Johan Nordenstam

Anal incontinence after vaginal delivery: a five-year prospective cohort study.

OBJECTIVE: The long-term prevalence of anal incontinence after vaginal delivery is unknown. The aim of the present study was to evaluate the prevalence of anal incontinence in primiparous women 5 years after their first delivery and to evaluate the influence of subsequent childbirth. METHODS: A total of 349 nulliparous women were prospectively followed up with questionnaires before pregnancy, at 5 and 9 months, and 5 years after delivery. A total of 242 women completed all questionnaires. Women with sphincter tear at their first delivery were compared with women without such injury. Risk factors for development of anal incontinence were also analyzed. RESULTS: Anal incontinence increased significantly during the study period. Among women with sphincter tears, 44% reported anal incontinence at 9 months and 53% at 5 years (P = .002). Twenty-five percent of women without a sphincter tear reported anal incontinence at 9 months and 32% had symptoms at 5 years (P < .001). Risk factors for anal incontinence at 5 years were age (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0–1.2), sphincter tear (OR 2.3; 95% CI 1.1–5.0), and subsequent childbirth (OR 2.4; 95% CI 1.1–5.6). As a predictor of anal incontinence at 5 years after the first delivery, anal incontinence at both 5 months (OR 3.8; 95% CI 2.0–7.3) and 9 months (OR 4.3; 95% CI 2.2–8.2) was identified. Among women with symptoms, the majority had infrequent incontinence to flatus, whereas fecal incontinence was rare. CONCLUSION: Anal incontinence among primiparous women increases over time and is affected by further childbirth. Anal incontinence at 9 months postpartum is an important predictor of persisting symptoms.

Transanal endoscopic microsurgery resection of rectal tumors: Outcomes and recommendations

PURPOSE: Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS: A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS: Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS: Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Metabolomic Characterization of Human Rectal Adenocarcinoma with Intact Tissue Magnetic Resonance Spectroscopy

PURPOSE: This study was designed to test whether metabolic characterization of intact, unaltered human rectal adenocarcinoma specimens is possible using the high-resolution magic angle spinning proton (1H) magnetic resonance spectroscopy technique. METHODS: The study included 23 specimens from five patients referred for ultrasonographic staging of suspected rectal cancer. Multiple biopsies of macroscopically malignant rectal tumors and benign rectal mucosa were obtained from each patient for a total of 14 malignant and 9 benign samples. Unaltered tissue samples were spectroscopically analyzed. Metabolic profiles were established from the spectroscopy data and correlated with histopathologic findings. RESULTS: Metabolomic profiles represented by principle components of metabolites measured from spectra differentiated between malignant and benign samples and correlated with the volume percent of cancer (P = 0.0065 and P = 0.02, respectively) and benign epithelium (P = 0.0051 and P = 0.0255, respectively), and with volume percent of stroma, and inflammation. CONCLUSIONS: Magnetic resonance spectroscopy of rectal biopsies has the ability to metabolically characterize samples and differentiate between pathological features of interest. Future studies should determine its utility in in vivo applications for non-invasive pathologic evaluations of suspicious rectal lesions.

Effect of hysterectomy on bowel function

Purpose: Hysterectomy is the most common major gynecologic procedure. Unwanted postoperative effects on bowel function are a topic of recent debate. The aim of the present study was to prospectively evaluate the influence of hysterectomy on bowel function. Methods: One hundred and twenty consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire covering bowel habits and symptoms preoperatively and at 6 and 12 months postoperatively. Forty-four patients underwent vaginal hysterectomy and 76 underwent abdominal hysterectomy. Concomitant bilateral salpingo-oopherectomy was performed in 17 patients. Results: After abdominal hysterectomy, patients reported increased symptoms of gas incontinence, urge to defecate, and inability to distinguish between gas and feces (P < 0. 05). There was a tendency of increased fecal incontinence. Subgroup analysis indicated that concomitant bilateral salpingo-oopherectomy resulted in an increased risk of fecal incontinence. No significant changes were detected in symptoms associated with constipation. Mean defecation frequency increased and the frequency of pelvic heaviness symptoms was reduced. After vaginal hysterectomy, there was no increased frequency of incontinence or constipation symptoms. The frequency of pelvic heaviness symptoms was reduced. Conclusions: Patients undergoing abdominal hysterectomy may run an increased risk for developing mild to moderate anal incontinence postoperatively and this risk is increased by simultaneous bilateral salpingo-oopherectomy. An increased risk of anal incontience symptoms could not be identified in patients undergoing vaginal hysterectomy. Our study does not support the assumption that hysterectomy is associated with de novo or deteriorating constipation.

