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Chronic and rectal invite consideration of C Brochard, A Ropert, M Chambaz, C Gouriou, C Cardaillac, T Grainville, G Bouguen, L Siproudhis

To cite this version:

C Brochard, A Ropert, M Chambaz, C Gouriou, C Cardaillac, et al.. Chronic pelvic pain and invite consideration of enterocele. Colorectal Disease, Wiley, 2020, 22 (3), pp.325-330. ￿10.1111/codi.14877￿. ￿hal-02365041￿

HAL Id: hal-02365041 https://hal-univ-rennes1.archives-ouvertes.fr/hal-02365041 Submitted on 9 Dec 2019

HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est archive for the deposit and dissemination of sci- destinée au dépôt et à la diffusion de documents entific research documents, whether they are pub- scientifiques de niveau recherche, publiés ou non, lished or not. The documents may come from émanant des établissements d’enseignement et de teaching and research institutions in France or recherche français ou étrangers, des laboratoires abroad, or from public or private research centers. publics ou privés. 35033 RennesCedex,FRANCE Henri 2 rue le Guillou l’Appareil de Maladies Digestif des Service Digestives, Fonctionnelles d’Explorations Service Brochard Charlène Correspondence to: Short runningheadtitle Nantes,France CHU deNantes, 5 4 3 Rennes 1,Rennes,France 2 Rennes, France 1 Cardaillac Brochard Charlène Article typeArticle :Original DR BROCHARD :0000-0001- CHARLENE (OrcidID

CHRONIC PELVIC PAIN AND RECTAL PROLAPSE INVITE CONSIDERATION INVITEPELVICCHRONIC CONSIDERATION PAINANDRECTALPROLAPSE Service CIC 1414,INPHY, deRennesUniversité France 1,Rennes, INSERMU1241, 1, Rennes de Université Pontchaillou, CHU Digestif, l’Appareil de Maladies des Service Accepted Fonc d’Explorations Services Article

de gynécologie 5 , Thomas Grainville Equipe EXPRES, Université de Rennes 1, Rennes, France Equipe EXPRES,Université France de Rennes1,Rennes, 1,2,3,4 - Aan Ropert Alain , obstétrique Mère reproduction,hôpital et médecine dela : enterocele andpelvic pain 1 , Guillaume Bouguen inels ietvs CU othilu Uiest de Université Pontchaillou, CHU Digestives, tionnelles OF 2,4

ENTEROCELE ENTEROCELE , ain Chambaz Marion

1,3,4 7354-6301) , Laurent Siproudhis 2 Car Gouriou Claire , 1,3,4 -Enfant, -Enfant, 1 , Claire Claire , Source ofFunding: . submitted version. AR, manuscript: CB, revision andLS;critical of themanuscript forimportant intellectual content: AR, andinterpretation LS;analysis MC,CG,CC, and of TG CBanddata: LS;drafting ofthe Author Word countofabstract Word count CC and CG, MC, AR, Ipsen. from fees lecture received CB Ferring. and Takeda from fees consultant received LS MSD. and Ferring Abbvie, from fees lecture received LS Janssen. Takeda, from fees consultant and Pfizer and Takeda MSD, Ferring, Abbvie, from fees lecture received GB Disclaimers: [email protected]: (0033)-2 Telephone Accepted Article

MC, CG,CC, GBandLS. TG, s’ TG have noconflictsofinterestTG

contributions

(excluding (excluding page, title abstract, references, 2024 table and figure):

-99-28 There There : : Study conceptanddesign: CB,GBof CB, and LS;acquisition data: 235 -43 wa -11 /Fax-11 (0033)-2-99-28

s nofunding. words. All authors reviewed the reviewedthe andapprovedAll authors thefinalpaper

-41 -04

words. words. . What doesthispaperadd toliterature? prolapse apastrectal and/or historyof surgery. pelvic Conclusio frequent more had enterocele with patients rectoceles and rectalprolapses overt compared to Patients groups. two the between comparable was function Anorectal p=0.04). 182/270, vs (104/135 score severe Kess the and to according p=0.01) 131/270, vs (83/135 (IBS) syndrome bowel irritable had frequently prociden anal p=0.003), 24/270, vs on pain (29/135 pelvic of frequently more complained They p=0.04). 75/270, vs (51/135 surgeries pelvic of history past a had frequently more and p=0.02) 36/270, vs (8/135 Re models. analysis multivariate and univariate using assessed were enterocele with associated Factors enterocele. without patients 270 with gender-matched and age were enterocele with patients thirty-five and hundred One space. rectovaginal enlarged an into bowel small the of . and manometry self underwent complaint Method: the of accuracy the improve preoperative floor assessment ofpelvic disorders. to and associations anatomic and/or functional main the highlight to enterocele, with patients of phenotype clinical the determine to were study this Aim: ABSTRACT

