NIH Public Access Author Manuscript World J Colorectal Surg. Author manuscript; available in PMC 2014 November 04.
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Published in final edited form as: World J Colorectal Surg. 2013 December ; 3(3): .
PELVIC FLOOR SYMPTOMS AND QUALITY OF LIFE ANALYSES IN WOMEN UNDERGOING SURGERY FOR RECTAL PROLPASE DR ELLINGTON1, M MANN1, CB BOWLING2, ER DRELICHMAN3, WJ GREER1, JM SZYCHOWSKI4, and HE RICHTER1 1Department
of Obstetrics and Gynecology, Division of Women’s Pelvic Medicine and Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama 2Department
of Obstetrics and Gynecology; Division of Urogynecology; University of Tennessee, Medical Center, Knoxville, TN
3Inflammatory
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4Department
Disease Center, Gastrointestinal Surgery, St John Health System, Southfield, MI
of Biostatistics; University of Alabama at Birmingham, Birmingham, AL
Abstract Objective—Characterize pelvic floor symptom distress and impact, sexual function and quality of life in women who underwent rectal prolapse surgery. Methods—Subjects undergoing rectal prolapse surgery from 2004–2009 completed questionnaires including the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Prolapse/Urinary Incontinence Sexual Questionnaire. Baseline demographic, medical, and surgical characteristics were extracted by chart review. Demographic and clinic outcomes of women undergoing transperineal and abdominal approaches were compared. Wilcoxon rank-sum test was used for continuous variables and Fisher’s exact test for categorical measures.
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Results—45 were identified; two deceased at follow-up. 28/43 subjects (65.1%) responded to the questionnaires. Mean time from original procedure was 3.9 ± 3.1 years. No differences in median total Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and subscale scores, and Prolapse/Urinary Incontinence Sexual Questionnaire scores in women undergoing open rectopexy versus transperineal proctectomy were seen (all p>0.05). 26 (60%) participants answered the Prolapse/Urinary Incontinence Sexual Questionnaire, nine reported sexual activity within the last month. All underwent abdominal procedures. Conclusion—There are few colorectal or other pelvic floor symptoms after rectal prolapse repair. Robust prospective studies are needed to more fully characterize and understand issues associated with rectal prolapse surgery in women.
Corresponding Author: David R. Ellington, M.D., University of Alabama at Birmingham, Department of Obstetrics and Gynecology, 1700 6th Avenue South, Women & Infants Center, Rm 5329, Birmingham, AL 35233, Phone: (205) 934 - 5631. Poster presentation at the Society of Gynecologic Surgeons Annual Meeting, San Antonio, TX, April 11–13, 2011.
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Introduction NIH-PA Author Manuscript
Rectal prolapse is a physically and emotionally debilitating condition that greatly impacts patient’s lives. It is defined as a full thickness protrusion, or procidentia, of the rectal mucosa, or as an intussusception of the rectosigmoid colon with descent of the perineum. When the intussusception remains superior to the anal sphincter, it is categorized as an internal or occult prolapse; when the intussusception descends externally beyond the anal sphincter, it is categorized as rectal prolapse.[1–2] In community-dwelling individuals the prevalence is estimated at 2.5 per 100,000, and approximately 90% of affected individuals are women.[3–4] Its occurrence peaks in the 7th decade of life and commonly coexists with other pelvic floor symptoms and physical findings including urinary and fecal incontinence, vaginal prolapse, constipation, rectal bleeding, mucous discharge, and sexual dysfunction. [5] The condition is progressive and, given the absence of effective conservative therapies, requires surgical intervention.
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Outcomes from abdominal and transperineal approaches to surgical management are few. In a five year retrospective study, Boccasanta et al. found that in selected cases, perineal rectosigmoidectomy provided a lower complication rate but a higher recurrence rate. Similarly, Kim and colleagues reported that the transperineal approach provided lower morbidity and a shorter hospital stay but a higher recurrence rate than the abdominal rectopexy.[6–7] In addition, Deen et al., in a small, but randomized controlled trial comparing abdominal versus perineal rectopexy reported that an abdominal approach to treatment gave better functional and physiological results. [8]
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Despite these prior studies, limited data exist addressing other pelvic floor specific and general quality of life outcomes for women undergoing rectal prolapse surgery. Recently, Glasgow et al. performed a 10-year retrospective analysis of patients (gender distribution unknown) solely undergoing perineal proctectomy in an effort to describe recurrence and quality of life using the gastrointestinal quality of life index. [9] Kim et al. analyzed a prospective series of thirty-eight patients, thirty-two of which were women, undergoing transperineal rectosigmoidectomy from 2004 to 2008 and revealed an improvement in quality of life utilizing the Patient Assessment of Constipation – Quality of Life (PACQOL). [10] Similarly, Riansuwan and colleagues compared outcomes of abdominal versus perineal operations for full thickness rectal prolapse utilized the Short Form-36 (SF-36) as an outcome measure reporting an improvement in the physical component summary score of the SF-36 in the abdominal arm versus the perineal arm. The mental component summary score of the SF-36 was comparable between the two groups. [11] Thus, given this paucity of data and the possibility of the presence of other pelvic floor symptoms, the purpose of this study was to further characterize pelvic floor symptoms, sexual function and symptomspecific quality of life in women undergoing surgery for rectal prolapse, and to perform an exploratory analysis, comparing outcomes in women undergoing abdominal versus transperineal approaches.
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Methods NIH-PA Author Manuscript
After IRB approval was obtained, a retrospective chart review of female patients undergoing rectal prolapse procedures by one author (ERD) at the University of Alabama at Birmingham Hospital from 2004–2009 was performed. Demographic, medical, and surgical characteristics as well as baseline symptoms were abstracted from the charts. Forty-five patients were identified as having undergone either abdominal or transperineal rectopexy procedures.
