Editor's Note:

Introduction

Posterior vaginal wall prolapse is defined as the loss of fibromuscular support overlying the rectum, laxity and separation of the levator ani plate with widening of the levator hiatus, and tearing or separation of the perineal musculature. This defect results in the protrusion of the rectum into the vagina and the resultant symptoms.

The primary indication for repair of a rectocele is obstructive defecation, sensation of “pressure” in the vagina and a feeling of incomplete bowel emptying. This may progress to difficult or painful defecation or sexual intercourse, constipation, incontinence, and prolapse of the bulge through the opening of the vagina.Conservative management includes lifestyle measures, pelvic floor muscle training and pessary use.

There are many operations correcting the posterior vaginal wall prolapse. Over the years, different surgical techniques prevent researchers comparing studies addressing the same problem: posterior vaginal wall prolapse repair. Having this in mindthe AUGS-IUGA joint report on terminology for posterior wall prolapse procedures were reviewed and useful guidelines introduced.

Surgeries for pelvic organ prolapse (POP) are common, but standardization of surgical terms is necessary to improve the quality of investigation and clinical outcome of these procedures. Posterior colporrhaphy with native tissues or grafts, levator ani plication and perineorrhaphy is typically performed transvaginally, although various other methods are also used (open or laparoscopically, transanal and transperineal). All studies on posterior vaginal repair with grafts have used a transvaginal approach.

Despite the introduction of several standardization documents on terminology for POP and pelvic floor dysfunction, little was documented for the surgical repair of POP. For research to produce meaningful data about specific procedures, standardized and widely accepted terminology must be adopted. Each term for a given procedure must indicate to researchers, clinicians and learners a specific methodology.

A. Posterior vaginal wall prolapse repair:

Figure 1: Image of posterior repair (IUJ2020; 31:429-43)

Procedure:

Step 1: A longitudinal incision is made in the posterior vaginal epithelium. The posterior vaginal wall is often infiltrated with local anaesthetic and/or a vasoconstricting agent for hydrodissection before the incision.

Step 2: The vaginal epithelium is dissected to expose the underlying fibromuscular layer, and this dissection is carried out laterally to the medial aspect of the levator ani muscles and inferiorly to the perineal body. If a graft is going to be used, an additional dissection may be performed opening the space between the fibromuscular layer and the rectum. The use of mesh in the posterior compartment is not recommended.

Step 3: Defects(s) in the fibromuscular layer of the posterior vaginal wall (if relevant) are identified.

Step 4: The fibromuscular layer of the posterior vaginal wall is plicated across the midline and/or site-specific defects repaired with suture. This step must be performed cephalad to the hymenal ring. If a graft is being used, midline plication and/or site-specific repair with sutures is optional. The graft is trimmed if indicated and attached as desired to the fibromuscular layer of the posterior vaginal wall or surrounding structures. The graft may be placed in a plane anterior to, posterior to, or within the fibromuscular layer of the posterior vaginal wall.

Step 5: The vaginal epithelium is closed over the repair.

Special Terminology Considerations

As all techniques of posterior vaginal repair are performed in close proximity to the rectum, the procedure may be mistaken for procedures to support the rectum (e.g., rectopexy) or for reconstruction of the anal sphincter (e.g., anal sphincteroplasty). As these are not vaginal prolapse indications, confusing terms, such as “rectal repair,” “anal repair,” or “rectocele repair,” are discouraged.

B. Perineal Repair

The perineorrhaphy surgery is performed for the repair of the perineum. The perineum is the area between the anus and the opening of the vagina. There are many indications for perineorrhaphy. The most common indication being the enlarged genital hiatus, mainly as a result of trauma to the perineum during vaginal childbirth.

Figure 2: Procedural steps of perineorrhaphy (IUJ2020;31:429-43)

Procedure:

Step 1: A perineal repair is begun by identifying the area of attenuation and the area of vaginal epithelium that needs to be excised. This is performed with Allis clamps at varying distances right and left of midline at the level of the hymen.

Step 2: A diamond- or sickle-shaped incision is made to remove a portion of distal vaginal epithelium and perineal skin. The underlying fibromuscular tissue may be undermined from the vaginal epithelium as well.

Step 3: Sutures are placed to approximate the selected perineal body components, which include the superficial transverse perineal muscles, the distal end of the fibromuscular layer of the posterior vaginal wall, the bulbospongiosus muscles, the anterior fibres of the external anal sphincter or its capsule, the puborectalis muscles and/or the perineal membrane.

Step 4: Closure of the vaginal epithelium overlying these deep sutures.

The aim of the perineal repair is to narrow the genital hiatus (GH) and lengthen the perineal body to provide distal support to the vagina. The perineal repair is usually performed at the end of the posterior vaginal wall repair.

