Chronic pelvic pain and rectal prolapse invite consideration of enterocele

International audienceAIM : Data on the pathogenesis and symptoms of enterocele are limited. The objectives of this study were to determine the clinical phenotype of patients with enterocele, to highlight the main functional and/or anatomical associations and to improve the accuracy of the preoperative assessment of pelvic floor disorders.METHOD : A total of 588 patients who were referred to a tertiary unit for an anorectal complaint completed a self-administered questionnaire and underwent physical examination, anorectal manometry and defaecography. Using defaecography, enterocele was defined as a radiological hernia of the small bowel into an enlarged rectovaginal space. One hundred and thirty-five patients with enterocele were age- and gender-matched with 270 patients without enterocele. Factors associated with enterocele were assessed using univariate and multivariate analysis models.RESULTS : Patients with enterocele were less frequently obese than patients without enterocele (8/135 vs 36/270; P = 0.02) and more frequently had a past history of pelvic surgery (51/135 vs 75/270; P = 0.04). They complained more frequently of pelvic pain on bearing down (29/135 vs 24/270; P = 0.003), anal procidentia (37/135 vs 46/270; P = 0.01) and more frequently had irritable bowel syndrome (83/135 vs 131/270; P = 0.01) and severe constipation according to the Kess score (104/135 vs 182/270; P = 0.04). Anorectal function was comparable between the two groups. Patients with enterocele had more frequent rectoceles and overt rectal prolapses than patients without enterocele.CONCLUSIONS : Enterocele should be investigated in patients with chronic pelvic pain, overt rectal prolapse and/or a past history of pelvic surgery

Impact de l’hystérectomie sur l’incontinence urinaire : revue de la littérature

International audienceIntroduction: The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature.Objective: To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease.Study design: We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence.Results: A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP<60mmH2O for 20% of cases versus 1,7% without hysterectomy, P=0.003). The vaginal route could increase the incidence of UI with OR of 2.3 (95%CI 1.0-5.2). Subtotal hysterectomy appears to increase UI with a 0,74 RR for total hysterectomy (95%CI 0.58-0.94). A radical hysterectomy with nerve conservation would preserve urinary functions, unlike pelvic radiotherapy, which is responsible for irreversible nerve damage by demyelination and bladder fibrosis

Préserver ou non l’utérus en cas de chirurgie du prolapsus : revue de la littérature.

National audienceObjective To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation. Material and Methods We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer. Results Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR = 2.21 [95% CI: 0.33–14.67]) or vaginal surgery (OR = 1.07 [95% CI: 0.38–2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3–11). Conclusion In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.Objectif Évaluer l’impact de la réalisation d’une hystérectomie en cas de cure de prolapsus sur les résultats anatomiques, fonctionnels, les complications per et postopératoires par rapport à la conservation utérine. Matériels et Méthodes Nous avons réalisé une revue de la littérature sur Pubmed, Medline, Embase et Cochrane en utilisant les termes et MeSH (Medical Subject Headings of the National Library of Medicine) suivants : uterine prolapse ; genital prolapse ; prolapse surgery ; vaginal prolapse surgery ; abdominal prolapse surgery ; hysterectomy ; hysteropexy ; sacrocolpopexy ; surgical meshes ; complications ; sexuality ; neoplasia ; urinary ; incontinence ; cancer. Résultats Parmi les 168 résumés étudiés, nous avons retenu 63 articles. Il n’existait pas de différence significative en termes de résultats anatomiques et fonctionnels en cas de promontofixation (OR = 2,21 [IC95 % : 0,33–14,67[) et en cas de chirurgie vaginale sans pose de prothèse (OR = 1,07 [IC95 % : 0,38–2,99]). Il n’y avait pas non plus de différence en termes de symptomatologie urinaire ou de sexualité au décours quel que soit la voie d’abord. L’hystérectomie était associée à une morbidité plus importante (saignements, allongement du temps opératoire, allongement de la durée d’hospitalisation), un risque augmenté d’exposition prothétique en cas d’hystérectomie totale (8,6 % IC95 % : 6,3–11). Conclusion En l’absence de preuve de supériorité en termes de résultats anatomiques et fonctionnels, avec une augmentation du taux de complications, l’hystérectomie concomitante en cas de cure de prolapsus ne doit probablement pas être réalisée de manière systématique