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Patients were contacted via mail from August of 2009 to January of 2010. The mailing included a letter of study intent as well as the following validated, short-form, questionnaires: The Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and the Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). [12–13] In addition, patients were asked whether they would be willing to participate in a follow-up in-person interview and physical examination. They were offered compensation for their time and expenses. If patients did not respond within a two-week time period, they were contacted by telephone in an effort to improve recruitment and clarify any questions or concerns. If no response was received within a three month time frame, a repeat mailing was sent to the non-responding patients. All mailings were concluded at six months. Patients willing to participate in the follow-up interview and physical examination portion of the study were seen by the investigators. Those patients underwent assessment for recurrence of rectal prolapse, a standardized pelvic organ prolapse quantification (POP-Q) examination, and were asked about their subjective satisfaction and experience with their rectal prolapse procedure. [14]
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Quality of life data was collected and scored. The PFDI-20, total score ranges from 0–300, thePFIQ-7 total score ranges from 0–300 and the PISQ-12 total score ranges from 0 to 48. All subscales scores of the of the PFDI-20 and PFIQ-7 range from 0–100 and were included in the analysis: Urogenital/Urinary Distress Inventory (UDI), measuring symptoms of frequent urination, urgency incontinence, stress incontinence, voiding difficulties; Colorectal Anal Distress Inventory (CRADI), measuring symptoms of straining to have a bowel movement, not totally emptying bowels with a bowel movement, fecal incontinence, incontinence of flatus, pain with passing stool, sense of urgency to have a bowel movement, rectal protrusion; and the Pelvic Organ Prolapse Distress Inventory (POPDI), measuring pressure in the lower abdomen, heaviness in the pelvic area, bulge that she can see or feel in the vagina area, having to push on the vagina or around the rectum to have a bowel movement, incomplete bladder emptying, pushing on the bulge in the vaginal area to start or complete urination. Impact of these symptoms on QOL was collected using the Incontinence Impact Questionnare (IIQ), Colorectal Anal Impact Questionnaire (CRAIQ), and Pelvic Organ Prolapse Impact Questionnaire (POPIQ). Higher total and subscale scores relate higher distress and impact for the PFDI-20 and PFIQ-7 questionnaires. Higher scores for the PISQ-12 questionnaire mean better sexual function. Wilcoxon rank-sum test was used for continuous variables and for test of equality of surgical group median scores; Fischers exact test was utilized for categorical measures.
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Results NIH-PA Author Manuscript
Forty-five women were identified as having undergone either an abdominal rectopexy or transperineal proctectomy. Two patients were deceased at the time of follow-up, due to medical conditions unrelated to their rectal prolapse procedure. Of the 43 patients contacted for the study, 28 subjects (65.1%) responded to the questionnaires. Nineteen of these patients underwent a transperineal approach and 24 underwent an abdominal approach.
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Patient demographics are noted in Table 1. The overall average age of study participants was (mean ± sd) 66.1±16.9 years. Women undergoing transperineal and abdominal approaches were similar in age (70.6±15.1 versus 62.6±17.7, respectively). Social factors including alcohol and cigarette use were comparable in both surgical groups, as were medical comorbidities including hypertension, diabetes mellitus, and coronary artery disease. Thirtysix of the 43 (83.7%) total participants had previously undergone a hysterectomy, and twelve of 43 (27.9%) had previously undergone surgery for pelvic organ prolapse prior to their rectal prolapse surgery. The average time since the patient’s original procedure was 3.9 ± 3.1 years. Twelve patients required re-operation with an average time since the second procedure at 2.6 ± 2.5 years. Baseline pelvic floor symptoms are presented in Table 2. The majority of subjects exhibited symptoms of rectal protrusion and pain; 20% describe concurrent vaginal bulging symptoms and 18% described having concurrent urinary incontinence. Mean PFDI total and subscale scores, and PFIQ total and subscale scores for the overall population, as well as a comparison of median scores in those subjects undergoing an open versus transperineal repair are presented in Table 3. An exploratory test for differences between the 2 surgical approaches revealed no significant differences in outcome measures. Of the 26 (60%) participants who answered the PISQ-12, 9 reported sexual activity within the last month. All 9 of these patients had undergone an abdominal procedure; when responding whether or not they avoided sexual intercourse because of bulging in the vagina, seven out of nine responded with “never”. Of the remaining 17 of 26 PISQ-12 responders, only 15 completed the remaining portions of the questionnaire, and only two study participants reported having a sexual partner at the time of questionnaire administration. [12–13]
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Four of the 43 participants (9.1%) presented for follow-up physical examination and inperson interview. Three of these patients had undergone perineal proctectomy and one had undergone an abdominal rectopexy. One of these patients had a rectal prolapse recurrence, approximately four years after a perineal proctectomy, and subsequently underwent an abdominal rectopexy. The remaining two patients reported satisfaction with their primary procedure. The patient who had undergone an abdominal procedure was satisfied with her primary surgery.
Discussion Rectal prolapse remains a relatively understudied medical condition, especially in women where other pelvic floor conditions may be present. Few studies have addressed other pelvic
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floor symptoms and symptom specific quality of life outcome data in this patient population. This study provides much needed data and attempts to characterize pelvic floor symptoms and type of rectal prolapse surgery in women. Although not a priori powered to robustly compare the outcomes of these two surgical approaches, these results suggest that there may be no significant difference in patient symptoms with respect to bowel, bladder, or vaginal distress or impact. Comparative data was not available between the two groups with regard to sexual function, as only subjects in the abdominal arm of the study reported sexual function, though limited. This may suggest better sexual function outcomes in this group, or may suggest that the abdominal approach is more often performed in a younger, healthier population of individuals who may be inherently more likely to be sexually active.
