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Rectocele: victim of availability bias? Results of a Belgian survey of colorectal and gynecological surgeons

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Abstract

Introduction and hypothesis

Women with a symptomatic rectocele may undergo different trajectories depending on the specialty consulted. This survey aims to evaluate potential differences between colorectal surgeons and gynecologists concerning the management of a rectocele.

Methods

A web-based survey was sent to abdominal surgeons (CS group) and gynecologists (G group) asking about their perceived definition, diagnostic workup, multidisciplinary discussion (MDT) and surgical treatment of rectoceles. The answers of both groups were analyzed with the chi-square test or Fisher’s exact test at p < 0.050.

Results

A rectocele was defined as a prolapse of the posterior vaginal wall by 78% of the G and 41% of the CS group. All gynecologists and 49% of the CS group evaluated a rectocele clinically in dorsal decubitus, with 91% of gynecologists using a speculum and 65% using the Pelvic Organ Prolapse-Quantification (POP-Q) scoring system, compared to < 1/3 of colorectal surgeons. A digital rectal examination was performed by 90% of the CS group and 57% of the G group. A transvaginal ultrasound was only used by the G group, while anal manometry was opted for by the CS group (65%) and minimally by the G group (14%). In the G group, a posterior repair was the preferred surgical technique (78%), whereas 63% of the CS group preferred a rectopexy. Multidisciplinary discussions (MDT) were mostly organized ad hoc.

Conclusions

An availability bias is seen in different aspects of rectocele evaluation and treatment. Colorectal surgeons and gynecologists are acting based on their training and experience. Motivation for pelvic floor MDT starts with creating awareness of the availability bias.

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References

  1. Durnea CM, Khashan AS, Kenny LC, Durnea UA, Smyth MM, O'Reilly BA. Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women. Int Urogynecol J. 2014;25(11):1463–70. https://doi.org/10.1007/s00192-014-2382-1.

    Article  PubMed  CAS  Google Scholar 

  2. Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783–90. https://doi.org/10.1007/s00192-013-2169-9.

    Article  PubMed  Google Scholar 

  3. Mustain WC. Functional disorders: rectocele. Clin Colon Rectal Surg. 2017;30(1):63–75. https://doi.org/10.1055/s-0036-1593425.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Balata M, Elgendy H, Emile SH, Youssef M, Omar W, Khafagy W. Functional outcome and sexual-related quality of life after Transperineal versus transvaginal repair of anterior rectocele: a randomized clinical trial. Dis Colon Rectum. 2020;63(4):527–37. https://doi.org/10.1097/DCR.0000000000001595.

    Article  PubMed  Google Scholar 

  5. Dietz HP, Korda A. Which bowel symptoms are most strongly associated with a true rectocele? Aust N Z J Obstet Gynaecol. 2005;45(6):505–8. https://doi.org/10.1111/j.1479-828X.2005.00486.x.

    Article  PubMed  Google Scholar 

  6. Mowat A, Maher D, Baessler K, Christmann-Schmid C, Haya N, Maher C. Surgery for women with posterior compartment prolapse. Cochrane Database System Rev 2018;(3). https://doi.org/10.1002/14651858.CD012975.

  7. Fares WH. The 'availability' bias: underappreciated but with major potential implications. Crit Care. 2014;18(2):118. https://doi.org/10.1186/cc13763.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Eysenbach G. Improving the quality of web surveys: the checklist for reporting results of internet E-surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34. https://doi.org/10.2196/jmir.6.3.e34.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Federale overheidsdienst (FOD) Belgium https://www.belgium.be/nl/gezondheid/gezondheidszorg/medische_diensten/ziekenhuizen.

  10. Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc Royal Soc Med. 1966;59(6):477–82.

    Article  CAS  Google Scholar 

  11. Skomorowska E, Hegedus V, Christiansen J. Evaluation of perineal descent by defaecography. Int J Color Dis. 1988;3(4):191–4. https://doi.org/10.1007/bf01660711.

    Article  CAS  Google Scholar 

  12. Alves-Ferreira PC, Gurland B, Zutshi M, Hull T. Perineal descent does not imply a more severe clinical disorder. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2012;14(11):1372–9. https://doi.org/10.1111/j.1463-1318.2012.03018.x.

    Article  CAS  Google Scholar 

  13. Huizinga C, Deen-Molenaar C, van van der Mijnsbrugge G, van der Vaart H. Enquête onder gynaecologen en chirurgen over rectocele. Ned tijdschrift geneeskunde. 2014;158:A7242.

  14. D'Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004;91(11):1500–5. https://doi.org/10.1002/bjs.4779.

    Article  PubMed  CAS  Google Scholar 

  15. Wong M, Meurette G, Abet E, Podevin J, Lehur PA. Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2011;13(9):1019–23. https://doi.org/10.1111/j.1463-1318.2010.02349.x.

