Int Urogynecol J (2012) 23:537–551 DOI 10.1007/s00192-011-1629-3

REVIEW ARTICLE

Posterior vaginal compartment prolapse and defecatory dysfunction: are they related? Cara L. Grimes & Emily S. Lukacz

Received: 5 August 2011 / Accepted: 6 December 2011 / Published online: 6 January 2012 # The International Urogynecological Association 2011

Abstract While posterior vaginal compartment prolapse and defecatory dysfunction are highly prevalent conditions in women with pelvic floor disorders, the relationship between anatomy and symptoms, specifically obstructed defecation, is incompletely understood. This review discusses the anatomy of the posterior vaginal compartment and definitions of defecatory dysfunction and obstructed defecation. A clinically useful classification system for defecatory dysfunction is highlighted. Available tools for the measurement of symptoms, physical findings, and imaging in women with posterior compartment prolapse are discussed. Based on a critical review of the literature, we investigate and summarize whether posterior compartment anatomy correlates with function. Definitions of obstructed defecation and significant posterior compartment prolapse are proposed for future exploration. Keywords Defecatory dysfunction . Obstructed defecation . Posterior prolapse . Rectocele

Introduction Pelvic organ prolapse (POP) is a heterogeneous disorder with a spectrum of anatomical defects in multiple vaginal compartments (anterior, apical, posterior). These defects may be associated with a wide array of symptoms. While some women are asymptomatic, many report symptoms that C. L. Grimes (*) : E. S. Lukacz Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Reproductive Medicine, University of California, San Diego, La Jolla, CA, USA e-mail: [email protected]

fall into four categories: protrusion or bulge symptoms, lower urinary tract symptoms, sexual dysfunction and defecatory dysfunction (DD) [1, 2]. Disorders in the posterior compartment can be both functional disturbances (as with DD) and anatomical disturbances (bulge or protrusion). The symptoms of DD are common and not necessarily specific to prolapse. While the presence of posterior prolapse has been associated with DD, specifically obstructed defecation, there is considerable overlap with other anorectal disorders. The relationship between posterior vaginal wall prolapse and DD is incompletely understood and deserves further study. The prevalence of posterior compartment prolapse ranges from 18 to 40% in community dwelling women [3, 4]. In those presenting to a urogynecology clinic, this number can range from 9 to 76% depending on the definition used [5, 6]. Similarly, complaints of obstructed defecation are pervasive, and these numbers can vary depending on the definition. The prevalence of constipation in the general population is estimated at 2–27%, with most studies estimating prevalence at 10–15% [7]. In urogynecology populations, obstructed defecation symptoms can be found in 9–60% [8, 9]. The specific symptom of splinting may occur in 18–25% of women, straining in 27%, and incomplete evacuation in 26% [9–11]. The point at which prolapse becomes clinically significant is of great interest. Most studies show that symptoms correlate with a threshold of the leading edge of the prolapse at or beyond the hymen [12–16]. It is likely that a threshold exists at which posterior compartment prolapse becomes associated with defecatory dysfunction. If this can be shown to be true, then the next logical assumption is that improving the anatomical defect in the posterior compartment will improve defecatory dysfunction. This leads us into three key questions that have not been satisfactorily answered

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regarding the posterior vaginal compartment prolapse and DD: 1. Does posterior vaginal compartment anatomy correlate with function? 2. Does restoring the anatomy of the posterior vaginal compartment improve defecatory function? 3. What is the best surgical approach to restore posterior compartment anatomy and/or to restore defecatory function? The goals of this review are to recognize existing contributions to the literature, to review posterior compartment anatomy, to explore working definitions of DD and obstructed defecation and a modification on the classification of DD to evaluate measurement tools of symptoms, physical exam findings and imaging techniques, and to explore the association between posterior compartment prolapse and obstructed defecation. Through review of these topics, we will explore whether these three questions have been satisfactorily answered by existing studies and suggest a direction for future research to provide our field with definitive conclusions.

Definitions and classification Anatomy The posterior compartment contains the posterior vaginal wall, fibromuscular layers between the vagina and rectum (rectovaginal septum), rectal wall, the levator ani muscles, the uterosacral/cardinal ligament complex apically, and the Fig. 1 Posterior compartment anatomy

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perineal body caudally (Fig. 1). Rectocele is a common term used to describe the prolapse of the rectum toward the anterior rectal and posterior vaginal wall into the lumen of the vagina (Fig. 2a) [17]. A more inclusive and accurate term would be posterior vaginal compartment prolapse as this includes any organ protrusion into the posterior vaginal wall related to defects/attenuation in the rectovaginal septum (rectoceles), cul-de-sac (enteroceles), or perineum (perineal descent). Perineal descent is defined as a perineum greater than or equal to 2 cm below the level of the ischial tuberosities either at rest or with straining [18]. Posterior compartment prolapse can result from defects in any of the posterior compartment structures. Together, levator ani muscles and the uterosacral/cardinal ligaments take mechanical pressure off of the connective tissue of the vaginal and rectal walls (rectovaginal septum). The rectovaginal septum consists of connective tissue, sometimes referred to as endopelvic “fascia”, though this is not in fact a true fascial layer. The rectovaginal septum includes the lamina propria of the vagina, fibromuscular tissue, and adventitia and is composed of smooth muscle, collagen, and elastin [19]. The vaginal and rectal walls provide much of the support in the posterior compartment. Kleeman et al. described the layers of the vaginal and rectal wall and clarified what component is often referred to as “fascia” and what component most surgeons plicate and attempt to repair [19]. The layers of the vaginal and rectal wall include vaginal epithelium, lamina propria of the vagina, fibromuscular wall of the vagina, adventitia, outer muscular wall of the rectum, inner muscular wall of the rectum, lamina propria of the rectum, and rectal mucosa. It is the fibromuscular wall of the vagina and adventitia that comprise the layer often referred to as the