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Importantly, these results provide results of symptom specific quality of life outcomes to facilitate planning of future larger studies to compare perineal and abdominal approaches. For example, the observed standard deviation from the CRADI subscale in the abdominal surgical group can be used to conservatively estimate the sample size required for a twosample t-test to detect a pre-specified difference in mean CRADI scores, specifically, with 80% power a study with 50 patients in each group would be able to detect a 15 point difference, which has recently been noted to be the minimally clinically important difference for this outcome measure. [15] In a recent study, the Gastrointestinal Quality of Life Index was employed to assess only gastrointestinal related in patients undergoing a transperineal approach to rectal prolapse (gender distribution not provided). Gastrointestinal Quality of Life Index scores were significantly lower in those subjects with recurrence and respondents reported satisfaction following proctectomy with 63% scoring within 1 standard deviation of scores of healthy controls.[9] Additional current research has employed general quality of life assessment tools, such as the SF-36 and quality of life measures that are designed specifically for bowel symptoms such as constipation and fecal incontinence, namely, the use of the PAC-QOL and the Cleveland Clinic Incontinence Score (CCIS) and the Cleveland Clinic Constipation Score (CCCS), but neither of these studies looked at other pelvic floor symptoms. [10–11]
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The data in the current study, though limited in sample size, does provide greater insight into symptom-specific quality of life of not only bowel, but bladder, vaginal prolapse, and sexual function distress and impact. There is a dearth of this type of pelvic floor symptom data in women undergoing surgery for rectal prolapse. It is somewhat intuitive that in women with rectal prolapse, there may be other prolapse or lower urinary tract symptoms reflective of generalized impairment of pelvic support or impaired innervation. This study is limited by its retrospective nature with a small sample size which undermines the ability to generalize the exploratory comparison of the two surgical approaches. In addition, despite a relatively strong questionnaire response rate, the study would have been greatly strengthened by the addition of validated pre-operative baseline symptom specific quality of life assessments. However, the post-operative data collected utilized validated questionnaires and outcomes from these procedures and were able to be characterized. Polin and colleagues reported mean post-operative CRADI and CRAIQ scores of 30.4 and 28.4, respectively, 27 months out from surgery for symptomatic rectoceles, reflecting significant improvements from baseline.[16] Although not directly comparable, the
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postoperative scores reported here for the CRADI and CRAIQ subscales from our patient population were 35.8 and 29.3 respectively. Undoubtedly, a population of patients undergoing rectocele repair differs from that of a population of patients with rectal prolapse; however, given the paucity of symptom specific distress and quality of life impact data in this patient population, results from a comparative analysis of the posterior compartment may provide perspective on the current patient population until further studies are conducted. In conclusion, these results suggest that after repair of rectal prolapse there are few colorectal or other pelvic floor complaints. Sexual activity and function appears to be higher in those women undergoing an abdominal repair, however, it is clear that more robust prospective studies are needed to more fully characterize and understand issues associated with rectal prolapse repair, especially in women where other pelvic floor defects may be present.
Acknowledgments NIH-PA Author Manuscript
Grant Support: Partially supported by the National Institutes of Diabetes and Digestive and Kidney Diseases 2K24-DK068389 to HER.
References
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1. Felt-Bersma RJ, Cuesta MA. Rectal Prolpase, rectal intussusception, rectocele and solitary ulcer syndrome. Gastroenterol Clin North Am. 2001; 20:199–222. [PubMed: 11394031] 2. Roig JV, Buch E, Alos R, Solana A, Fernandez C, Villoslada C. Anorectal function in patients with complete rectal prolapse: differences between continent and incontinent individuals. Rev Esp Enferm Dig. 1998; 90:794–805. [PubMed: 9866412] 3. Kairaluoma MV, Kellodumpu IH. Epidemiology Aspects of Complete Rectal Prolapse. Scand J Surg. 2005; 94:207–210. [PubMed: 16259169] 4. Corman, ML. Colon and Rectal Surgery. 2. Philadelphia: JB Lippincott; 1989. Rectal Prolapse; p. 209-47. 5. Peters WA, Smith MR, Drescher CW. Rectal Prolpase in Women with Other Defects of Pelvic Floor Support. American Journal of Obstetrics and Gynecology. 2001; 184:1488–94. [PubMed: 11408872] 6. Boccasanta P, Rosati R, Venturi M, Cioffi U, De Simone M, Montorsi M, Peracchia A. Surgical Treatment of Complete Rectal Prolpase: Results of Abdominal and Perineal Approaches. Journal of Laparoendoscopic and Advanced Surgical Techniques. 1999; 9:235–238. [PubMed: 10414538] 7. Kim DS, Tsang CBS, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete Rectal Prolapse: Evolution of Management and Results. Dis Colon Rectum. 1999; 42:460–469. [PubMed: 10215045] 8. Deen KI, Grant E, Billingham C, Keighley MRB. Abdomina Resection Rectopexy with Pelvic Floor Repair Versus Perineal Rectosigmoidectomy and Pelvic Floor Repair for Full-Thickness Rectal Prolapse. British Journal of Surgery. 1994 9. Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Recurrence and Quality of Life Following Perineal Protectomy for Rectal Prolapse. Journal of Gastrointestinal Surgery. 2008; 12:1446–1451. [PubMed: 18516652] 10. Kim M, Reibetanz J, Boenicke L, Germer CT, Jayne D, Isbert C. Quality of Life after Transperineal Rectosigmoidectomy. British Journal of Surgery. 2010; 97:269–272. [PubMed: 20035537] 11. Riansuwan W, Tracy Hull, Jane Bast, Jeff Hammel, Jame Church. Comparison of Perineal Operations with Abdominal Opertations for Full-Thickness Rectal Prolapse. World Journal of Srugery. 2010; 34:1116–1122.
