OBSTRUCTED DEFECATION AND PARITY INWOMEN WITHOUT ANATOMICAL ABNORMALITIES OF THE ANORECTUM
F. A. SOLAR ALTAMIRANO, T.FRIEDMAN, N. SUBRAMANIAM, H. DIETZ;
Sydney Med. Sch. Nepean,Sydney, Australia.
Introduction: Damage to pelvicfloor tissues is a known complication of childbirth (1) and may beone of the etiological factors in defecatory dysfunction, which iscommon in parous women. The pathophysiology of defecation disordersis not fully understood. Vaginal delivery increases the risk ofurinary and defecatory symptoms (2), and it is thoughtthat some of this effect may be due to impairment of rectosigmoid andanorectal innervation.
Objective: To determine whetherthere is an association between vaginal parity and symptoms ofobstructed defecation in women without anatomical abnormalities ofthe anorectum, as evidence of a presumptive neuropathic effect ofchildbirth.
Methods: We retrospectively evaluated therecords of 2274 patients who attended a tertiary urogynecologicalcentre between 8 September 2011 and 30 June 2016 for theinvestigation of symptoms of pelvic floor dysfunction. The assessmentincluded a structured interview, urodynamic testing, a clinical(POP-Q) examination and 4D transperineal ultrasound as previouslydescribed (3). Evaluations were performed supine following bladderemptying. For the purposes of this study we excluded patients withanatomical abnormalities of the anorectum such as true rectocoele,enterocele and rectal intussusception, and those with previous pelvicfloor surgery including hysterectomy. The presence of anintussusception or rectal prolapse was recorded at the time of theexamination, while rectocele and enterocele were diagnosed offline ata later date by the first author on a desktop PC, using proprietarysoftware, blinded to all other data. We stratified all remainingpatients according to parity: 1- nulligravid; 2- parous, deliveredonly by caesarian; 3- one vaginal birth; 4- two vaginal births; 5-three or more vaginal deliveries. We determined the prevalence ofincomplete emptying, the need to strain, digitation (external,vaginal or anal) in these five groups. The statistical analysis (X2tests) was performed using IBM v 22 SPSS software.
Results:2274 women were examined during the inclusion period. We excluded 107patients for incomplete data and 1413 for either previous pelvicfloor surgery (661 hysterectomy and 477 incontinence/ prolapsesurgery) or anatomical abnormalities of the anorectum (812 truerectocoele, 139 enterocele, 60 patients intussusception), leaving 754patients for analysis. The median age of this population was 51 years(16-88) with mean BMI of 27kg/m2 (15-64). Defecationsymptoms were common: the sensation of incomplete emptying wasreported by 318 (42%), straining to empty by 390 (52%) and digitationby 72 (16%). Any of the above symptoms were reported by 399 (53%)women.
Table 1 shows associations between parity groups andsymptoms, none of which were significant (all p>0.1). Table 2demonstrates associations for two subgroups: vaginally parous andvaginally nulliparous, with similar results.
Table1: Association between symptoms of obstructed defecation andparity
2-Werepregnant delivered only by cesarean
3-3- One vaginal delivery at least
4-Twovaginal deliveries at least
5-5-Three and above vaginal deliveries
Table2: Association between symptoms of obstructed defecation andvaginal parity
Conclusions: When anatomicalabnormalities of the anorectum such as rectocele, enterocoele andrectal intussusception are excluded, pregnancy and childbirth do notseem to have any effect on the prevalence of symptoms of obstructeddefecation. This argues against the hypothesis that pregnancy and/orvaginal birth may have a deleterious effect on anorectalinnervation.
References: 1. AJR 1997; 169:1555-1558
2.Dis Colon Rectum 2011; 54:1
3. Int Urogynecol J 2016; 27: 939-944