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a. Posterior Defect: “Rectocele”

b. Posterior Apical Defect: Traction “Enterocele”

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“fascial layer” left to plicate more proximally. The plane of dissection in order to repair a distal posterior vaginal wall defect with plication should be thin enough to leave most of the adventitial and fibromuscular layer on the rectal side which can then be plicated. The rectovaginal septum is juxtaposed between the vaginal epithelium and the muscular walls of the rectum, supported caudally by the uterosacral/cardinal ligaments, laterally by the arcus tendineus fascia rectovaginalis and the levator anis, and inferiorly by the perineal body [20, 21]. When uterosacral/cardinal ligaments stretch or levator muscles weaken through direct injury, avulsion, or neuromuscular damage from obstetrical trauma, excessive force may be placed on the rectovaginal septum leading to attenuation and/or discrete breaks and posterior vaginal compartment prolapse [22–24]. Anatomic classification

c. Posterior Apical Defect: Pulsion “Enterocele”

Fig. 2 Types of posterior compartment prolapse. a Posterior defect: “rectocele”. b Posterior apical defect: traction “enterocele”. c Posterior apical defect: pulsion “enterocele”

rectovaginal septum or fascia. The separation of these layers from the lamina propria of the vagina is what many surgeons find in the operating theater and describe plicating. It is this layer that can only be easily found in the distal one third of the vagina as this is where the rectum and vagina are densely fused. Proximal to this, there is increased adipose tissue in the adventitial layer which guides dissection so that there does not appear to be a

Nichols and Randall originally described their classification of posterior compartment prolapse in three categories: low— dislocation of the rectovaginal septum from the perineal body, mid—overstretching of the rectovaginal septum, and high—damage to the anterolateral attachments of the vagina and uterosacral/cardinal complex [25]. Richardson attributed defects to discrete breaks in the rectovaginal septum and described five types of posterior compartment prolapse based on five discrete breaks in the rectovaginal septum that lead to loss of support and subsequent bulge including: 1—low transverse, 2—midline vertical, 3—lateral, 4—L-shaped, and 5—U-shaped [26]. He noted that the most commonly encountered defect is the low transverse defect. Midline vertical injuries are likely the result of obstetrical injury caused by lacerations or episiotomies. DeLancey expanded on this knowledge by describing the contribution of the levator ani muscles and perineal membrane [22]. He described three types of posterior compartment prolapse: 1—distal failure in the perineal body, 2—failure of the levator ani muscles to close the genital hiatus, and 3— failure that is more proximal with the loss of upward suspension of the posterior wall by the uterosacral ligaments. Two types of enteroceles, a specific type of posterior compartment prolapse, have been described [27]. A traction enterocele occurs when the posterior cul-de-sac is pulled down with the prolapsing cervix or vaginal cuff but is not distended by the intestines (Fig. 2b). A pulsion enterocele results when the intestinal contents of the enterocele distend the rectovaginal septum and produce a protruding mass (Fig. 2c). While anatomic descriptions of posterior compartment prolapse have been widely explored, their relationship to function is less well established.

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Function

Classification of defecatory dysfunction

Anorectal dysfunction includes any condition that affects normal anorectal function and includes anal incontinence and DD. Anal incontinence is not typically a symptom of posterior compartment prolapse; rather it is a defect related to the anal sphincter and it’s neurologic and |muscular function. Anal incontinence is out of the scope of this review. Anal incontinence has been widely studied, whereas DD is still incompletely understood. DD is a heterogeneous disorder that encompasses any difficulty with defecation, excluding anal incontinence [18]. Unfortunately, there is no universally accepted classification of DD; however, a common symptom of DD is “constipation” which is a non-specific but frequently used term by many patients and their providers.

There is no universally accepted classification of DD. A well-described classification of DD has been proposed by Gutman and Cundiff in Novak’s Gynecology [35]. While it is important to group disorders for the purpose of research and discussion, it is imperative to note that any classification schemes may impose artificial restrictions on disease processes. Figure 3 is an adaptation of Gutman and Cundiff’s classification system with an overlay of disorders with multiple names (in quotations) and with the analogous Rome III classification system names (in parentheses). We attempt to align our definitions with consensus definitions used by the ICS/IUGA joint report published in December 2009 on the terminology for pelvic floor dysfunction, and these definitions are referenced (Table 1). DD can be divided into DD caused by systemic diseases and DD due to other causes. DD in the “other” category can be divided into functional disorders and anatomic disorders. Functional disorders have no anatomic or systemic etiology and comprise the colonic motility disorders. Anatomic disorders may result in obstructed defecation. Obstructed defecation is a condition potentially related to pelvic organ support defects or pelvic floor dyssynergia that the pelvic reconstructive surgeon must be able to distinguish and treat appropriately. Gastrointestinal disorders are included here as they can be distal defects that may act similarly to pelvic organ prolapse to obstruct defecation. For the purposes of this review DD is defined as a heterogeneous disorder that encompasses any difficulty with defecation, excluding anal incontinence, while obstructed defecation is defined as a subset of DD due to anatomic defects (posterior compartment prolapse) with associated abnormal evacuation symptoms including straining, incomplete emptying/evacuation, splinting (need to digitally replace the prolapse or otherwise apply manual pressure to the vagina or perineum), and manual evacuation/digitation (need to place fingers in the vagina or rectum to evacuate stool. We will focus on obstructed defecation causes of DD, specifically those related to defects in pelvic organ support.