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12. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005; 193:103–113. [PubMed: 16021067] 13. Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S, Qualls C. A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Int Urogynecol J. 2003; 14:164–168. 14. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardization of terminology for female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996; 175:10–17. [PubMed: 8694033] 15. Jelovsek JE, Chen Z, Markland AD, Brubaker L, Dyer KY, Meikle S, Rahn DD, Siddiqui NY, Tuteja A, Barber MD. Minimum important differences for scales assessing symptom severity and quality of life in patients with fecal incontinence. Female Pelv Med Reconstruc Surg. 2010; 16:S66. 16. Polin Michael R, Jonathan Gleason, Jeff Szychowski, Holley Robert L, Richter Holly E. Symptomatic Rectocele Repair: Long-term effects on symptom specific distress and impact on quality of life. Fem Pelvic Med Reconstruc Surg. 2011; (Supplement 1)(Number 2, 17):S14.
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Table 1
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Demographic Data Overall (n =43)
Perineal (19)
Abdominal (24)
p-value
Race/Ethnicity: n (%) African American
3 (7.0)
0 (0)
3 (12.5)
40 (93.0)
19 (100)
21 (87.5)
0.24
65 (45, 89)
68 (49, 90)
63.5 (34, 86)
0.22
Alcohol use: n (%)
9 (21.4)
3 (16.7)
6 (25.0)
0.71
Cigarette use: n (%)
11 (26.2)
7 (38.9)
4 (16.7)
0.16
HTN*
21 (48.8)
11 (57.9)
10 (41.7)
0.36
DM*
4 (9.3)
3 (15.8)
1 (4.2)
0.31
CAD*
7 (16.3)
2 (10.5)
5 (20.8)
0.44
Hysterectomy: n (%)
36 (83.7)
15 (79.0)
21 (87.5)
0.68
POP Surgery: n (%)
12 (27.9)
5 (26.3)
7 (29.2)
1.00
2.8 (1.7, 9.0)
4.4 (0.9, 6.7)
0.11
Caucasian Age (years) †
Medical conditions: n (%)
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Most recent procedure type: n (%) Trans Perineal
19 (44.2)
Abdominal
24 (55.8)
Years since 1st procedure† 2nd procedure performed: n (%)
3.2 (1.4, 6.7) 12 (27.9)
Years between procedures†
3.0 (0.4, 5.9)
3.0 (0.3, 9.1)
3.0 (0.4, 5.7)
0.75
Years since 2nd procedure†
2.1 (2.2, 5.3)
3.0 (0.1, 9.0)
1.9 (0.2, 5.3)
1.00
Years since most recent procedure†
2.8 (0.7, 5.2)
2.2 (0.3, 3.6)
3.3 (0.7, 5.3)
0.24
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†
Median (interdecile range);
*
HTN=hypertension, DM=diabetes mellitus, CAD=coronary artery disease
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Table 2
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Baseline Pelvic Floor Symptoms* (N=45) Vaginal and Lower Urinary Tract, n (%) -Vaginal protrusion, pressure, prolapse
9 (20)
- Urinary incontinence
8 (18)
Rectal Symptoms, n (%) -Rectal protrusion, bulging, prolapse, pressure
36 (80)
-Rectal pain
12 (27)
-Difficulty with bowel movement (incomplete, constipation, diarrhea
11 (28)
-Fecal incontinence
10 (22)
-Rectal bleeding
14 (31)
*
Symptoms not mutually exclusive
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NIH-PA Author Manuscript 82.3 ± 57.8 26.5 ± 24.0 35.8 ± 25.1 19.9 ± 22.5 55.6 ± 57.1 17.5 ± 21.8 29.3 ± 31.4 8.8 ± 15.7 31.2 ± 4.7
PFDI* (total)
UDI* (urinary/bladder distress)
CRADI* (bowel distress)
POPDI* (vagina/prolapse distress)
PFIQ* (total)
IIQ* (urinary impact)
CRAIQ* (bowel impact)
POPIQ* (vaginal/prolapse impact)
PISQ* Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Approach
0 9
9 18
9 18
9 18
9 18
9 19
9 19
9 19
9 19
N
N/A 32.0 (23.0, 36.0)
0.0 (0.0, 61.9) 0.0 (0.0, 19.0)
23.8 (0.0, 90.5) 19.0 (0.0, 76.2)
0.0 (0.0, 71.4) 4.8 (0.0, 42.9)
47.6 (0.0, 204.8) 38.0 (38.1, 109.5)
20.8 (0.0, 75.0) 12.5 (0.0, 58.3)
40.6 (6.3, 71.9) 25.0 (9.4, 78.1)
29.2 (0.0, 62.5) 16.7 (0.0, 70.8)
87.5 (17.7, 168.8) 57.3 (15.6, 182.3)
Median (interdecile range)
N/A
0.49
0.66
0.96
0.72
0.45
0.67
0.50
0.54
p
PFDI = Pelvic Floor Distress Inventory, UDI = Urinary/Bladder Distress Inventory, CRADI = Colorectal Anal Distress Inventory, POPDI = Pelvic Organ Prolapse Distress Inventory, PFIQ = Pelvic Impact Questionnaire, IIQ = Incontinence Impact Questionnaire, CRAIQ = Colorectal Anal Impact Questionnaire, POPIQ = Pelvic Organ Prolapse Impact Questionnaire, PISQ = Prolapse/Urinary Incontinence Sexual Questionnaire
*
Mean ± SD
Questionnaire
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Quality of Life Data
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Table 3 ELLINGTON et al. Page 10
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Published in final edited form as: World J Colorectal Surg. 2013 December ; 3(3): .
