP undergo genital prolapse surgery more frequently and at a significantly younger age than age-matched control subjects. Accumulating evidence suggests that pelvic organ disorders should be recognized as part of an intimately connected multicompartment unit and not as isolated disorders.13,14 Current knowledge on the relationship between rectal and genital prolapse is, however, mostly limited to anecdotal reports15 and case series.1,16,17 Genital prolapse has been described as present in 9 to 27 percent of patients with RP,1,16,18 although rarely necessitating simultaneous surgical intervention. A previous case-control study showed that genital prolapse was more common among patients with RP and/or anal incontinence compared with a control group.19 However,
32
ALTMAN ET AL
a low response rate in the study group (34 percent) and significant differences in age and number of vaginal deliveries between patients with RP and control subjects affect the validity of the conclusions. It is known that female RP may occur at all ages,18 and patients in our study underwent rectopexy between 26 and 75 years of age. In patients with RP there was a peak in abdominal rectopexy in the fifth and seventh decades showing a biphasic distribution, whereas hysterectomy for uterine prolapse peaked in the beginning of the sixth decade. In patients with RP, mean age at menopause was 49.8 years and mean age at hysterectomy for uterine prolapse was 54.7 years. The peak in uterine prolapse surgery for the control group appeared almost a decade later (Fig. 1). Thus, patients requiring RP surgery before or around menopause are younger at the time of hysterectomy because of uterine prolapse compared with the control group. Consequently, this group of patients is at increased risk of ensuing posthysterectomy vaginal wall prolapse20 and would also be more eligible for secondary surgical procedures.21 Perimenopausal patients with RP should be the main focus of a comprehensive and multidisciplinary pelvic floor investigation to identify other pelvic floor abnormalities and if necessary perform concurrent surgical procedures. An increased prevalence of genital prolapse surgery in patients with RP suggests that the two
Dis Colon Rectum, January 2006
prolapse disorders may share a common pathogenesis, a biologically plausible assumption. The present study was able to demonstrate higher prevalence rates of surgically managed genital prolapse in patients with RP than what previously has been reported.18,22 Recently, more reports have implicated changes in the pelvic organ supportive tissues as an important contributory pathogen in the development of genital prolapse.23 The most likely explanation for this deficiency in structural support is found in the connective tissues. High rates of UI and pelvic organ prolapse have been reported in patients with generalized connective tissue disorders such as Marfans syndrome and Ehlers–Danlos disease.24 Collagen types I and III are the most important structural proteins in the extracellular connective tissue matrix, providing support and tensile strength to the pelvic floor. The precise mechanism regulating connective tissue turnover is largely unknown although it has been shown that collagen metabolism is influenced by aging and estrogen levels.25,26 This is in agreement with our results, identifying postmenopausal status as the single most important risk factor for uterine prolapse surgery (Table 3). In the present study, hereditary incidence of genital prolapse was independently associated with an increased risk of undergoing genital prolapse surgery. The incidence of UI varies between ethnic groups,6
Figure 1. Time-to-event graph for patients with rectal prolapse and controls. Group 1 = Hysterectomy due to uterine prolapse in the rectal prolapse group. Group 2 = Ripstein procedure in the rectal prolapse group. Group 3 = Hysterectomy due to uterine prolapse in the control group.