Constipation A common, but not clinically useful, definition of constipation is less than three stools per week. This is based on prevalence studies in the general population that indicate that greater than 95% of women have greater than three bowel movements per week [28]. The American College of Gastroenterology Chronic Constipation Task Force and the American Society of Colon and Rectal Surgeons define constipation as unsatisfactory defecation characterized by infrequent stool, difficult stool passage, or both. Difficult stool passage includes straining, a sense of difficulty passing stool, incomplete evacuation, hard/lumpy stools, prolonged time to stool, or need for manual maneuvers to pass stool, and symptoms must be reported for at least 3 months [7, 29]. This is an expansion on the Rome III criteria, which are consensus-based definitions for clinical classification and are further discussed later [30, 31]. Recently, the International Continence Society (ICS) and the International Urogynecologic Association (IUGA) issued a joint report on terminology for female pelvic floor dysfunction based on the Rome II criteria and defined constipation as the complaint that bowel movements are infrequent and/or incomplete and/or there is need for frequent straining or manual assistance to defecate [32]. Other consensus groups and authors include more specific symptoms for constipation such as dyschezia (difficult defecation), painful defecation, excessive straining, digital manipulation to facilitate defecation, splinting, abnormal variations in stool consistency (dry, hard, or small stools), sensation of incomplete emptying/stool trapping, perineal heaviness, and infrequency of defecation [18, 33, 34]. The wide range of definitions and specific symptoms classified as constipation reflect that constipation is the prominent symptom complex of DD, and not a definitive diagnostic finding.

Evaluation Symptoms Evaluating symptoms of DD includes ascertaining a complete medical and surgical history, focusing on identification of systemic causes of DD better managed by gastroenterology or neurology specialists (such as multiple sclerosis, colon cancer, etc.). The first step is to screen out women with “alarm symptoms” and refer them for colonoscopy and/or gastrointestinal consultation [30, 31]. Alarm

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ANORECTAL DYSFUNCTION

ANAL INCONTINENCE

DEFECATORY DYSFUNCTION “constipation”

FECAL INCONTINENCE

FLATAL INCONTINENCE

SYSTEMIC CAUSES OF DEFECATORY DYSFUNCTION Endocrine disorders Neurologic disorders Metabolic disorders Psychiatric disorders

OTHER CAUSES OF DEFECATORY DYSFUNCTION ANATOMIC DISORDERS

FUNCTIONAL GASTROINTESTINAL DISORDERS “motility disorders “

OBSTRUCTED DEFECATION (symptoms of straining, incomplete evacuation, splinting, manual evacuation/digitation) “outlet obstruction”

GASTROINTESTINAL Rectal prolapse “rectal intussusception” Neoplasia Anal stricture Anal fissure Prolapsing hemorrhoids Fecal impaction Trauma

“outlet constipation”

“pelvic floor dysfunction”

Constipation predominant Irritable bowel syndrome (ROME III – C1)

PELVIC ORGAN SUPPORT DEFECTS (POSTERIOR COMPARTMENT) Posterior defect (rectocele) Posterior apical defect (enterocele) Perineal descent

DEFECATORY DYSSYNERGIA “functional defecation disorders” (ROME III-F3) “anismus” “functional obstructed defecation” “rectosphincteric dyssynergia” “pelvic floor dyssynergia” “disordered defecation” “spastic floor syndrome” ”paradoxical puborectalis syndrome”

Functional constipation (ROME III – C3)

Colonic inertia “slow transit constipation”

Fig. 3 Classification of defecatory dysfunction Table 1 Important definitions for evaluation of the posterior vaginal compartment Terminology

Definition

Anatomy Posterior compartment Posterior compartment prolapse Posterior defect (rectocele) Posterior apical defect (enterocele) Traction enterocele Pulsion enterocele Perineal descent Function Defecatory dysfunction Constipation Obstructed defecation Straining Incomplete emptying/ evacuation Splinting/digitation

Posterior vaginal wall, fibromuscular tissue (rectovaginal septum), perineal body, uterosacral/cardinal ligaments, and the levator ani muscles Any defect in the posterior vaginal support Prolapse of the posterior vaginal wall into the lumen of the vagina with rectal wall behind the defect Prolapse of the apical portion of the posterior vaginal wall adjacent to the small or large intestine Posterior cul-de-sac is pulled down with the prolapsing cervix or vaginal cuff but is not distended by the intestines [27]. The intestinal contents of the enterocele distend the rectal–vaginal septum and produce a protruding mass [27]. Perineum greater than or equal to 2 cm below the level of the ischial tuberosities either at rest or with straining

Heterogeneous disorder that encompasses any difficulty with defecation, excluding anal incontinence Complaint that bowel movements are infrequent and/or incomplete and/or there is need for frequent straining or manual assistance to defecate (Rome II criteria) [32] Defecatory dysfunction due to anatomic and structural defects with associated abnormal evacuation symptoms including: Complaint of the need to make an intensive effort (by abdominal straining or Valsalva) to either initiate, maintain, or improve defecation [32] Complaint that the rectum does not feel empty after defecation [32] Complaint of the need to digitally replace the prolapse or to otherwise apply manual pressure, for example, to the vagina or perineum (splinting), or to the vagina or rectum (manual evacuation/digitation) to assist voiding or defecation [32]