PELVIC FLOOR SYMPTOMS AND QUALITY OF LIFE ANALYSES IN WOMEN UNDERGOING SURGERY FOR RECTAL PROLPASE DR ELLINGTON1, M MANN1, CB BOWLING2, ER DRELICHMAN3, WJ GREER1, JM SZYCHOWSKI4, and HE RICHTER1 1Department
of Obstetrics and Gynecology, Division of Women’s Pelvic Medicine and Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama 2Department
of Obstetrics and Gynecology; Division of Urogynecology; University of Tennessee, Medical Center, Knoxville, TN
3Inflammatory
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4Department
Disease Center, Gastrointestinal Surgery, St John Health System, Southfield, MI
of Biostatistics; University of Alabama at Birmingham, Birmingham, AL
Abstract Objective—Characterize pelvic floor symptom distress and impact, sexual function and quality of life in women who underwent rectal prolapse surgery. Methods—Subjects undergoing rectal prolapse surgery from 2004–2009 completed questionnaires including the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Prolapse/Urinary Incontinence Sexual Questionnaire. Baseline demographic, medical, and surgical characteristics were extracted by chart review. Demographic and clinic outcomes of women undergoing transperineal and abdominal approaches were compared. Wilcoxon rank-sum test was used for continuous variables and Fisher’s exact test for categorical measures.
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Results—45 were identified; two deceased at follow-up. 28/43 subjects (65.1%) responded to the questionnaires. Mean time from original procedure was 3.9 ± 3.1 years. No differences in median total Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and subscale scores, and Prolapse/Urinary Incontinence Sexual Questionnaire scores in women undergoing open rectopexy versus transperineal proctectomy were seen (all p>0.05). 26 (60%) participants answered the Prolapse/Urinary Incontinence Sexual Questionnaire, nine reported sexual activity within the last month. All underwent abdominal procedures. Conclusion—There are few colorectal or other pelvic floor symptoms after rectal prolapse repair. Robust prospective studies are needed to more fully characterize and understand issues associated with rectal prolapse surgery in women.
Corresponding Author: David R. Ellington, M.D., University of Alabama at Birmingham, Department of Obstetrics and Gynecology, 1700 6th Avenue South, Women & Infants Center, Rm 5329, Birmingham, AL 35233, Phone: (205) 934 - 5631. Poster presentation at the Society of Gynecologic Surgeons Annual Meeting, San Antonio, TX, April 11–13, 2011.
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Introduction NIH-PA Author Manuscript
Rectal prolapse is a physically and emotionally debilitating condition that greatly impacts patient’s lives. It is defined as a full thickness protrusion, or procidentia, of the rectal mucosa, or as an intussusception of the rectosigmoid colon with descent of the perineum. When the intussusception remains superior to the anal sphincter, it is categorized as an internal or occult prolapse; when the intussusception descends externally beyond the anal sphincter, it is categorized as rectal prolapse.[1–2] In community-dwelling individuals the prevalence is estimated at 2.5 per 100,000, and approximately 90% of affected individuals are women.[3–4] Its occurrence peaks in the 7th decade of life and commonly coexists with other pelvic floor symptoms and physical findings including urinary and fecal incontinence, vaginal prolapse, constipation, rectal bleeding, mucous discharge, and sexual dysfunction. [5] The condition is progressive and, given the absence of effective conservative therapies, requires surgical intervention.
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Outcomes from abdominal and transperineal approaches to surgical management are few. In a five year retrospective study, Boccasanta et al. found that in selected cases, perineal rectosigmoidectomy provided a lower complication rate but a higher recurrence rate. Similarly, Kim and colleagues reported that the transperineal approach provided lower morbidity and a shorter hospital stay but a higher recurrence rate than the abdominal rectopexy.[6–7] In addition, Deen et al., in a small, but randomized controlled trial comparing abdominal versus perineal rectopexy reported that an abdominal approach to treatment gave better functional and physiological results. [8]
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Despite these prior studies, limited data exist addressing other pelvic floor specific and general quality of life outcomes for women undergoing rectal prolapse surgery. Recently, Glasgow et al. performed a 10-year retrospective analysis of patients (gender distribution unknown) solely undergoing perineal proctectomy in an effort to describe recurrence and quality of life using the gastrointestinal quality of life index. [9] Kim et al. analyzed a prospective series of thirty-eight patients, thirty-two of which were women, undergoing transperineal rectosigmoidectomy from 2004 to 2008 and revealed an improvement in quality of life utilizing the Patient Assessment of Constipation – Quality of Life (PACQOL). [10] Similarly, Riansuwan and colleagues compared outcomes of abdominal versus perineal operations for full thickness rectal prolapse utilized the Short Form-36 (SF-36) as an outcome measure reporting an improvement in the physical component summary score of the SF-36 in the abdominal arm versus the perineal arm. The mental component summary score of the SF-36 was comparable between the two groups. [11] Thus, given this paucity of data and the possibility of the presence of other pelvic floor symptoms, the purpose of this study was to further characterize pelvic floor symptoms, sexual function and symptomspecific quality of life in women undergoing surgery for rectal prolapse, and to perform an exploratory analysis, comparing outcomes in women undergoing abdominal versus transperineal approaches.
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Methods NIH-PA Author Manuscript
After IRB approval was obtained, a retrospective chart review of female patients undergoing rectal prolapse procedures by one author (ERD) at the University of Alabama at Birmingham Hospital from 2004–2009 was performed. Demographic, medical, and surgical characteristics as well as baseline symptoms were abstracted from the charts. Forty-five patients were identified as having undergone either abdominal or transperineal rectopexy procedures.