    Article  CAS  Google Scholar 

  16. Wong MT, Abet E, Rigaud J, Frampas E, Lehur PA, Meurette G. Minimally invasive ventral mesh rectopexy for complex rectocoele: impact on anorectal and sexual function. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2011;13(10):e320–6. https://doi.org/10.1111/j.1463-1318.2011.02688.x.

    Article  CAS  Google Scholar 

  17. Ye GY, Wang Z, Matzel KE, Cui Z. Short-term outcomes of laparoscopic ventral rectopexy for obstructed defecation in patients with overt pelvic structural abnormalities-a Chinese pilot study. Int J Color Dis. 2017;32(9):1337–40. https://doi.org/10.1007/s00384-017-2815-7.

    Article  CAS  Google Scholar 

  18. Doumouchtsis SK, Raheem AA, Milhem Haddad J, Betschart C, Contreras Ortiz O, Nygaard CC, Medina CA, La Torre F, Iancu G, Cervigni M, Zanni G. An update of a former FIGO working group report on Management of Posterior Compartment Prolapse. Int J Gynaecol Obstet: Off Organ Int Federation Gynaecol Obstet. 2020;148(2):135–44. https://doi.org/10.1002/ijgo.13006.

    Article  Google Scholar 

  19. Nessi A, Kane A, Vincens E, Salet-Lizee D, Lepigeon K, Villet R. Descending perineum associated with pelvic organ prolapse treated by sacral Colpoperineopexy and Retrorectal mesh fixation: preliminary results. Front Surg. 2018;5:50. https://doi.org/10.3389/fsurg.2018.00050.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Pucciani F. Descending perineum syndrome: new perspectives. Techniques Coloproctol. 2015;19(8):443–8. https://doi.org/10.1007/s10151-015-1321-6.

    Article  CAS  Google Scholar 

  21. Lundby L, Laurberg S. Laparoscopic ventral mesh rectopexy for obstructed defaecation syndrome: time for a critical appraisal. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2015;17(2):102–3. https://doi.org/10.1111/codi.12830.

    Article  CAS  Google Scholar 

  22. Toozs-Hobson P, Freeman R, Barber M, Maher C, Haylen B, Athanasiou S, Swift S, Whitmore K, Ghoniem G, de Ridder D. An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse. Int Urogynecol J. 2012;23(5):527–35. https://doi.org/10.1007/s00192-012-1726-y.

    Article  PubMed  Google Scholar 

  23. Taylor C, Atkins L, Richardson A, Tarrant R, Ramirez AJ. Measuring the quality of MDT working: an observational approach. BMC Cancer. 2012;12:202. https://doi.org/10.1186/1471-2407-12-202.

    Article  PubMed  PubMed Central  Google Scholar 

  24. ACOG committee opinion. Number 792. Clin Guid Standardiz Pract Improve Outcomes. 2019;134(4):e122–5.

    Google Scholar 

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Authors participation on manuscript

S Van den Broeck: Project development, Data collection, Management data analysis, Manuscript writing.

Y Jacquemyn: Project development: Manuscript editing.

G Hubens: Manuscript editing.

H De Schepper: Manuscript editing.

A Vermandel: Manuscript editing.

N Komen: Project development, Manuscript editing.

Presentation at prior meeting congress

Belgian Surgical week 9–11/9/2021.

Elisabeth Centre, Antwerp, Belgium.

9/11/2021.

Author information

Authors and Affiliations

  1. Department of Abdominal, Pediatric and Reconstructive Surgery, Antwerp University Hospital, Drie Eikenstraat 566, 2650, Edegem, Belgium

    Sylvie Van den Broeck, Guy Hubens & Niels Komen

  2. Antwerp ReSURG, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, University of Antwerp, 2610, Antwerp, Belgium

    Sylvie Van den Broeck, Yves Jacquemyn, Guy Hubens & Niels Komen

  3. Department of Obstetrics and Gynaecology, Antwerp University Hospital, 2650, Edegem, Belgium

    Yves Jacquemyn

  4. Global Health Institute (GHI), Faculty of Medicine and Health Sciences, University of Antwerp, 2610, Edegem, Antwerp, Belgium

    Yves Jacquemyn

  5. Department of Gastroenterology and Hepatology, Antwerp University Hospital, 2650, Edegem, Belgium

    Heiko De Schepper

  6. Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, 2610, Antwerp, Belgium

    Alexandra Vermandel

Authors
  1. Sylvie Van den Broeck
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  2. Yves Jacquemyn
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  3. Guy Hubens
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Correspondence to Sylvie Van den Broeck.