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symptoms include: hematochezia, unintentional weight loss, family history of colon cancer or inflammatory bowel disease, anemia, positive fecal occult blood tests, and acute onset of constipation in elderly persons [7]. These questions should be asked early in the evaluation of patients presenting with pelvic floor disorders. While positive responses do not exclude significant pelvic organ prolapse, they do suggest more pressing underlying medical conditions. Also, some clinicians have noted a subset of patients whose defecatory dysfunction may be linked to musculoskeletal pelvic floor dysfunction, ie pain in the lower abdomen and/or pelvis that is mistaken for a feeling of incomplete evacuation. Clinical experience is that these symptoms may go away with non-steroidal anti-inflammatory drugs, and this is certainly a reasonable first line treatment option. While this is a common shared experience among clinicians, there is little literature to support this and requires further study. Overall, symptoms can be divided into those suggesting functional disorders such as slow transit (bloating, pain, etc.) and those with obstructed defecation (straining, incomplete evacuation, splinting, manual evacuation/digitation). Functional disorders are referred to the gastroenterologist, while obstructed defecation may be best managed by the pelvic reconstructive or colorectal specialists. Several instruments are available to assist the physician or researcher in assessing obstructed symptoms. Unfortunately, there is no one universally accepted, standardized, validated tool for measuring defecatory symptoms. Key instruments are summarized as follows. Colorectal instruments The Bristol Stool Form Scale was developed as a measure of intestinal transit time. It is a self-reported, validated pictorial questionnaire that predicts intestinal transit time [36]. Stool form (specifically a value less than 3) predicts delayed transit time vs normal transit in constipated adults [37]. One limitation to this tool is that it does not assess symptoms or degree of bother related to bowel evacuation. A change in this stool form scale also correlates with changes in transit time [36]. The Obstructed Defecation Syndrome (ODS) Questionnaire is a simplified, specific version of the Wexner/ Agachan/Cleveland Clinic Scale (CCS) and the Knowles– Eccersley–Scott-Symptom (KESS) questionnaire [38]. It is a validated, disease-specific scoring system of constipation severity, specifically outlet obstruction (excluding slow transit constipation and mixed forms). It was designed to allow monitoring of efficacy of therapy by consisting of questions representing modifiable symptoms. It is the only scale to quantify severity and designed to allow comparison of results in clinical trials.

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Gastrointestinal instruments The Functional Gastrointestinal Disorders Rome criteria are consensus-based guidelines, based on symptom criteria that are not explained by other pathologically based disorders. There can be clinical overlap of the functional gastrointestinal disorders with other diseases. The important Rome classifications for DD include the diagnostic criteria for Functional Constipation (C3) and Functional Defecatory Dysfunction (F3) [30, 31]. The use of these criteria is encouraged in the gastrointestinal literature and is widely cited. Functional Constipation (C3) is defined as symptoms occurring ≥3 days per month in the past 3 months with symptom onset at least 6 months prior to diagnosis. Symptoms should include two or more of the following: straining, lumpy or hard stool, sensation of incomplete evacuation, sensation of anorectal obstruction/blockage, and manual maneuvers to facilitate defecation (eg digital evacuation, support of the pelvic floor), and less than three defecations per week. These symptoms should occur during >25% of all defecations. Also, loose stools are rarely present without the use of laxatives, and there should be insufficient criteria for a diagnosis of IBS. Functional Defecation Disorders (F3) is defined as ≥3 days per month in the past 3 months with symptom onset at least 6 months prior to diagnosis with two or more of the following during repeated attempts to defecate: evidence of impaired evacuation based on balloon expulsion test or imaging, inappropriate contraction of the pelvic floor muscles (i.e. anal sphincter or puborectalis), or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, abnormal EMG activity, or inadequate propulsive forces assessed by manometry or imaging. While the Rome criteria related to DD are widely used in the gastrointestinal literature, they have not been validated with respect to content, construct, or reliability in clinical populations. Female pelvic medicine and pelvic reconstructive surgery instruments The Pelvic Floor Distress Inventory (PFDI) is a commonly used and validated scale in the field of urogynecology [39, 40]. It was designed to assess symptom distress in women with pelvic floor dysfunction. It consists of 46 items and three scales, the Urinary Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (POPDI), and the Colorectal-Anal Distress Inventory (CRADI). The long form of the CRADI has 17 items and four subscales: obstructive, incontinence, pain/irritation, and rectal prolapse. While this questionnaire was intended to be administered in its entirety, the CRADI obstructive subscale has been shown to significantly correlate with a diagnosis of DD (defined by Barber as self-report of infrequent stools, straining,

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splinting, digital evacuation, and sensation of incomplete evacuation) (rho00.29, P<0.01) and has been shown to be internally consistent (alphas 0.82–0.89) and reproducible (interclass correlations: 0.86–0.87) [39]. While a correlation has been shown, it is weak. The CRADI short form has been shown to correlate with the long-form scale (r00.93) [40]. Also, recent work has determined that the minimum important difference (MID) for the CRADI is 11, which will be useful to investigate change in symptoms after an intervention in future studies [41]. However, this MID was determined in a cohort of patients symptomatic from fecal incontinence and may not be applicable to an obstructed defecation population. A recent abstract has shown that a trend in recent studies is to use PFDI short-form questions 4, 7, and 8 (splinting, straining, incomplete evacuation) to represent obstructed defecation, though the questions have not been validated as a group [6, 42]. Physical examination The goal of a good measurement tool for the posterior compartment is to accurately determine the degree and type of posterior compartment prolapse and the best surgical method to treat the anatomy and dysfunction. Every provider specializing in the evaluation of pelvic floor dysfunction has a personal standardized approach to the physical examination of the patient with pelvic support defects. The International Continence Society (ICS), American Urogynecologic Society (AUGS), and the Society of Gynecologic Surgeons (SGS) adopted a standard system of terminology and diagnostic criteria for female pelvic organ prolapse and pelvic floor dysfunction in 1996 [27]. The POP-Q provides a standardized quantitative description of pelvic organ position and has demonstrated excellent interrater and intrarater reliability. The clinical utility of site-specific measures of the vaginal wall allow for the assessment of changes in prolapse over time by the same or different observers. Thus, it allows for similar judgments regarding the outcome of surgical repair of prolapse [44]. While the POP-Q standardizes assessment of points on the posterior vaginal wall, it does not allow for the determination of the type of posterior compartment prolapse (enterocele vs. rectocele). Additionally, the correlation between preoperative and intraoperative evaluation of pelvic support defects is unproven due to effects of anesthesia, diminished muscle tone, and loss of consciousness in operative patients [27]. Burrows et al. showed that sensitivity and positive predictive value of clinical evaluation compared to evaluation in the operating room was less than 40% [43]. Additional limitations include that it is unclear if the posterior POP-Q can be influenced by the amount of stool in the rectum at the time of exam. The ICS/AUGS/SGS 1996 consensus has also suggested a series of ancillary techniques to aid in further characterizing