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Patients were contacted via mail from August of 2009 to January of 2010. The mailing included a letter of study intent as well as the following validated, short-form, questionnaires: The Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and the Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). [12–13] In addition, patients were asked whether they would be willing to participate in a follow-up in-person interview and physical examination. They were offered compensation for their time and expenses. If patients did not respond within a two-week time period, they were contacted by telephone in an effort to improve recruitment and clarify any questions or concerns. If no response was received within a three month time frame, a repeat mailing was sent to the non-responding patients. All mailings were concluded at six months. Patients willing to participate in the follow-up interview and physical examination portion of the study were seen by the investigators. Those patients underwent assessment for recurrence of rectal prolapse, a standardized pelvic organ prolapse quantification (POP-Q) examination, and were asked about their subjective satisfaction and experience with their rectal prolapse procedure. [14]
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Quality of life data was collected and scored. The PFDI-20, total score ranges from 0–300, thePFIQ-7 total score ranges from 0–300 and the PISQ-12 total score ranges from 0 to 48. All subscales scores of the of the PFDI-20 and PFIQ-7 range from 0–100 and were included in the analysis: Urogenital/Urinary Distress Inventory (UDI), measuring symptoms of frequent urination, urgency incontinence, stress incontinence, voiding difficulties; Colorectal Anal Distress Inventory (CRADI), measuring symptoms of straining to have a bowel movement, not totally emptying bowels with a bowel movement, fecal incontinence, incontinence of flatus, pain with passing stool, sense of urgency to have a bowel movement, rectal protrusion; and the Pelvic Organ Prolapse Distress Inventory (POPDI), measuring pressure in the lower abdomen, heaviness in the pelvic area, bulge that she can see or feel in the vagina area, having to push on the vagina or around the rectum to have a bowel movement, incomplete bladder emptying, pushing on the bulge in the vaginal area to start or complete urination. Impact of these symptoms on QOL was collected using the Incontinence Impact Questionnare (IIQ), Colorectal Anal Impact Questionnaire (CRAIQ), and Pelvic Organ Prolapse Impact Questionnaire (POPIQ). Higher total and subscale scores relate higher distress and impact for the PFDI-20 and PFIQ-7 questionnaires. Higher scores for the PISQ-12 questionnaire mean better sexual function. Wilcoxon rank-sum test was used for continuous variables and for test of equality of surgical group median scores; Fischers exact test was utilized for categorical measures.
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Results NIH-PA Author Manuscript
Forty-five women were identified as having undergone either an abdominal rectopexy or transperineal proctectomy. Two patients were deceased at the time of follow-up, due to medical conditions unrelated to their rectal prolapse procedure. Of the 43 patients contacted for the study, 28 subjects (65.1%) responded to the questionnaires. Nineteen of these patients underwent a transperineal approach and 24 underwent an abdominal approach.
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Patient demographics are noted in Table 1. The overall average age of study participants was (mean ± sd) 66.1±16.9 years. Women undergoing transperineal and abdominal approaches were similar in age (70.6±15.1 versus 62.6±17.7, respectively). Social factors including alcohol and cigarette use were comparable in both surgical groups, as were medical comorbidities including hypertension, diabetes mellitus, and coronary artery disease. Thirtysix of the 43 (83.7%) total participants had previously undergone a hysterectomy, and twelve of 43 (27.9%) had previously undergone surgery for pelvic organ prolapse prior to their rectal prolapse surgery. The average time since the patient’s original procedure was 3.9 ± 3.1 years. Twelve patients required re-operation with an average time since the second procedure at 2.6 ± 2.5 years. Baseline pelvic floor symptoms are presented in Table 2. The majority of subjects exhibited symptoms of rectal protrusion and pain; 20% describe concurrent vaginal bulging symptoms and 18% described having concurrent urinary incontinence. Mean PFDI total and subscale scores, and PFIQ total and subscale scores for the overall population, as well as a comparison of median scores in those subjects undergoing an open versus transperineal repair are presented in Table 3. An exploratory test for differences between the 2 surgical approaches revealed no significant differences in outcome measures. Of the 26 (60%) participants who answered the PISQ-12, 9 reported sexual activity within the last month. All 9 of these patients had undergone an abdominal procedure; when responding whether or not they avoided sexual intercourse because of bulging in the vagina, seven out of nine responded with “never”. Of the remaining 17 of 26 PISQ-12 responders, only 15 completed the remaining portions of the questionnaire, and only two study participants reported having a sexual partner at the time of questionnaire administration. [12–13]
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Four of the 43 participants (9.1%) presented for follow-up physical examination and inperson interview. Three of these patients had undergone perineal proctectomy and one had undergone an abdominal rectopexy. One of these patients had a rectal prolapse recurrence, approximately four years after a perineal proctectomy, and subsequently underwent an abdominal rectopexy. The remaining two patients reported satisfaction with their primary procedure. The patient who had undergone an abdominal procedure was satisfied with her primary surgery.
Discussion Rectal prolapse remains a relatively understudied medical condition, especially in women where other pelvic floor conditions may be present. Few studies have addressed other pelvic
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floor symptoms and symptom specific quality of life outcome data in this patient population. This study provides much needed data and attempts to characterize pelvic floor symptoms and type of rectal prolapse surgery in women. Although not a priori powered to robustly compare the outcomes of these two surgical approaches, these results suggest that there may be no significant difference in patient symptoms with respect to bowel, bladder, or vaginal distress or impact. Comparative data was not available between the two groups with regard to sexual function, as only subjects in the abdominal arm of the study reported sexual function, though limited. This may suggest better sexual function outcomes in this group, or may suggest that the abdominal approach is more often performed in a younger, healthier population of individuals who may be inherently more likely to be sexually active.