Special Terminology Considerations

If the surgeon is performing a posterior vaginal repair at the same time, which is common, the terms “colpoperineorrhaphy” or “colpoperineoplasty” to designate the performance of both procedures should be avoided as it does not clearly delineate the posterior vaginal repair and the perineal repair. The term “perineoplasty” is not acceptable for perineal repair, as the term “perineoplasty” has been used interchangeably with widening genital hiatus for vaginal stenosis. However, the synonym “perineorrhaphy” is acceptable as this term more specifically describes the nature of perineal repair.

Reflections

Native tissue posterior vaginal wall repair is more effective than transanal repair for posterior vaginal wall prolapse in preventing recurrence of prolapse in the light of both objective and subjective measures. Site specific defect repair is also effective at correcting prolapse but not as anatomically successful as the posterior colporrhaphy. Although short-term follow-up shows that site-specific repair causes less postoperative dyspareunia as compared to posterior colporrhaphy, longer follow-up has shown that the site specific repair has higher rate of recurrence prolapse and similar rates of dyspareunia.

Evidence does not support the utilization of any mesh or graft materials at the time of posterior vaginal wall repair. The addition of mesh does not improve anatomic outcome, or prevent enterocoele, but may give rise to mesh associated complications (erosions, dyspareunia, and recurrence). Evidence is insufficient to permit conclusions about the relative effectiveness or safety of other types of surgery (open or laparoscopic posterior vaginal wall repair).

Levator ani plication compared to midline fascial plication, showed mean differences in the preoperative and postoperative Ap scores to be greater in the fascial plication group. The Prolapse Quality of Life (P-QoL) scores were significantly improved in both groups, with no differences between groups in sexual function before or after intervention. Bowel function was improved in the fascial repair group but not in Levator plication group as assessed by the Birmingham bowel and urinary symptoms questionnaire.

Perineorraphy can be performed either alone or at the end of posterior vaginal wall prolapse and can lead to a decrease of the size of the genital hiatus (GH). A Pelvic Organ Prolapse-Quantification (POP-Q) measurement of the genital hiatus of ≥3.75 cm is highly predictive of apical support loss. The primary function of the GH is to prevent the uterus and vaginal wall from prolapsing. Women with a preoperative genital hiatus of 4 cm or greater, not surgically normalized after native tissue POP repair, are at significantly increased odds of anatomic failure in all compartments.

Conclusion

Standardized terminology of surgical procedures needed. The acknowledgment of these standardized terms in academic articles, should be indicated in the section “material and methods”. Clearly defined terms, the steps of the procedure and recommendations for procedural terminology as published by AUGS-IUGA in 2020, will improve the quality of investigations and comparisons between studies.

References

AUGA- IUGA. Joint report on terminology for surgical procedures to treat posterior compartment prolapse pelvic organ prolapse .IJU 2020;31:429-43.

C. Obstetric Anal Sphincter Injuries (OASIS)
Dr Justin Molebatsi

Vaginal delivery is a significant cause of anal dysfunction in women and although care during vaginal birth has improved, many women sustain varying degrees of perineal trauma during vaginal delivery. These perineal injuries, particularly those involving the anal sphincter complex, can have a significant short and long-term impact on women’s health and quality of life. Studies have shown that up to 40% of women who have sustained OASI have anal dysfunction.

“Labour has been called, and is still believed by many to be, a normal function... and yet it is a decidedly pathological process. Everything of course depends on what we define as normal. If a woman falls on a pitch-fork, and drives the handle through her perineum, we call that pathological- but if a large baby is driven through the pelvic floor, we say that is natural, and therefore normal” -DeLee

The notion that this problem is a normal consequence of childbirth is greatly concerning as some women may not seek medical attention.

Definitions

Perineal trauma during childbirth can either be spontaneous during childbirth or secondary following extension of an episiotomy. Severe trauma can involve injury to the anal sphincters and rectal mucosa. OASIS includes only third and fourth degree perineal tears. Third degree tears involve disruption of the anal sphincter complex which includes both the internal and external anal sphincter complex. Forth degree tears involve disruption of the rectal mucosa in addition to injury to the anal sphincter. The following table describes perineal tears as per the RCOG.

Clinical Impact

OASIS can have a significant impact to women’s health and quality of life. Complications can either be classified as either short or long term. Short termcomplications of OASI include haemorrhage and Perineal pain which may be associated with oedema and bruising. Perineal pain can also lead to urinary retention and defecatory problems. Long term complications that patients may encounter include dyspareunia and altered sexual function, Anal incontinence and anorectal symptoms. Missed tears or poorly repaired tears may also present a potential source of litigation.

