Vaginal prolapse and bowel symptoms
Women with pelvic organ prolapse often experience bowel symptoms that may or may not be related to the vaginal prolapse. The classical bowel symptoms experienced include:
• Obstructed defaecation
• Faecal incontinence
Many women with vaginal prolapse also have difficulty with complete bowel evacuation. This may manifest as sensation of incomplete bowel evacuation were the faeces may become trapped in the rectocoele (bowel prolapse into the vagina) as seen in the diagram.
Some women then experience the need for repeated evacuation to empty their bowel or to use digital pressure on the perineum (area between the vagina and rectum) or vagina to complete evacuation of the lower bowel. This is referred to as “digitation to defecate”. Women who have impaired defecation and a rectocoele can be confident that a posterior vaginal repair is very likely to be effective in correcting the faeces being entrapped in the rectocele. Those with impaired defaecation without a vaginal prolapse (rectocoele) need imaging to exclude a rectal prolapse as a cause of the symptoms.
Approximately 4% of women who have given birth experience faecal incontinence. About 10% of women with vaginal prolapse experience faecal incontinence and generally the bowel leakage is not related to the vaginal prolapse. Causes of faecal incontinence include
• External anal sphincter defect
• Nerve damage to the pelvic floor (Pudendal nerve Neuropathy)
• Rectal prolapse (complete rectal prolapse shown occurring with uterine procidentia
While defects of the external sphincter maybe detected on rectal examination investigations including endoanal ultrasound, nerve studies and or imaging will help differentiate between the various causes. We would work with a colorectal surgeon when required to correct these problems.
Chronic constipation is infrequent bowel movements or difficult passage of stools that persists for several weeks or longer and is defined as having fewer than three bowel movements a week. Other symptoms may include:
• Hard or lumpy stools
• Straining to evacuate
• Pressing on the abdomen or using a finger in the rectum to assist in evacuation of the rectum
Constipation is related to prolonged and slow transit of the faeces through the bowel and is not caused by vaginal prolapse. Constipation and associated straining to evacuate causes vaginal prolapse. Women undergoing prolapse surgery should understand the importance of correcting and managing the constipation to decrease the risk of recurrence of the vaginal prolapse.
In 2017 the International Collaboration on Incontinence (ICI 2017) committee on the surgical management of prolapse produced this guideline statement that summarises a planned approach to the management of bowel symptoms.
Basically, the flow diagram states:
1. Women without bowel symptoms should be managed as per the POP surgical guideline.
2. Women with obstructed defecation (incomplete evacuation or those using digital pressure to assist in evacuation of their bowel) with a rectocele should be managed as per the POP surgical guideline.
3. Those with obstructed defecation without rectocele should be investigated to exclude rectal prolapse (rectum extruding from the anus). If rectal and vaginal prolapse present combined gynaecological and colorectal surgery could be considered.
4. Women with faecal incontinence require colorectal diagnostics as discussed above and those with rectal prolapse as a cause may require combined gynaecology and colorectal surgery. Other causes of fecal incontinence such as anal sphincter injury or nerve damage will require separate colorectal interventions in addition to the gynaecology intervention.
5. Women with vaginal prolapse and constipation should understand
- The prolapse is likely to be at least partially caused by the constipation
- The constipation will not be resolved by the prolapse surgery
- Ongoing post-operative management of constipation is required to minimise the risk of prolapse recurrence.