Vol. 49, No. 1
GENITAL AND RECTAL PROLAPSE ARE ASSOCIATED
commonly indicating a higher incidence among Caucasians. In a study by Rinne and Kirkinen5 30 percent of patients under 45 years of age who had genital prolapse had a familial incidence. Hereditary incidence and ethnicity thus may be important when counseling individual patients and making risk assessments. There were no significant differences between study and control groups regarding either the prevalence or the age at onset of urge and stress UI. These results are contrary to the findings of GonzalezArgente et al.19 who reported that 52 percent of the patients with RP suffered from daily UI episodes compared with 17 percent in the control group. The corresponding figures in the present study were 31 and 26 percent. This difference in results might be explained by selection bias caused by the low response rate in the previous study, but also by the fact that patients with RP were significantly older than the control subjects.19 Rheumatic disease was associated with an increased risk of urge UI (Table 3). One may hypothesize that a generalized connective tissue inflammatory process could also affect the detrusor muscle of the bladder wall, resulting in bladder overactivity. This association has not been previously described and warrants further studies in patients with rheumatic disorders. However, we were unable to confirm the previously described association between rheumatic arthritis and genital prolapse.27 In the present study, rheumatic disease was not associated with either rectal prolapse or with genital prolapse (Table 3). Although UI often coexists with genital prolapse and anal incontinence,28 it is likely that the pathogenesis resulting in RP differs from that of stress UI, and even more likely from that of urge UI. This assumption is supported by the fact that stress UI did not share any of the risk factors predisposing for RP (Table 3) and that age at onset of stress UI did not differ significantly between the study and control groups. Epidemiologic studies that examined the association between parity and genital prolapse agree that pregnancy and delivery are important risk factors for genital prolapse. However, there is disagreement about whether it is parity itself, the number of vaginal deliveries, or prolonged labor that predisposes for pelvic floor defects later in life.5,21,27 There is also evidence that demonstrates that direct tissue trauma at delivery may have a harmful effect on pelvic floor function.29 Pelvic floor lacerations and damage to pelvic floor innervation is assumed to occur primarily at first delivery,30,31 with obstetric
33
interventions such as vacuum extraction, forceps, and episiotomy further increasing the risk.30–32 In the present study, there was a strong independent association between the number of vaginal deliveries and vaginal wall prolapse surgery (Table 3). The number of instrumental deliveries or other obstetrical interventions were too few to allow further stratification in our statistical analysis. Similarly, parity and vaginal delivery have been associated with an increased risk of RP. However, this is contradicted by reports that show that up to one-third of patients with RP are nulliparous.18,33,34 The number of nulliparous women in the present study was 12 percent in patients with RP compared with 9.7 percent in the control group. These results suggest that trauma at vaginal delivery may have a less detrimental effect on rectal fixation compared with other pelvic organ supportive structures such as the rectovaginal fascia. The finding that two or more vaginal deliveries was a significant risk factor for vaginal wall prolapse surgery but not for RP surgery (Table 3) supports this assumption. Abdominal surgery was significantly more common in patients with a history of rectal and genital prolapse surgery. Prior hysterectomy and other abdominal surgery also resulted in an increased risk of vaginal wall prolapse surgery (Table 3). This agrees with previous studies that suggest that some surgical procedures may be directly related to the etiology of female pelvic floor disorders,5,6 presumably by affecting internal supportive fascia structures. This association is probably stronger when considering pelvic surgery and less plausible when considering upper gastrointestinal procedures. Although speculative, it is also possible that the rectopexy itself affects the pelvic floor suspension apparatus by changing the vaginal pressure axis in general, and at defecation in particular. This change in pelvic floor dynamics may predispose for pelvic organ prolapse and could in part explain some of our results. A case-control study design was chosen to obtain statistical power in a reasonable time because RP is far less prevalent than genital prolapse in the general population. Strengths of our study, such as the uniform classification and diagnosis of the study cohort, the homogeneous population samples, and the high response rates in both cohorts, need to be weighed against possible sources of bias associated with a retrospective study. We tried to minimize the risk of recall bias by specifically seeking the time of the surgical procedures performed and not rely on symptoms that
ALTMAN ET AL
34
supposedly arise from genital prolapse because it has been demonstrated that even patients with advanced stages of genital prolapse often are asymptomatic.35,36 The uniform classification and diagnosis of the study cohort reduce the risk of misclassification bias. To further avoid misclassification, all reports on vaginal wall prolapse surgery were analyzed as one variable since it would be presumptuous to expect all patients to accurately recollect the specific site of vaginal wall repair. Finally, one should consider that the patient group may be more prone to repeat pelvic surgery following the primary procedure because of an increased awareness of pelvic floor morbidity, and thus selection bias may contribute to the high number of reconstructive pelvic floor procedures in women with surgically corrected rectal prolapse. In summation, our results indicate a strong association between rectal and genital prolapse surgery, suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.
8.
9.
10.
11.
12.
13.
14.
ACKNOWLEDGMENT The authors thank the Medical Statistics Service Group at the Karolinska Institute for statistical advice.
REFERENCES 1. Loygue J, Nordlinger B, Cunci O, Malafosse M, Huguet C, Parc R. Rectopexy to the promontory for the treatment of rectal prolapse. Report of 257 cases. Dis Colon Rectum 1984;27:356 – 9. 2. Henry MM, Swash M. Coloproctology and the pelvic floor. London: Butterworth-Heinemann 1992; 316–20, 352 – 3. 3. Kupfer CA, Goligher JC. One hundred consecutive cases of complete prolapse of the rectum treated by operation. Br J Surg 1970;57:482 – 7. 4. Peters WA 3rd, Smith MR, Drescher CW. Rectal prolapse in women with other defects of pelvic floor support. Am J Obstet Gynecol 2001;184:1488 – 94. 5. Rinne KM, Kirkinen PP. What predisposes young women to genital prolapse? Eur J Obstet Gynecol Reprod Biol 1999;84:23 – 5. 6. Swift SE, Pound T, Dias JK. Case-control study of etiologic factors in the development of severe pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:187 – 92. 7. Holmstrom B, Broden G, Dolk A. Results of the Ripstein operation in the treatment of rectal prolapse
15.