Risk Factors

There is no clear reason why OASI happens, neither is there a way to predict their occurrence but certain risk factors have been described including:

Maternal Risk Factors

• Primiparity
• Increased maternal age
• Race
• Maternal diabetes
• Female genital mutilation (Infibulation)
• Increased mass

Delivery Risk Factors

• Operative vaginal surgery (Forceps > Vacuum)
• Episiotomy
• Epidural
• Prolonged second stage of Labour
• Shoulder dystocia
• VBAC
• Augmentation of labour

Infant Risk Factors

• Macrosomia
• Malpresentation
• Postmaturity
• OP Position

Diagnosis

Careful examination of all women who have sustained more than just superficial injury should be performed before suturing. Examination should be done with adequate exposure, lighting and analgesia and should include: Perineal inspection with Labial parting, Inspection of the distal posterior vagina and inspection for a third degree tear behind an “intact” perineum.

The examination should be done with the examiners dominant index finger in the patient’s rectum and the thumb in the vagina. Palpate with a “pin-rolling” motion to assess thickness of the perineum.

When the external anal sphincter tears, the edges retract and a defect can often be palpated along the sphincter muscle. It is crucial to identify both the external and internal anal sphincters as examination of the IAS will also permit detection of a button hole injury.

Taken from: Obstet Gynecol Surv. 2018; 73(1): 33-39

Principles and Types of Repair

OASIS repair should always be undertaken by an appropriately trained clinician. OASIS should always be repaired in theatre as it provides access to optimal lighting, appropriate equipment and aseptic conditions. No studies have evaluated type of anaesthesia used for OASIS repair.

Choice of Suture Material

Very little research has been donecomparing different suture types used for sphincter repair. However, monofilament sutures are preferable to braided sutures.

Absorbable and delayed absorbable sutures have been used. There has only been one RCT that has assessed different suture materials with no significant difference found between coated polyglactin (vicryl 2-0) and polydioxanone (PDS 3-0). An important principle is that the sutures should be cut short and knots covered by the overlying perineal muscle.

Repair of Anal Mucosa

Mucosa can be repaired interrupted 3-0 vicryl sutures, with the knots tied in the anal lumen. Alternatively the mucosa can be approximated with 3-0 PDS suture with a submucosal continuous suture.

IAS

This sphincter is a 3 – 5 mm continuation of the rectal smooth muscle and can be difficult to identify. It is under autonomic nervous control and is responsible for maintaining continence at rest by contributing 70 -85% of resting anal pressure. Damage to this sphincter can result in an impaired “sampling reflex” leading to passive incontinence. The IAS is repaired with a end-to-end anastomosis using a simple running stitch with PDS 3-0.

EAS

Torn ends of the EAS, normally under tonic contraction tend to retract within their sheaths. Muscle ends must be identified and grasped with Allis clamps and can then be approximated by one of two techniques end-to-end or overlapping sutures as illustrated below.

Following anal sphincter repair, the perineal body must be reconstructed by suturing the perineal muscles. This takes tension off and provides support for the underlying sphincter muscle repair. The superficial vaginal epithelium and perineal epithelium can then be repaired with a running intracutaneous stitch with Monochryl 3-0. If an adequately skilled clinician is not available for OASI repair, repair can be delayed for 8-12 hours with no detrimental effect.

Post-Operative Management

Prophylactic single dose of intravenous Antibiotics (2nd generation Cephalosporins) should be given for the reduction of perineal would complications following repair of OASI. Currently no studies have evaluated the value of additional doses of antibiotics following repair of 3rd and 4th degree tears.

Post op Bowel regimen (Laxatives) should be prescribed following the primary repair of OASIS as they are associated with earlier and less painful first bowel movement and earlier discharge

Constipating agents and bulking agents are not recommended.

NSAIDS are consideredfirst line therapy for analgesia. Rectal analgesia including Diclofenac reduces perineal trauma related pain in the first 24hrs following birth and results in women using less analgesia in the first 48 hours. Follow up should occur 1-2 weeks following the repair to assess the healing and examine for early evidence of wound complications.

Subsequent Pregnancy

When determining mode of delivery for a subsequent pregnancy, it is Important to take into consideration if the patient has any symptoms of anal incontinence, assess sphincter integrity and what the patient’s wishes are. However, following a successful repair, most women can safely deliver vaginally in a subsequent pregnancy. Many patients may opt for a caesarean delivery, if the anal sphincter repair has been successful.

In summary of all the repairs mentioned above, please see illustrations below:

Taken from: Obstet Gynecol Surv. 2018; 73(1): 33-39

References

• References available on request.