Effects of Hysterectomy on Bowel Function: A Three-Year, Prospective Cohort Study

PurposeThis study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence.MethodsIn this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics.ResultsThe bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05–2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up.ConclusionsNeither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.

Immediate or delayed repair of obstetric anal sphincter tears: a randomised controlled trial

Objective  To investigate if an 8‐ to 12‐hour time delay of primary repair affects anal incontinence at 1‐year follow up.

Clinical and histological safety assessment of rectocele repair using collagen mesh

Aim.  To clinically and histologically evaluate inflammatory response following rectocele repair using porcine collagen mesh.

Pelvic Organ Prolapse and Urinary Incontinence in Women With Surgically Managed Rectal Prolapse: A Population-Based Case-Control Study

PurposeThis study aimed to investigate the prevalence of genital prolapse surgery and urinary incontinence in female patients operated on for rectal prolapse compared with a matched control group without rectal prolapse.MethodsFifty-two patients with a history of abdominal rectal prolapse surgery and 200 randomly selected age-matched and gender-matched control subjects without rectal prolapse received an extensive health care history survey.ResultsResponse rate in the patient group was 48 of 52 (92 percent) and 165 of 200 (82 percent) in the control group. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (odds ratio = 3.1; 95 percent confidence interval = 1.4–6.9) and vaginal wall prolapse (odds ratio = 3.2; 95 percent confidence interval = 1.3–7.8). Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (P < 0.01). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (P < 0.05). There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence.ConclusionOur results indicate a strong association between rectal and genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.

Genitalprolaps und Harninkontinenz bei Frauen mit operativ behandeltem Rektumprolaps

ZusammenfassungFragestellung:Ziel dieser Studie war es, die Prävalenz von Genitalprolaps-Operationen und Harninkontinenz bei Patientinnen, die wegen eines Rektumprolaps operiert worden waren, im Vergleich zu einer entsprechenden Kontrollgruppe ohne Rektumprolaps zu untersuchen.Patienten und Methodik:52 Patientinnen mit Rektumprolaps-Operationen in der Vorgeschichte sowie 200 willkürlich ausgewählte, alters- und geschlechtsangepasste Kontrollpersonen ohne Rektumprolaps erhielten einen ausführlichen Gesundheitsfragebogen.Ergebnisse:Die Rücklaufquote betrug in der Patientinnengruppe 48 von 52 (92%) und in der Kontrollgruppe 165 von 200 (82%). Ein Rektumprolaps war mit einem gesteigerten Operationsrisiko wegen eines Uterusprolaps (Odds-Ratio = 3,1; 95%-Konfidenzintervall = 1,4–6,9) und eines Vaginalprolaps (Odds-Ratio = 3,2; 95%-Konfidenzintervall = 1,3–7,8) assoziiert. Das mittlere Alter bei einer Hysterektomie wegen Uterusprolaps betrug 54,7 Jahre in der Patientinnengruppe, verglichen mit 62,6 Jahren in der Kontrollgruppe (p < 0,01). Das mittlere Alter bei Vaginalprolaps-Operation betrug 60,2 Jahre in der Patientinnengruppe, verglichen mit 66,6 Jahren in der Kontrollgruppe (p < 0,05). Es fanden sich keine signifikanten Unterschiede zwischen den Gruppen bezüglich einer höheren Prävalenz oder des Alters beim ersten Auftreten einer Harninkontinenz.Schlussfolgerung:Die Ergebnisse zeigen einen starken Zusammenhang zwischen einer rektalen und genitalen Prolapsoperation. Dies legt nahe, dass der Diagnose eines Rektumprolaps, der operiert werden soll, eine multidisziplinäre Beckenboden-Untersuchung folgen muss.AbstractPurpose:This study aimed to investigate the prevalence of genital prolapse surgery and urinary incontinence in female patients operated on for rectal prolapse compared with a matched control group without rectal prolapse.Methods:Fifty-two patients with a history of abdominal rectal prolapse surgery and 200 randomly selected age- and gender-matched control subjects without rectal prolapse received an extensive health care history survey.Results:Response rate in the patient group was 48 of 52 (92 percent) and 165 of 200 (82 percent) in the control group. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (odds ratio = 3.1; 95 percent confidence interval = 1.4–6.9) and vaginal wall prolapse (odds ratio = 3.2; 95 percent confidence interval = 1.3–7.8). Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (p < 0.01). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (p < 0.05). There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence.Conclusion:Our results indicate a strong association between rectal and genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.