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pelvic organ prolapse [27]. Most of these techniques have not been standardized or validated. Techniques described in the literature include: performance of a digital rectovaginal examination while patient is straining to differentiate between a high rectocele and enterocele, digital assessment of the contents of the rectovaginal septum during the examination to differentiate between a “traction” enterocele and a “pulsion” enterocele, measurements of perineal descent, measurement of the transverse diameter of the genital hiatus or the protruding prolapse, and description and measurement of rectal prolapse. Standing examination Some authors advocate starting the physical examination with the patient standing. An index finger can be placed in the rectum and a thumb in the vagina to palpate the rectovaginal septum and feel for small bowel to identify an enterocele [45]. Perineal measurement Widening of the genital hiatus and perineal decent can be measured with a perineocaliper or by placing a ruler along the posterior vaginal wall at the level of the ischial tuberosities. Descent is measured as the distance the perineal body moves on straining and is abnormal when the perineum is greater than or equal to 2 cm below the level of the ischial tuberosities [18]. Visual assessment Some describe localizing the site of posterior compartment prolapse by visualizing a loss of rugation pattern to identify a discrete fascial tear [24]. Using forceps to assess a midline posterior compartment prolapse has been described as placing an open curved ring forceps into the vagina posteriorly and laterally in an effort to reduce the bulge [45]. Additionally, an enterocele may be appreciated on rectovaginal exam as bowel seen herniating into the vagina demonstrating a “double bubble” [20]. Others report laxity of the anterior rectal wall using a single finger placed into the rectum to identify the location of the defect [20, 33, 45, 46]. The ballooning appearance seen with this examination method has been called “the spinnaker sail deformity” [47]. There is little data showing the reliability and reproducibility for any of these techniques though they are commonly used and likely contribute clinically meaningful information. Further studies are needed to establish reliable measurement tools for defects in the posterior compartment.

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Imaging The role of imaging in the posterior compartment is not yet firmly established and varies widely across institutions. The ICS/IUGA 2010 committee suggests consideration of diagnostic testing before pelvic reconstructive surgery, which can include defecography, colporecto-cystourethrography (colpo-cystodefecography), or MRI [32]. Recent data also suggests that translabial ultrasound may play a role [8]. Defecography Defecography is a radiological examination to evaluate anatomy (posterior compartment prolapse, enterocele, intussusception) and function (contraction of puborectalis, rectal emptying and trapping). It is often used in women with posterior compartment prolapse and evacuation dysfunction. Groenendijk et al. determined that defecography has a diagnostic accuracy of 42% for the posterior compartment with high sensitivity and low specificity for rectoceles compared to POP-Q [49]. Unfortunately, definitions of rectocele based on defecography vary widely with 48% of nulliparous asymptomatic women demonstrating rectocele on defecography [4]. Multiple studies have little to weak correlation between physical examination by POP-Q and defecography [49–51]. Colpo-cystodefecography This test is similar to defecography but includes the instillation of radio-opaque media into the bladder, vagina, and rectum while obtaining images during rest and straining. Often studies do not make the distinction and group these studies in the category of defecography. MRI Dynamic MRI assesses muscles and fibromuscular tissue of the pelvic floor using cine loop obtained at rest, during squeezing, straining, and/or defecation [52]. It allows for the assessment of each vaginal compartment in relationship during rest and strain. A meta-analysis by Broekhuis et al. reviewed published studies comparing dynamic MRI imaging and POP-Q stage and concluded that MRI has not yet been properly validated and suffers from a lack of standardization of reference lines [52]. This report found a low correlation between MRI and clinical examination of the posterior compartment. Interestingly, they suggest that this makes dynamic MRI a promising method to evaluate the posterior compartment as it may prove to be more accurate then clinical examination, especially in identifying enterocele and rectal intussusceptions. A concern regarding MRI is that it is limited by imaging in the supine position

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which may not represent normal function of reproduce symptoms due to the absence of normal gravitational forces in the sitting position. Perineal ultrasonography Pelvic floor ultrasonography has gained popularity in the field of pelvic reconstructive medicine as it represents a relatively inexpensive office-based imaging modality with practical application. The bladder, cervix or vaginal vault, and rectum can be imaged at rest and at maximal strain and viewed in relation to each other. It can be used to differentiate between rectoceles and enteroceles. Unfortunately, poor correlation exists between perineal ultrasonography and POP-Q of the posterior compartment [53]. However, this is a promising imaging tool that will likely be shown useful in future studies. Other Other studies that may be useful in the evaluation of defecatory dysfunction include barium enema, colonoscopy, anoscopy, colonic transit studies, anal manometry, EMG, endoanal ultrasound, and balloon expulsion studies. However, these are not specific to posterior compartment prolapse and therefore are beyond the scope of this review. Imaging studies such as defecography, dynamic MRI, and ultrasound may play an important role in differentiating between enterocele and rectocele and could prove to have better accuracy than current clinical examinations. Existing studies suffer from non-validated and varying functional and anatomic definitions of rectocele. Further, the populations studied are generally symptomatic referral populations with no control group. Until there is more research on the utility of these individual imaging tests and their correlation with functional and anatomical severity, studies should be seen as investigational and limited to those that will ultimately contribute information on decision making for treatment, while limiting cost. While these modalities may be useful in understanding the anatomy of the posterior compartment, the expense of these imaging techniques needs to be weighed against their clinical utility. An interesting study noted the lack of evidence for the clinical value of these diagnostic tests and examined the effects of MRI, defecography, urodynamic evaluation, and anorectal function tests including anal endosonography compared to a consensus outcome on treatment selection in women with primary POP [48]. They assigned a diagnostic value from 0 to 100% for each test based on the test’s relative importance to decision making and found that history taking and pelvic examination (POP-Q) were the most useful tests. Defecography was found to be the most valuable (9–65%) diagnostic test, especially in women with

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posterior wall prolapse and fecal incontinence. MRI was not useful.