16.
17.
18.
19.
20.
21.
22.
Dis Colon Rectum, January 2006
and internal rectal procidentia. Dis Colon Rectum 1986;29:845 – 8. Schultz I, Mellgren A, Dolk A, Johansson C, Holmstrom B. Long-term results and functional outcome after Ripstein rectopexy. Dis Colon Rectum 2000;43:35 – 43. Goei R, Baeten C. Rectal intussusception and rectal prolapse: detection and postoperative evaluation with defecography. Radiology 1990;174:124 – 6. Bremmer S, Uden R, Mellgren A. Defaeco-peritoneography in the diagnosis of rectal intussusception and rectal prolapse. Acta Radiol 1997;38:578 – 83. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501 – 6. Dupont WD, Plummer WD. Power and sample size calculations for studies involving linear regression. Control Clin Trials 1998;19:589 – 601. Jackson SL, Weber AM, Hull TL, Mitchinson AR, Walters MD. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997;89:423 – 7. Meschia M, Buonaguidi A, Pifarotti P, Somigliana E, Spennacchio M, Amicarelli F. Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse. Obstet Gynecol 2002; 100:719 – 23. Amico JC, Marino AW Jr. Prolapse of the vagina in association with rectal procidentia. Dis Colon Rectum 1968;11:115 – 9. Azpuru CE. Total rectal prolapse and total genital prolapse: a series of 17 cases. Dis Colon Rectum 1974; 17:528 – 31. Vongsangnak V, Varma JS, Watters D, Smith AN. Clinical, manometric and surgical aspects of complete prolapse of the rectum. J R Coll Surg Edinb 1985; 30:251 – 4. Ryan P. Observations upon the etiology and treatment of complete rectal prolapse. ANZ J Surg 1980; 50:109 – 15. Gonzalez-Argente FX, Jain A, Nogueras JJ, Davila GW, Weiss EG, Wexner SD. Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse. Dis Colon Rectum 2001;44:920 – 6. Barham K, Collopy BT. Posthysterectomy rectal and vaginal prolapse, a commonly overlooked problem. ANZ J Obstet Gynaecol 1993;33:300 – 3. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579 – 85. Failes D, Killingback M, Stuart M, De Luca C. Rectal prolapse. ANZ J Surg 1979;49:72 – 5.
Vol. 49, No. 1
GENITAL AND RECTAL PROLAPSE ARE ASSOCIATED
23. Jackson SR, Avery NC, Tarlton JF, Eckford SD, Abrams P, Bailey AJ. Changes in metabolism of collagen in genitourinary prolapse. Lancet 1996;347:1658 – 61. 24. Carley ME, Schaffer J. Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers-Danlos syndrome. Am J Obstet Gynecol 2000;182:1021–3. 25. Bentley JP. Aging of collagen. J Invest Dermatol 1979;73:80 – 3. 26. Takano CC, Girao MJ, Sartori MG, et al. Analysis of collagen in parametrium and vaginal apex of women with and without uterine prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:342 – 5. 27. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynaecol 2000;107:1460 – 70. 28. Lacima G, Espuna M, Pera M, Puig-Clota M, Quinto L, Garcia-Valdecasas JC. Clinical, urodynamic, and manometric findings in women with combined fecal and urinary incontinence. Neurourol Urodyn 2002;21:464 – 9. 29. Snooks SJ, Swash M, Henry MM, Setchell M. Risk factors in childbirth causing damage to the pelvic floor innervation. Br J Surg 1985;72:S15 – 7.
35
30. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308:887 – 91. 31. Zetterstrom JP, Lopez A, Anzen B, Dolk A, Norman M, Mellgren A. Anal incontinence after vaginal delivery: a prospective study in primiparous women. Br J Obstet Gynaecol 1999;106:324 – 30. 32. Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women. Am J Obstet Gynecol 2001;185:444 – 50. 33. Hawley P. Symposium: Procidentia of the rectum: Ivalon-sponge repair. Dis Colon Rectum 1975;18:461 – 3. 34. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia. 30 years’ experience. Dis Colon Rectum 1985;28:96 – 102. 35. Samuelsson EC, Arne Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180:299 – 305. 36. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003;189:372 – 7.
