Difficult bowel movements, incomplete bowel movements, fecal incontinence (FI) and other intestinal distress symptoms are among the common pelvic floor dysfunction (PFD) symptoms in patients with pelvic organ prolapse (POP), which can affect patients’ quality of life in severe cases. The quality of life of patients can be affected in severe cases. According to statistics, 88% of patients with urinary incontinence and POP have at least one symptom of bowel distress, the most common of which are dyspareunia (60%), dyspareunia (59%) and FI (58%) [1]. With the increasing aging of the population, the number of elderly POP patients is increasing and bowel distress symptoms are more common. This population is often elderly and frail, with a high level of co-morbidities that make it difficult to tolerate more complex pelvic floor reconstruction procedures. Vaginal closure has become one of the most common procedures for these patients because of its low surgical risk, rapid postoperative recovery, high anatomical success rate and low recurrence rate [2]. Current studies on vaginal closure have focused on its anatomical success rate and its efficacy on patients’ urinary distress symptoms, but less on its effect on patients’ bowel distress symptoms. In this regard, the Department of Obstetrics and Gynecology of the First Affiliated Hospital of the PLA General Hospital conducted an investigation of 60 patients who underwent vaginal closure for severe POP from October 2005 to February 2010 to investigate the bowel distress symptoms and their effects on patients’ quality of life.
1 Data and methods
1.1 Clinical data
From October 2005 to February 2010, 63 patients with POP were treated with total or partial vaginal closure in the Department of Obstetrics and Gynecology of our hospital. 60 patients completed the preoperative questionnaire except for 3 cases of senile dementia and mental disorders. 60 patients were aged 58-84 years, mean (73±5) years; body mass index (BMI) 18.7-32.4 All 60 patients had a POP-Quantitative (POP-Q) stage III-IV, of which 50 (83%) were stage III and 10 (17%) were stage IV. The posterior vaginal wall was bulging in 39 cases (65%). 6 cases (10%) had fascial defects in specific areas of the posterior vaginal wall, and 56 cases (93%) had a second-degree old perineal laceration. There were no anal sphincter injuries. The mean perineal body length before surgery was (2.6±0.9) cm. 11 patients (18%) each had straining to defecate and incomplete defecation, and 3 patients (5%) had dry fecal incontinence before surgery. No patient required hand-assisted defecation, and there were no symptoms such as painful defecation and rectal prolapse.
1.2 Surgery
Total or partial closure of the vagina, repair of specific defects of the rectus fascia and anal levator suture + perineal body repair were used [2].
1.3 Questionnaire
The Colorectal Anal Distress Inventory (CARDI-8), a subscale of the classic POP symptom questionnaire Pelvic Floor Distress Scale Short Form, and the Colorectal Anal Impact Questionnaire (CARIQ-7), a subscale of the Quality of Life Questionnaire Pelvic Floor Impact Questionnaire Short Form, were used [3].The CARDI-8 questionnaire included a total of difficult defecation, incomplete defecation, dry fecal incontinence, dilute fecal incontinence, gas incontinence, urgency of defecation The CARDI-8 questionnaire consists of 8 questions including difficult defecation, incomplete defecation, dry fecal incontinence, dilute fecal incontinence, gas incontinence, urge to defecate, defecation pain and rectal prolapse. The CARDI-8 score (0-100) = the sum of the scores of each question divided by the number of corresponding questions × 25, the higher the score, the more severe the bowel distress symptoms, and vice versa. The CARIQ-7 questionnaire assesses the impact of intestinal distress symptoms on the quality of life of patients in seven areas, including daily chores, daily exercise, recreation, transportation, interpersonal interaction, mental anxiety and psychological frustration. The scoring criteria: no impact on quality of life 0, mild impact 1, moderate impact 2, severe impact 3. CARIQ-7 score (0-100) = the sum of the scores of each question divided by the corresponding number of questions × 100/3, the higher the score means the greater the impact of intestinal distress symptoms on quality of life, and vice versa, the lower the score.
1.4 Criteria for judging the results
Symptoms with a single symptom score ≥ 2 were considered as intestinal distress symptoms. Postoperative remission of intestinal distress symptoms was defined as the disappearance of symptoms or reduction of the original symptom score after surgery. New symptoms were defined as the appearance of intestinal distress symptoms after surgery that were different from those before surgery.
1.5 Survey method
The questionnaire survey was implemented exclusively by non-operative staff and completed together with the patients. The preoperative questionnaire was completed before the surgery was performed after admission to the hospital, and the postoperative questionnaire was completed at the 2-month, 6-month, and 1-year postoperative outpatient follow-up visits. Those who could not come to the hospital for follow-up were followed up by telephone. All patients who completed the questionnaire were conscious and could answer the questions independently.
1.6 Statistical methods
SPSS 10.0 software was used for statistical analysis, and t-test or rank sum test was used for quantitative data, and P < 0.05 was considered statistically significant.
2 Results
Among the 60 patients who completed the questionnaire, 45 (75%) had total vaginal closure, 15 (25%) had partial vaginal closure, 56 (93%) had anal levator suture + perineal body repair, and 6 (10%) had rectal specific fascial defect repair. 60 patients had no surgical side effects. The postoperative disease rate was 5% (3/60 cases), including 2 cases of urinary tract infection and 1 case of bacteraemia. The follow-up rates were 93% (56/60 patients), 88% (53/60 patients) and 87% (52/60 patients) at 2 months, 6 months and 1 year postoperatively, respectively, with one patient dying of heart disease at 8 months postoperatively. All follow-up patients had a postoperative POP-Q stage ≤ stage I. The objective success rate of the procedure was 100%. The mean length of the perineal body was (3.5±0.9) cm at one year after surgery. 6 of the 11 patients with preoperative obstruction had disappeared at 2 months after surgery, and the remaining 5 had improved to varying degrees. 2 of the 3 patients with fecal incontinence had relief of symptoms at 2 months after surgery, and 1 had no improvement. The CARDI-8 and CARIQ-7 scores decreased significantly at 2 months postoperatively (Tables 1 and 2) and were maintained until 1 year postoperatively. None of the patients had new symptoms of intestinal distress at 1 year postoperatively.
Table 1 Scores before and after vaginal closure in 60 patients (`x±s )
Questionnaire
Preoperative
(n=60)
2 months postoperatively (n=56)
6 months postoperatively (n=53)
12 months postoperatively (n=52)
CARDI-8
CARIQ-7
12.92±15.80
8.10±14.33
5.19±7.18*
4.51±8.92**
4.57±5.95*
3.85±5.97**
4.48±5.93*
3.78±5.93*