Does posterior compartment anatomy correlate with function? Studies correlating posterior compartment anatomy and obstructed defecation symptoms are confounded by differences in patient populations and challenges in standardizing anatomical measurements and symptoms. However, there are some themes that emerge within the literature. Almost all of the studies available for review are prospective cohort studies (level IIb evidence), and most are adequately powered to show statistically significant differences. Most standardize the anatomic definitions using the POP-Q to measure the posterior compartment, defining posterior compartment prolapse by ordinal stages or by a cutoff (usually −1 or hymen). However, there are differences in how bowel symptoms are defined and measured. These studies are outlined in Table 2. In general, studies that assess the correlation between amount or degree (ordinal stage) of posterior prolapse and degree of bowel symptoms show weak to no correlation with r values ranging from 0.23 to 0.33 and tau-b of 0.227 [2, 11, 13, 54–57]. However, when assessment of posterior prolapse is defined as a dichotomous variable (presence vs. absence of prolapse), there appears to be a better correlation between posterior compartment prolapse and specific obstructed defecation symptoms [6, 13, 58]. The symptom that most often correlates with the presence of posterior compartment prolapse (using a cutoff point of Bp≥0) is digitation. This includes manual evacuation (emptying the rectum with fingers) or splinting (applying pressure to the perineum or inside the vagina) to achieve defecation [2, 13, 57–62]. Studies that looked at presence of posterior compartment prolapse (defined by different thresholds) and digitation also show significant association [6, 58, 63]. Recently, Erekson et al. published a well-designed crosssectional study that strongly linked the presence and amount of posterior compartment prolapse and the obstructed defecation symptom of splinting [6]. The population included 721 women presenting for initial care at a tertiary pelvic floor center, 233 (32.3%) of whom had ≥stage 2 prolapse and 67 (9.3%) had Bp≥0. Several different definitions of posterior compartment prolapse were explored including as an ordinal variable (maximal vaginal descensus, Bp) and as a dichotomous variable (≥ stage 2, Bp≥0). These definitions were correlated with three main symptoms of obstructed defecation (splinting, straining, and manual evacuation by CRADI questions 4, 7, and 8). The odds of having posterior prolapse (using the above definitions) based on symptoms of splinting were 1.16 for maximal vaginal descensus, 1.19

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for Bp point, 1.63 for ≥stage 2 posterior compartment prolapse, and 2.04 for Bp≥0. There were no associations between posterior compartment prolapse and straining or incomplete evacuation. Another recent study, by Saks et al., is a well-designed cross-sectional study that similarly links the presence, but not the amount, of posterior compartment prolapse and splinting, straining, and incomplete emptying [64]. These data provide the most conclusive evidence to date that posterior compartment prolapse is associated with the obstructed defecation symptom of splinting, especially in women with Bp≥0. While Erekson et al. failed to identify significant associations between symptoms of incomplete emptying or straining with posterior compartment prolapse, others have reported a relationship with incomplete emptying [2, 58, 59] and straining [61, 65]. Both incomplete emptying and straining have been shown to have a weak to moderate correlation with amount of posterior compartment prolapse (r values of 0.66 and tau-b of 0.119 for incomplete emptying and r values of 0.1–0.67 for straining). There is also some data to suggest that the presence of posterior compartment prolapse based on a dichotomous definition (defined as Bp≥ −1 or prolapse) is associated with incomplete emptying and straining [58, 63]. Review of these studies does not demonstrate a definitive correlation between increasing posterior compartment prolapse and worsening obstructed defecation though symptoms of obstructed defecation are likely related at least partially to the presence of prolapse of the posterior compartment. This may be due to the wide range of populations studied, different definitions of DD, variety of questionnaires used, and multiple causes of occult obstructed defecation in individual women [66]. The best-designed studies utilizing validated measures show a significant association between presence of posterior compartment prolapse and specific obstructed defecation symptoms, most significantly splinting, straining, and incomplete emptying. Developing more rigorous definitions and means of assessing symptoms of obstructed defecation such as splinting, straining, and incomplete evacuation will lead to a better understanding of this relationship. A cutoff point at which symptoms are significant should be investigated and standardized for future research. Based on the current literature, we propose that setting this cutoff at Bp≥ 0 represents a significant posterior compartment prolapse association with obstructed defecation. Further, there is evidence that surgery in the posterior compartment may improve some of these symptoms of obstructed defecation [18, 67, 68]. However, we must continue to investigate methods to stratify symptoms so that we can accurately counsel patients about which symptoms we expect surgery to alleviate. In conclusion, existing literature does not allow us to definitively answer any of our three key questions regarding

Jelovsek 2005 [55]

da Silva 2006 [56]

Bradley 2006 [11]

Miedel 2008 [69]

Jelovsek 2010 [55]

II-2 (prospective cohort)

II-2 (prospective cohort)

II-2 (prospective cohort)

II (crosssectional cohort)

II-2 (casecontrol)

Ellerkman 2001 [2]

Fialkow 2002 [58]

II-2 (prospective cohort)

II-2 (prospective cohort)

Yes

Weber 1998 [54]

Study author and publication date

II-2 (prospective cohort)

No

Level of evidence (type of study)

185

237

128 cases, 127 controls

282

314

132

302

143

Number of subjects

Pelvic floor clinic: single center, all women presenting

Pelvic floor clinic: single center, all women presenting

Pelvic floor clinic: single center Cases have stage 3–4 prolapse; controls have stage 0–1 prolapse

Pelvic floor clinic: multicenter, women scheduled for prolapse surgery Community sample

Pelvic floor clinic: single center, all women presenting

Pelvic floor clinic: single center, symptomatic

Pelvic floor clinic: single center, women planning surgery

Study population

Table 2 Does posterior compartment anatomy correlate with function?