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Importantly, these results provide results of symptom specific quality of life outcomes to facilitate planning of future larger studies to compare perineal and abdominal approaches. For example, the observed standard deviation from the CRADI subscale in the abdominal surgical group can be used to conservatively estimate the sample size required for a twosample t-test to detect a pre-specified difference in mean CRADI scores, specifically, with 80% power a study with 50 patients in each group would be able to detect a 15 point difference, which has recently been noted to be the minimally clinically important difference for this outcome measure. [15] In a recent study, the Gastrointestinal Quality of Life Index was employed to assess only gastrointestinal related in patients undergoing a transperineal approach to rectal prolapse (gender distribution not provided). Gastrointestinal Quality of Life Index scores were significantly lower in those subjects with recurrence and respondents reported satisfaction following proctectomy with 63% scoring within 1 standard deviation of scores of healthy controls.[9] Additional current research has employed general quality of life assessment tools, such as the SF-36 and quality of life measures that are designed specifically for bowel symptoms such as constipation and fecal incontinence, namely, the use of the PAC-QOL and the Cleveland Clinic Incontinence Score (CCIS) and the Cleveland Clinic Constipation Score (CCCS), but neither of these studies looked at other pelvic floor symptoms. [10–11]
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The data in the current study, though limited in sample size, does provide greater insight into symptom-specific quality of life of not only bowel, but bladder, vaginal prolapse, and sexual function distress and impact. There is a dearth of this type of pelvic floor symptom data in women undergoing surgery for rectal prolapse. It is somewhat intuitive that in women with rectal prolapse, there may be other prolapse or lower urinary tract symptoms reflective of generalized impairment of pelvic support or impaired innervation. This study is limited by its retrospective nature with a small sample size which undermines the ability to generalize the exploratory comparison of the two surgical approaches. In addition, despite a relatively strong questionnaire response rate, the study would have been greatly strengthened by the addition of validated pre-operative baseline symptom specific quality of life assessments. However, the post-operative data collected utilized validated questionnaires and outcomes from these procedures and were able to be characterized. Polin and colleagues reported mean post-operative CRADI and CRAIQ scores of 30.4 and 28.4, respectively, 27 months out from surgery for symptomatic rectoceles, reflecting significant improvements from baseline.[16] Although not directly comparable, the
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postoperative scores reported here for the CRADI and CRAIQ subscales from our patient population were 35.8 and 29.3 respectively. Undoubtedly, a population of patients undergoing rectocele repair differs from that of a population of patients with rectal prolapse; however, given the paucity of symptom specific distress and quality of life impact data in this patient population, results from a comparative analysis of the posterior compartment may provide perspective on the current patient population until further studies are conducted. In conclusion, these results suggest that after repair of rectal prolapse there are few colorectal or other pelvic floor complaints. Sexual activity and function appears to be higher in those women undergoing an abdominal repair, however, it is clear that more robust prospective studies are needed to more fully characterize and understand issues associated with rectal prolapse repair, especially in women where other pelvic floor defects may be present.
Acknowledgments NIH-PA Author Manuscript
Grant Support: Partially supported by the National Institutes of Diabetes and Digestive and Kidney Diseases 2K24-DK068389 to HER.
References
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1. Felt-Bersma RJ, Cuesta MA. Rectal Prolpase, rectal intussusception, rectocele and solitary ulcer syndrome. Gastroenterol Clin North Am. 2001; 20:199–222. [PubMed: 11394031] 2. Roig JV, Buch E, Alos R, Solana A, Fernandez C, Villoslada C. Anorectal function in patients with complete rectal prolapse: differences between continent and incontinent individuals. Rev Esp Enferm Dig. 1998; 90:794–805. [PubMed: 9866412] 3. Kairaluoma MV, Kellodumpu IH. Epidemiology Aspects of Complete Rectal Prolapse. Scand J Surg. 2005; 94:207–210. [PubMed: 16259169] 4. Corman, ML. Colon and Rectal Surgery. 2. Philadelphia: JB Lippincott; 1989. Rectal Prolapse; p. 209-47. 5. Peters WA, Smith MR, Drescher CW. Rectal Prolpase in Women with Other Defects of Pelvic Floor Support. American Journal of Obstetrics and Gynecology. 2001; 184:1488–94. [PubMed: 11408872] 6. Boccasanta P, Rosati R, Venturi M, Cioffi U, De Simone M, Montorsi M, Peracchia A. Surgical Treatment of Complete Rectal Prolpase: Results of Abdominal and Perineal Approaches. Journal of Laparoendoscopic and Advanced Surgical Techniques. 1999; 9:235–238. [PubMed: 10414538] 7. Kim DS, Tsang CBS, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete Rectal Prolapse: Evolution of Management and Results. Dis Colon Rectum. 1999; 42:460–469. [PubMed: 10215045] 8. Deen KI, Grant E, Billingham C, Keighley MRB. Abdomina Resection Rectopexy with Pelvic Floor Repair Versus Perineal Rectosigmoidectomy and Pelvic Floor Repair for Full-Thickness Rectal Prolapse. British Journal of Surgery. 1994 9. Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Recurrence and Quality of Life Following Perineal Protectomy for Rectal Prolapse. Journal of Gastrointestinal Surgery. 2008; 12:1446–1451. [PubMed: 18516652] 10. Kim M, Reibetanz J, Boenicke L, Germer CT, Jayne D, Isbert C. Quality of Life after Transperineal Rectosigmoidectomy. British Journal of Surgery. 2010; 97:269–272. [PubMed: 20035537] 11. Riansuwan W, Tracy Hull, Jane Bast, Jeff Hammel, Jame Church. Comparison of Perineal Operations with Abdominal Opertations for Full-Thickness Rectal Prolapse. World Journal of Srugery. 2010; 34:1116–1122.