Genitalprolaps und Harninkontinenz bei Frauen mit operativ behandeltem Rektumprolaps@@@Pelvic Organ Prolapse and Urinary Incontinence in Women With Surgically Managed Rectal Prolapse: a Population-Based Case-Control Study: Eine bevölkerungsbasierte Fall-Kontroll-Studie

ZusammenfassungFragestellung:Ziel dieser Studie war es, die Prävalenz von Genitalprolaps-Operationen und Harninkontinenz bei Patientinnen, die wegen eines Rektumprolaps operiert worden waren, im Vergleich zu einer entsprechenden Kontrollgruppe ohne Rektumprolaps zu untersuchen.Patienten und Methodik:52 Patientinnen mit Rektumprolaps-Operationen in der Vorgeschichte sowie 200 willkürlich ausgewählte, alters- und geschlechtsangepasste Kontrollpersonen ohne Rektumprolaps erhielten einen ausführlichen Gesundheitsfragebogen.Ergebnisse:Die Rücklaufquote betrug in der Patientinnengruppe 48 von 52 (92%) und in der Kontrollgruppe 165 von 200 (82%). Ein Rektumprolaps war mit einem gesteigerten Operationsrisiko wegen eines Uterusprolaps (Odds-Ratio = 3,1; 95%-Konfidenzintervall = 1,4–6,9) und eines Vaginalprolaps (Odds-Ratio = 3,2; 95%-Konfidenzintervall = 1,3–7,8) assoziiert. Das mittlere Alter bei einer Hysterektomie wegen Uterusprolaps betrug 54,7 Jahre in der Patientinnengruppe, verglichen mit 62,6 Jahren in der Kontrollgruppe (p < 0,01). Das mittlere Alter bei Vaginalprolaps-Operation betrug 60,2 Jahre in der Patientinnengruppe, verglichen mit 66,6 Jahren in der Kontrollgruppe (p < 0,05). Es fanden sich keine signifikanten Unterschiede zwischen den Gruppen bezüglich einer höheren Prävalenz oder des Alters beim ersten Auftreten einer Harninkontinenz.Schlussfolgerung:Die Ergebnisse zeigen einen starken Zusammenhang zwischen einer rektalen und genitalen Prolapsoperation. Dies legt nahe, dass der Diagnose eines Rektumprolaps, der operiert werden soll, eine multidisziplinäre Beckenboden-Untersuchung folgen muss.AbstractPurpose:This study aimed to investigate the prevalence of genital prolapse surgery and urinary incontinence in female patients operated on for rectal prolapse compared with a matched control group without rectal prolapse.Methods:Fifty-two patients with a history of abdominal rectal prolapse surgery and 200 randomly selected age- and gender-matched control subjects without rectal prolapse received an extensive health care history survey.Results:Response rate in the patient group was 48 of 52 (92 percent) and 165 of 200 (82 percent) in the control group. Rectal prolapse was associated with an increased risk of surgery for uterine prolapse (odds ratio = 3.1; 95 percent confidence interval = 1.4–6.9) and vaginal wall prolapse (odds ratio = 3.2; 95 percent confidence interval = 1.3–7.8). Mean age at hysterectomy because of uterine prolapse was 54.7 years in the patient group compared with 62.6 years in the control group (p < 0.01). Mean age at vaginal wall prolapse surgery was 60.2 years in the patient group compared with 66.6 years in the control group (p < 0.05). There were no significant differences between the cohorts regarding prevalence or age at debut of urinary incontinence.Conclusion:Our results indicate a strong association between rectal and genital prolapse surgery suggesting that diagnosis of rectal prolapse necessitating surgical intervention should prompt a multidisciplinary pelvic floor assessment.