Dichotomous variable (< or ≥stage 2)

39/102 (38%) manual evacuation

Non-validated questionnaire 56/107 (52%) unable to defecate

Ordinal variable (Likert scale)

7/237 (24%) splinting

123/237 (52%) incomplete evacuation

Standardized questionnaire (compiled from validated instruments) 158/237 (67%) constipation

POPQ 69/185 (37%) ≥stage 2

Ordinal variable (stage)

144/237 (61%) ≥stage 2

POPQ

Ordinal variable (stage)

POPQ

Dichotomous variable Rome II Modular Questionnaire, PFDI-20 Dichotomous variable

POPQ 56/282 (20%) isolated rectocele

median Bp00

POPQ ≥stage 2

Dichotomous variable (Ap/Bp < or ≥−1)

POPQ 70/132 (53%) ≥stage 2

Dichotomous (stage ≥3)

POPQ 39/302 (13%) ≥stage 3

Ordinal variable (stage)

POP-Q 74/143 (52%) ≥stage 2

Anatomical measurement tool Prevalence of posterior compartment defect Categorization of outcomes

Validated questionnaire 205/282 (73.2%) had at least one bowel symptom 90/282 (32%) difficulty emptying

Dichotomous variable (presence 0 meets Rome II criteria for functional disorders) CRADI, CRAIQ

17/132 (13%) splinting

25/132 (19%) incomplete evacuation

41/132 (31%) straining

Dichotomous variable (presence 0 meets Rome II criteria for functional disorders) Rome II 54/132 (41%) obstructed defecation

Dichotomous variable (presence 0 yes) Rome II Modular Questionnaire 19% outlet obstruction

44/141 (31%) manual evacuation

Questionnaire 105/142 (74%) straining

Defecatory symptom measurement tool Prevalence of defecatory symptom Categorization of outcomes

Association between posterior compartment prolapse (dichotomous variable) and symptoms (dichotomous

Weak correlation between posterior compartment prolapse (ordinal variable) and symptoms (ordinal variable): incomplete evacuation (tau-b 0.118) and splinting (tau-b 0.227)

No association between symptoms (dichotomous variable) and posterior vaginal wall prolapse (ordinal variable)

No association between symptoms (dichotomous variable) and posterior wall prolapse (dichotomous variable)

No correlation between symptom and stage

No association between symptoms (dichotomous variable) and posterior prolapse (dichotomous variable)

No correlation between stage of pelvic organ prolapse or posterior prolapse and symptom

No correlation between symptoms (dichotomous variable) and stage of prolapse (ordinal variable)

Finding

546 Int Urogynecol J (2012) 23:537–551

Study author and publication date

Barber 2003 (abstract) [57]

Tan 2005 [13]

Kahn 2005 [61]

Burrows 2004 [60]

Jelovsek 2005 [55]

Digesu 2005 [65]

Soligo 2006 [70]

Level of evidence (type of study)

II-2 (prospective cohort)

II-2 (prospective cohort)

II-2 (prospective cohort)

II-2 (historical cohort)

II-2 (crosssectional)

II-2 (prospective cohort)

III (retrospective)

Table 2 (continued)

286

786

355

302

330

1004

1912

162

Number of subjects

Pelvic floor clinic: single center, symptomatic and asymptomatic

Gynecology clinic: single center, symptomatic (bulge) vs asymptomatic (gyn chief complaints)

Pelvic floor clinic: single center, symptomatic

Pelvic floor clinic: single center, women planning surgery

Gynecology clinic: multicenter, asymptomatic women

Pelvic floor clinic: multicenter, symptomatic and asymptomatic

Pelvic floor clinic: two centers, all women presenting

Study population

Questionnaire

Dichotomous (presence 0 difficult stool passage ≥25% of the times)

Ordinal (not at all, a little, moderately, a lot) Questionnaire 249/786 (32%) constipated

32/355 (9%) manual evacuation

86/355 (24%) constipation

103/355 (29%) incomplete evacuation

Dichotomous variable (presence 0 meets Rome II criteria for functional disorders) Validated questionnaire 108/355 (30%) straining (moderately or a lot)

Ordinal variable (never or rarely, less than once a week, less than once a week but less than once a day, and once a day or more) Dichotomous variable (presence 0 less than once a week or greater) Rome II Modular Questionnaire 19% outlet obstruction

95/330 (29%) digital assistance

Questionnaire 204/330 (63%) straining

Dichotomous variable (presence 0 yes)

75/1004 (8%) splinting

239/1004 (24%) straining

Non validated questionnaire 243/1004 (24%) incomplete emptying

Non-validated questionnaire —digital assistance (0 splinting and disimpaction)

PFDI Dichotomous variable (presence 0 yes)

POPQ

Dichotomous (HWS ≥degree 2)

Ordinal (stage)

Half Way System (HWS) 83/786 (11%) HWS ≥degree 2

POPQ 233/355 (66%) symptomatic from bulge

Dichotomous (stage ≥3)

POPQ 39/302 (13%) ≥stage 3

Ordinal variable (stage, POPQ points)

POPQ 322 (97.6%) ≥stage 2

Ordinal variable (stage, POPQ points)

POPQ 114/1004 (11%) ≥stage 2

POPQ 322/1912 (17%) >0 cm

POPQ Ordinal variable (stage)

Dichotomous variable (Bp < or ≥−1)

68/104 (63%) incomplete evacuation Dichotomous variable Presence

Anatomical measurement tool Prevalence of posterior compartment defect Categorization of outcomes