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Appendix 1

Appendix 1

  1. (1)

    Are you a surgeon or a gynecologist?

    1. a.

      Surgeon

    2. b.

      Gynecologist

  2. (2)

    Gender

    1. a.

      Male

    2. b.

      Female

  3. (3)

    How many years have you been recognized as a specialist?

    1. a.

      < 5 years

    2. b.

      5–10 years

    3. c.

      > 10 years

  4. (4)

    How many surgeries per month do you perform for pelvic organ prolapse (POP)?

    1. a.

      < 1

    2. b.

      1–5

    3. c.

      5–10

    4. d.

      > 10

  5. (5)

    In your opinion, what is the definition of an anterior rectocele?

    1. a.

      Prolapse of the posterior vaginal wall

    2. b.

      Weakening of the anterior side of the rectum

    3. c.

      Other, specify: …

  6. (6)

    In your opinion, how does an anterior rectocele arise? (Multiple choices possible)

    1. a.

      Dilatation of the rectum

    2. b.

      Herniation of the rectovaginal septum

    3. c.

      Injury of the levator ani muscle

    4. d.

      Injury of the paravaginal supporting tissue

    5. e.

      Other: please specify:

  7. (7)

    How do you clinically evaluate a rectocele? (Tick the appropriate box for you)

 

Dorsal decubitus

Upright posture

Side lying

posture

At rest

With Valsalva

Inspection

     

Speculum

     

Digital vaginal examination

     

Digital rectal examination

     

Baden-Walker

     

POP-Q

     

Other

Specify

     
  1. (8)

    What is the definition of a descending perineum syndrome according to you? (Multiple choices possible)

    1. a.

      I do not know this condition → proceed to question 10

    2. b.

      A lowered perineum at rest

    3. c.

      A lowered perineum during straining

    4. d.

      There is no definition; this syndrome is not a recognized entity

    5. e.

      Other, specify: …

  2. (9)

    How do you clinically evaluate a descending perineum? (Multiple choices possible)

    1. a.

      I do not evaluate this

    2. b.

      By sight at rest

    3. c.

      By sight, I let the patient strain and see if a descending perineum is present, yes or no

    4. d.

      With a caliper (Beco)

    5. e.

      By measuring genital hiatus (gh) and perineal body (pb) (POP-Q) at rest

    6. f.

      By measuring genital hiatus (gh) and perineal body (pb) (POP-Q) during straining

    7. g.

      Other: specify: …

    Unlike colorectal surgeons/proctologists, gynecologists also see patients primarily for standard gynecological follow-up. Questions 10 and 11 are for gynecologists only

  3. (10)

     When you see patients in your gynecological practice, do you always ask if there are urinary and/or fecal problems?

    1. a.

      Yes, always

    2. b.

      No

    3. c.

      Sometimes

    4. d.

      Only at the first check-up after labor

    5. e.

      Other → specify:

  4. (11)

     If a vaginal bulge is observed during a clinical examination/smear test, do you always ask if there are urinary and/or fecal problems?

    1. a.

      Yes always → go to question 12

    2. b.

      Never → go to question 13

    3. c.

      Sometimes → specify … and go to question 12

  5. (12)

     How do you proceed if there are symptoms?

    1. a.

      I refer the patient to a general practitioner

    2. b.

      I refer the patient to a pelvic floor function specialist

    3. c.

      I start therapy myself

    4. d.

      I discuss the patient at the multidisciplinary meeting

  6. (13)

     Do you treat patients with obstructive defecation syndrome (ODS)?

    1. a.

      Yes

    2. b.

      No ➔ Proceed to question 17

  7. (14)

     Which scoring system do you use for obstructive defecation? (Multiple choices possible)

    1. a.

      None

    2. b.

      Obstructed defecation, Altomare

    3. c.

      Defecation Distress Inventory (DDI)

    4. d.

      Bristol stool scale

    5. e.

      Vaizey score

    6. f.

      Wexner score

    7. g.

      Other: specify …

  8. (15)

     What primary treatment do you use for obstructive defecation syndrome (ODS)? (multiple choices)

    1. a.

      None

    2. b.

      Laxatives

    3. c.

      Fibers

    4. d.

      Anal irrigation

    5. e.

      Pelvic floor physiotherapy

    6. f.

      Other, specify:

  9. (16)

     What technical examinations do you perform for additional diagnostics, in most cases, before proceeding with an invasive procedure for obstructive defecation (ODS)? (Several choices available)

    1. a.

      None, a clinical examination is sufficient

    2. b.

      Transvaginal ultrasound

    3. c.

      Transperineal ultrasound

    4. d.

      Transrectal ultrasound

    5. e.

      Rx defecography: Only of the posterior compartment

    6. f.

