EAES Academy

Introduction

Pelvic floor disorders (PFD) are a broad spectrum of symptoms in three pelvic compartments. Clinical presentations such as internal and open rectal prolapse, rectocele, enterocele, fecal incontinence and constipation are predominately signs of defects in posterior department. PFD affects nearly 60% of women in postmenopausal age, young and nulliparous could be affected and male patients as well. Due to complex presentation patients present themself to different medical specialists primarily. In a proctology setting patients with rectal prolapse, obstructed defecation and constipation are seen. Diagnosis should be confirmed with careful patient's history, detailed clinical examination and more than one diagnostic procedure (pelvic floor US, defecography, manometry, colonoscopy) to define morphological and functional deficits. Obtaining Continence and Obstructed defecation scores and Quality of life questionnaires are mandatory. Patients should always be approached first with conservative measures like dietary consultation, pelvic floor rehabilitation and other life style changes. Leading symptoms and grade of presentation are the usual reasons for potential surgical treatment for very selected patients.
Various surgical approaches to correct PFD are known: perineal, open, endorectal, laparoscopic, robotic, with resection of bowel or not. In the last decades, MIS gained popularity because of minimal harm and good results. On the other side laparoscopic technique is demanding, more expensive and has a longer learning curve. Robotic surgery may have some advantages, but is even more expensive and limited.
Before surgical intervention one should answer two questions taking into account grade of symptoms, clinical findings and clear proof of functional or anatomical deficit:
1. Is there a clear indication for surgery?
2. What kind of procedure to perform?
Concomitant symptoms, age, previous surgery, other diseases and patients’ preference are mandatory to discuss. Surgeons’ expertise is very important.
Methods:

In our practice we have developed a standard process to define appropriate patient specific treatment and procedure. As a proctology unit, approximately 900 pts/y with some degree of PFD in the posterior department visit our clinic as a first visit. During this visit leading symptoms are usually defined. Digital rectal examination, proctoscopy and rectoscopy roughly determine potential anatomical defects. Next steps are proposed in long lasting and very symptomatic patients: conservative treatment and further diagnostics. In the case patients have developed symptoms and do not have clear contraindications, potential surgical approach is discussed already at the first visit. Next pelvic floor US, defecography, manometry, EMG of pelvic floor (very exceptional) is indicated. Patients are referred to dietary consultation and physiotherapist. Patients with signs of constipation are sent to radiopaque markers transit time and CT colonography. Female patients with signs of middle and anterior compartment PFD are referred to urogynecologist. Usual time to finish work-up and conservative treatments is about 6 - 8 months. Internal MDT team (Iatros MC) discuss about 250 pts a year during and after work-up and treatments. At the end surgical treatment is discussed with 40 – 50 pts/y. Indications for surgery are: degree of symptoms, clinical findings and unsuccessful conservative treatment. Surgical correction is finally and only offered to those patients who ask for it!
Proposed surgical treatments are:
- Laparoscopic rectopexy (without resection) for internal and open rectal prolapse, rectocele and enterocele,
- Perineal resection for open rectal prolapse,
- Delorme procedure for internal prolapse,
- Perineal correction of rectocele and enterocele.
- Subtotal colectomy for CIC (laparoscopic)
Conclusion:
Unfortunately it is not possible to give a clear conclusion. Due to complexity of symptoms and clinical findings it is very difficult to define a standard surgical procedure for PFD correction. Low complication rate, fast recovery and surgeons’ preference are the main reasons for laparoscopic approach in our clinical practice.