Defecatory symptom measurement tool Prevalence of defecatory symptom Categorization of outcomes

Association between posterior prolapse (dichotomous) and Constipation

Correlation between straining and Ap (r00.51) and Bp (r00.67. Correlation between constipation and Ap (r00.49) and Bp (r00.49). Correlation between incomplete evacuation with Ap (r00.51) and Bp (r00.66)

Association between pb and outlet obstruction

Association with posterior prolapse (ordinal variable) and digitation (splinting or manual evacuation)

Correlation between perineal descent (gh + pb) correlates weakly with straining (r<0.1)

Weak correlation between digitation (splinting + manual evacuation) and bp (r00.23)

Weak correlation between posterior compartment prolapse (ordinal variable) and symptoms (dichotomous variable): splinting (r00.33)

variable): manual evacuation and incomplete emptying

Finding

Int Urogynecol J (2012) 23:537–551 547

Study author and publication date

Morgan 2007 [63]

Bradley 2008 [71]

Slieker-ten Hove 2009 [62]

Erekson 2010 [6]

Saks 2010 [64]

Level of evidence (type of study)

II-2 (prospective cohort)

II-2 (prospective cohort)

II-2 (crosssectional cohort)

II-2 (crosssectional cohort)

II-2 (crosssectional cohort)

Table 2 (continued)

260

721

649

260

Number of subjects

Pelvic floor clinic: single center, symptomatic and asymptomatic

Pelvic floor clinic: single center, symptomatic and asymptomatic

Community sample of Dutch women, symptomatic and asymptomatic

Gynecology clinic: single center, asymptomatic

Pelvic floor clinic: single center, symptomatic and asymptomatic

Study population

66/260 (25%) incomplete bowel evacuation Dichotomous variable (presence 0 moderate or severe bother)

61/260 (23%) straining

Baden Walker Halfway System 59/260 (23%) posterior wall defect

Dichotomous variables (≥stage 2, Bp≥0)

Dichotomous variable (presence 0 moderate or severe bother)

PFDI-20 50/260 (19%) splinting

67/721 (9.3%) Bp≥0 Multiple definitions explored: continuous variables (stage, point Bp, maximal vaginal descensus)

150/721 (20.8%) straining

POPQ 233/721 (32.3%) ≥stage 2

144/721 (20.0%) incomplete bowel evacuation

Dichotomous variable (presence 0 frequency at least ≥1/month or at least a little bother) CRADI questions 4, 7, and 8 118/721 (16.4%)splinting

79/649 (12%) symptomatic bulge Ordinal variable (stage, POPQ points)

35 (5.5%) ≥stage 3

95/633 (15%) splinting

247 (38.5%) ≥stage 2

53/639 (8.4%) manual evacuation

POPQ

Ordinal variable (stage, POPQ points)

POPQ 165/260 (63%) ≥stage 2 POP

Dutch-validated version of the Defecation Distress Inventory 22/637 (3.5%) straining

Questionnaire 111/260 (42.7%) at least one obstructive symptom Dichotomous variable (presence 0 yes)

Dichotomous (presence 0 most or every bowel movement)

44/285 (15%) incomplete evacuation Dichotomous (≥1 cm beyond hymen)

151/286 (53%) leading edge >1 cm beyond the hymen

35/284 (12%) splinting 36/285 (13%) straining

Anatomical measurement tool Prevalence of posterior compartment defect Categorization of outcomes

Defecatory symptom measurement tool Prevalence of defecatory symptom Categorization of outcomes

Association between presence of posterior vaginal wall prolapse and splinting, straining, incomplete emptying

Association between ≥stage 2 and splinting, OR 1.63 (1.06–2.53). Association between Bp and splinting, OR1.19 (1.05–1.35). Association between maximal vaginal descensus and splinting, OR 1.16 (1.07–1.26). Association between Bp≥0 and splinting, OR 2.04 (1.11–3.76). Association between perineal descent and splinting, OR 1.23 (1.09–1.40). No association between any definition of posterior compartment prolapse and straining, or incomplete evacuation

No significant correlation between bowel symptoms and POPQ stage (ordinal). Correlation between splinting and Bp (r0−0.11), and Ap (r0−0.08). Correlation between pb and manual evacuation (r0−0.09). Correlation between gh and constipation (r00.08). Correlation between Bp and straining, Bp (r0−0.09)

Association between obstructive bowel symptoms and maximum vaginal descensus, OR 1.2 (1.1–1.4)

Association between any prolapse >1 cm and splinting (19.5% vs 4.4%, OR 5.2 (2.1–12.9)) straining (22.5% vs 1.5%, OR 19.2 (4.5–81.5)), incomplete evacuation (25.3% vs 4.4%, OR 7.2 (3.0–17.9))

Finding

548 Int Urogynecol J (2012) 23:537–551

Int Urogynecol J (2012) 23:537–551

the posterior vaginal compartment prolapse and DD. While studies support a link between the presence of posterior vaginal wall prolapse beyond the hymen and symptoms of obstructed defecation, especially splinting, the link between the amount or degree of prolapse and symptoms is less clear. Additionally, changes in function with surgical intervention are not well established. Well designed, prospective studies using valid and reliable objective and subjective measures are needed to clarify the relationship between changes in anatomy of the posterior vaginal compartment and defecatory function.

Summary The relationship between posterior compartment prolapse and obstructed defecation is incompletely understood. Standardized definitions of obstructed defecation and significant posterior compartment prolapse will allow for comparison across future trials. Continuing research is needed to elucidate what preoperative measures (symptoms, physical exam, and imaging) correlate with alleviation by surgery. Acknowledgement

Illustrations are made by Justin Marquis.

Conflicts of interest Grimes has no conflict of interest. Lukacz is a consultant for Pfizer, a recipient of research funding from Renew Medical, and a recipient of an educational grant from Johnson and Johnson.

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