DOES THE PRESENCE OF A TRUERECTOCELE INCREASE THE LIKELIHOOD OF SYMPTOMS OF PROLAPSE?
B. BROWN, N. SUBRAMANIAM, T.FRIEDMAN, F. A. SOLAR ALTAMIRANO, H. DIETZ;
Sydney Med. Sch.Nepean, Sydney, Australia.
Introduction: Posteriorcompartment prolapse occurs due to a true rectocele, hypermobileperineum, an enterocele, rectal intussususception or a combination ofthese findings. Contrast defecography, MRI or transperinealultrasound (TPUS) can differentiate between these aetiologies (1). Atrue rectocele on TPUS (disruption of the recto-vaginal septum with apocket depth of >=10mm) is clearly associated with symptoms ofobstructed defecation (2). However, it is unclear whether a truerectocele is independently associated with symptoms ofprolapse.
Objective: This study aims to investigate theassociation between a true rectocele diagnosed sonographically andsymptoms of prolapse reported as a "lump" or "bulge"in the vagina.
Methods: This was a retrospective cohortstudy of 2152 patients who presented to a urogynecology unit forsymptoms of pelvic floor dysfunction between 9/2011 and 6/2016.Assessment included a structured interview, POP-Q exam and 4D TPUS(2). TPUS volume data were acquired on maximum valsalva. Offlinemeasurements were performed by analysis of stored volume data sets ata later date, by assessors blinded to all clinical data. Adiscontinuity of the anterior anprectal contour was defined as a truerectocele. Pocket depth was measured perpendicular to a line placedthrough the anterior contour of the internal anal sphincter (seeFigure 1).
Figure 1: Diagnosis of a truerectocele on ultrasound. (A) shows appearances at rest, (B) onValsalva. The pocket is outlined by dots, the oblique lines showmeasurement of pocket depth. S= symphysis pubis, B= bladder, R=rectal ampulla, V= vagina, A= anal canal.
Results: 106 ofthe 2152 patients were excluded due to incomplete data. Of theremainder, Bp was the most distal point on POP-Q in 348. Statisticalanalysis was performed on this cohort. Mean age was 60 (33-86) andmean BMI 31kg/m2 (18-55). 153 patients (44%) presentedwith symptoms of prolapse at an average bother of 3/10 (0-10). 272were diagnosed with a true rectocele on TPUS, with a pocket depth of>= 10mm. Potential confounding factors including age, BMI, vaginalparity, forceps delivery, chronic constipation and previoushysterectomy were tested in a univariate analysis against symptoms ofprolapse. Age, vaginal parity and chronic constipation weresignificantly associated with symptoms of prolapse and thusidentified as potential confounders. Bp on POP-Q and true rectoceleon TPUS were both significantly associated with prolapse symptoms;however, on multivariate analysis the latter became nonsignificant (p= 0.059). Receiver operating characteristic (ROC) analysis confirmedthat the presence of a true rectocele on TPUS contributed minimallyto symptoms of prolapse (AUC 0.66 for model including pocket depth,AUC 0.65 without), see Figure 2.
Figure: ROC curves for predictionof symptoms of prolapse. The first model excludes, the secondincludes pocket depth.
Conclusions: The presence of a truerectocele on TPUS does not seem to contribute substantially to themanifestation of clinical symptoms of prolapse.
References:1. Ultrasound Obstet Gynecol 2005;26:73-772.
2. Int Urogynaecol J2015;26:1355-1359