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12. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005; 193:103–113. [PubMed: 16021067] 13. Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S, Qualls C. A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Int Urogynecol J. 2003; 14:164–168. 14. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardization of terminology for female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996; 175:10–17. [PubMed: 8694033] 15. Jelovsek JE, Chen Z, Markland AD, Brubaker L, Dyer KY, Meikle S, Rahn DD, Siddiqui NY, Tuteja A, Barber MD. Minimum important differences for scales assessing symptom severity and quality of life in patients with fecal incontinence. Female Pelv Med Reconstruc Surg. 2010; 16:S66. 16. Polin Michael R, Jonathan Gleason, Jeff Szychowski, Holley Robert L, Richter Holly E. Symptomatic Rectocele Repair: Long-term effects on symptom specific distress and impact on quality of life. Fem Pelvic Med Reconstruc Surg. 2011; (Supplement 1)(Number 2, 17):S14.
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Table 1
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Demographic Data Overall (n =43)
Perineal (19)
Abdominal (24)
p-value
Race/Ethnicity: n (%) African American
3 (7.0)
0 (0)
3 (12.5)
40 (93.0)
19 (100)
21 (87.5)
0.24
65 (45, 89)
68 (49, 90)
63.5 (34, 86)
0.22
Alcohol use: n (%)
9 (21.4)
3 (16.7)
6 (25.0)
0.71
Cigarette use: n (%)
11 (26.2)
7 (38.9)
4 (16.7)
0.16
HTN*
21 (48.8)
11 (57.9)
10 (41.7)
0.36
DM*
4 (9.3)
3 (15.8)
1 (4.2)
0.31
CAD*
7 (16.3)
2 (10.5)
5 (20.8)
0.44
Hysterectomy: n (%)
36 (83.7)
15 (79.0)
21 (87.5)
0.68
POP Surgery: n (%)
12 (27.9)
5 (26.3)
7 (29.2)
1.00
2.8 (1.7, 9.0)
4.4 (0.9, 6.7)
0.11
Caucasian Age (years) †
Medical conditions: n (%)
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Most recent procedure type: n (%) Trans Perineal
19 (44.2)
Abdominal
24 (55.8)
Years since 1st procedure† 2nd procedure performed: n (%)
3.2 (1.4, 6.7) 12 (27.9)
Years between procedures†
3.0 (0.4, 5.9)
3.0 (0.3, 9.1)
3.0 (0.4, 5.7)
0.75
Years since 2nd procedure†
2.1 (2.2, 5.3)
3.0 (0.1, 9.0)
1.9 (0.2, 5.3)
1.00
Years since most recent procedure†
2.8 (0.7, 5.2)
2.2 (0.3, 3.6)
3.3 (0.7, 5.3)
0.24
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†
Median (interdecile range);
*
HTN=hypertension, DM=diabetes mellitus, CAD=coronary artery disease
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Table 2
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Baseline Pelvic Floor Symptoms* (N=45) Vaginal and Lower Urinary Tract, n (%) -Vaginal protrusion, pressure, prolapse
9 (20)
- Urinary incontinence
8 (18)
Rectal Symptoms, n (%) -Rectal protrusion, bulging, prolapse, pressure
36 (80)
-Rectal pain
12 (27)
-Difficulty with bowel movement (incomplete, constipation, diarrhea
11 (28)
-Fecal incontinence
10 (22)
-Rectal bleeding
14 (31)
*
Symptoms not mutually exclusive
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NIH-PA Author Manuscript 82.3 ± 57.8 26.5 ± 24.0 35.8 ± 25.1 19.9 ± 22.5 55.6 ± 57.1 17.5 ± 21.8 29.3 ± 31.4 8.8 ± 15.7 31.2 ± 4.7
PFDI* (total)
UDI* (urinary/bladder distress)
CRADI* (bowel distress)
POPDI* (vagina/prolapse distress)
PFIQ* (total)
IIQ* (urinary impact)
CRAIQ* (bowel impact)
POPIQ* (vaginal/prolapse impact)
PISQ* Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Transperineal Abdominal
Approach
0 9
9 18
9 18
9 18
9 18
9 19
9 19
9 19
9 19
N
N/A 32.0 (23.0, 36.0)
0.0 (0.0, 61.9) 0.0 (0.0, 19.0)
23.8 (0.0, 90.5) 19.0 (0.0, 76.2)
0.0 (0.0, 71.4) 4.8 (0.0, 42.9)
47.6 (0.0, 204.8) 38.0 (38.1, 109.5)
20.8 (0.0, 75.0) 12.5 (0.0, 58.3)
40.6 (6.3, 71.9) 25.0 (9.4, 78.1)
29.2 (0.0, 62.5) 16.7 (0.0, 70.8)
87.5 (17.7, 168.8) 57.3 (15.6, 182.3)
Median (interdecile range)
N/A
0.49
0.66
0.96
0.72
0.45
0.67
0.50
0.54
p
PFDI = Pelvic Floor Distress Inventory, UDI = Urinary/Bladder Distress Inventory, CRADI = Colorectal Anal Distress Inventory, POPDI = Pelvic Organ Prolapse Distress Inventory, PFIQ = Pelvic Impact Questionnaire, IIQ = Incontinence Impact Questionnaire, CRAIQ = Colorectal Anal Impact Questionnaire, POPIQ = Pelvic Organ Prolapse Impact Questionnaire, PISQ = Prolapse/Urinary Incontinence Sexual Questionnaire
*
Mean ± SD
Questionnaire
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Quality of Life Data
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Table 3 ELLINGTON et al. Page 10
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