      Rx defecography: Cysto-colpo defecography

    7. g.

      Pelvic floor dynamic MRI

    8. h.

      Anal manometry

    9. i.

      Other: specify: …

  10. (17)

     If I find an anterior rectocele …

    1. a.

      I treat it myself: go to question 19.

    2. b.

      I do not treat it myself: go to question 18.

  11. (18)

     If I find an anterior rectocele, I refer the patient to …

    1. a.

      A gynecologist specialized in functional pelvic floor pathology

    2. b.

      A colorectal surgeon specialized in functional pelvic floor pathology

    3. c.

      A gastroenterologist specialized in functional pelvic floor pathology

    4. d.

      Multidisciplinary consultation

    5. e.

      Other: specify: …

  12. (19)

     What is your indication to proceed to an invasive procedure for an anterior rectocele? (Several choices possible)

    1. a.

      Incomplete evacuation

    2. b.

      Insufficient result of conservative treatment

    3. c.

      Feeling of heaviness

    4. d.

      When digital manipulation is necessary to evacuate

    5. e.

      When perineal pressure is required to evacuate

    6. f.

      The size of the rectocele independent of the patient’s complaints

    7. g.

      Impact of the complaints on the patient’s daily life/quality of life

    8. h.

      Other: specify:

  13. (20)

     Do you put patients on laxatives before surgery?

    1. a.

      Yes

    2. b.

      No ➔ go to question 22

  14. (21)

     If yes, which laxatives

    1. a.

      Polyethene glycol

    2. b.

      Magnesium hydroxide

    3. c.

      Fibers

    4. d.

      Other

  15. (22)

     Which procedure do you prefer for the anterior rectocele?

    1. a.

      Posterior repair without mesh ➔ which technique: …

    2. b.

      Posterior repair with mesh

    3. c.

      Transanal surgery → which technique:

    4. d.

      Sacrocolpopexy

    5. e.

      Ventral rectopexy with mesh

    6. f.

      Other: specify …

  16. (23)

     Does the proposed procedure remain the same in case of descending perineum?

    1. a.

      Yes ➔ proceed to question 25

    2. b.

      No

  17. (24)

     If not, which procedure do you choose if a descending perineum is also present?

    1. a.

      Posterior repair without mesh

    2. b.

      Posterior repair with mesh

    3. c.

      Transanal surgery → which: …

    4. d.

      Sacrocolpopexy

    5. e.

      Transperineal mesh

    6. f.

      Ventral mesh rectopexy

    7. g.

      No intervention

    8. h.

      Other: which one: …

  18. (25)

     Do you recommend the use of laxatives in the perioperative phase?

    1. a.

      Yes

    2. b.

      No

  19. (26)

     If so, which ones?

    1. a.

      Polyethene glycol

    2. b.

      Magnesium hydroxide

    3. c.

      Fibers

    4. d.

      Other, specify: …

  20. (27)

     How do you evaluate the outcome of the surgery? Several options are possible

    1. a.

      Not evaluated

    2. b.

      Questionnaire → which one? please specify: …

    3. c.

      I evaluate clinically

    4. d.

      Transperineal ultrasound

    5. e.

      Transvaginal ultrasound

    6. f.

      X-ray or MRI defecography

  21. (28)

     What do you evaluate? (Several choices possible)

    1. a.

      Correction of anatomy

    2. b.

      Patient satisfaction

  22. (29)

     How long after surgery do you evaluate?

    1. a.

      1 month

    2. b.

      3 months

    3. c.

      6 months

    4. d.

      1 year

    5. e.

      5 years

    6. f.

      > 5 years

  23. (30)

     Patients with pelvic prolapse are discussed in a multidisciplinary manner… (several choices available)

    1. a.

      Always

    2. b.

      Never → reason? …

    3. c.

      If several compartments are involved

    4. d.

      Only in case of failure of conservative treatment

    5. e.

      In case of complex pathology

  24. (31)

     What disciplines are involved in your multidisciplinary discussion (MDT)? (Several choices possible)

    1. a.

      Gynecology

    2. b.

      Urology

    3. c.

      Surgery

    4. d.

      Gastroenterology

    5. e.

      Pelvic floor physiotherapy

    6. f.

      Psychology

      Other: specify: …

  25. (32)

     Multidisciplinary consultation takes place

    1. a.

      1× per week

    2. b.

      2× per month

    3. c.

      1× per month

    4. d.

      Other: specify: …

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Van den Broeck, S., Jacquemyn, Y., Hubens, G. et al. Rectocele: victim of availability bias? Results of a Belgian survey of colorectal and gynecological surgeons. Int Urogynecol J 33, 3505–3517 (2022). https://doi.org/10.1007/s00192-022-05118-4

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