Accepted sults: Article Data on the pathogenesis and symptoms of enterocele are limited. The objectives of objectives The limited. are enterocele of symptoms and pathogenesis the on Data Patients with enterocele were less frequently obese than patients without enterocele enterocele without patients than obese frequently less were enterocele with Patients A total of 588 patients who were referred to a tertiary unit for an anorectal anorectal an for unit tertiary a to referred were who patients 588 of total A ns : neoee hud e netgtd n ains ih hoi pli pi, overt pain, pelvic chronic with patients in investigated be should Enterocele amnsee qetonie, hscl xmnto, anorectal examination, physical questionnaires, -administered Enterocele was defined using defecography as a radiological a as defecography using defined was Enterocele tia

3/3 v 4/7, =.1 ad more and p=0.01) 46/270, vs (37/135

without enterocele. bearing down down . the accuracy to improve ofthefinally preoperative assessment of pelvic floordisorders. enterocele, with patients of study case-matched a in enterocele with assess study present The important. during identified enterocele an [9 of assessment preoperative occurrence the by modified be may disorders floor 6 [4 experiences gynecological reported in except scarce, are enterocele on focusing Studies reported. poorly are manometry anorectal and evaluation clinical complaints, of assessments Indirect resonance magnetic [2,3 dynamic defecography over defecography conventional prefer Most enterocele. [1 poor is enterocele of diagnosis it defined is Enterocele INTRODUCTION of possibility the to attention draw considered.enterocele, and conventionaldefecography should be should features These pain. pelvic of complaints and prolapse rectal had frequently more enterocele with patients that highlights paper This

]. Few studies were performed by colorectal surgeons [7,8 surgeons colorectal by performed were studies Few ].

Accepted Articleinterpos es in the rectovaginal septum. The positive predictive value of the clinical clinical the of value predictive positive The septum. rectovaginal the in . ] oee, o al etr hv acs t cnetoa defecography. conventional to access have centers all not However, as ed the clinical and pathophysiologic features encoun features pathophysiologic and clinical the ed the descent of the into the lower , where cavity, pelvic lower the into intestine small the of descent the

]. Therefore, adequate pre-operative diagnosis of enterocoeles is enterocoeles of diagnosis pre-operative adequate Therefore, ]. to highlight the main functional and/or anatomic associations, and associations, anatomicand/or functional mainthe highlight ] , ] and radiological examinations are mandatory to diagnose to mandatory are examinations radiological and . Our aims were to determine the clinical phenotype clinical the determine to were aims Our . ] . Surgical correction of pelvic pelvic of correction Surgical . ] tered in patients in tered – . of surgery colpoanterior colpocele, posterior of surgery hysterectomy, into pelvic differentiated of was history surgery Past recorded. were histories obstetrical and surgical and and disease, depression), neurological diabetes, (including history medical weight, height, sex, Age, and manometry, time. anorectal same the at performed were procedures All database. a in recorded were defecography examination, physical questionnaires, Self-administered Functional testing assessment anorectal and radiation, inflammatory or boweldisease,anal rectal cancer, defecography. self self bleeding, anal discharge, mucus ), during straining evacuation, incomplete of sensation defecation, at blockage procidentia anal down, bearing pain, pelvic follows: as listed were prospectively ( database were dedicated a in Details included complaint. anorectal an for 2015 and 2005 between France) A Study Population SUBJECTS AND METHODS

Accepted Articlell - patients in this study had been referred to a tertiary unit (University Hospital, Rennes, Hospital, (University unit tertiary a to referred been had study this in patients diitrd usinars pyia examinati physical questionnaires, administered cele and colpopexy.cele Patients

ee excluded were

Symptoms as wererecorded previously described Fondamentum, - eotd acl incontinence. faecal reported

f hy ee rgat r had or pregnant were they if CNIL no. 1412467). Anorectal complaints Anorectal 1412467). no. CNIL n aoetl aoer and manometry anorectal on, or anal oranal rectal stricture , dyschezia (sensation of (sensation dyschezia l patients All a itr of history complete [10 .

pelvic pelvic – 12 ] . d syndrome (IBS) was defined according to the Rome III criteria [12 criteria III Rome the to according defined was (IBS) syndrome chart stool . medium contrast barium using described previously as performed was Defecography balloon air inflation. with distension isovolumic using recorded were thresholds perception Rectal effort. during recorded were Dyssynergic contraction. the during pressures maximal and pressures resting the between variation the was contraction Amplitude wassqueeze. Scientific, 30-second a canal during obtained anal lower Mui the in pressure (PIP4-4, squeeze mean The system Canada). Ontario, Mississauga, perfusion pneumohydraulic compressed powered 1 of rate a at perfused was lumens three the of Each holes. side distributed radially with Canada) Ontario, Mississauga, Scientific, Mui (R3B, assembly catheter water-perfused three-lumen a using monitored were pressures length, canal anal and canals anal lower and upper the in pressures resting maximal An [16 (GIQLI)) Index published previously offecalin studies [11,17 incontinence cohorts Life of Quality (Gastrointestinal complaints gastrointestinal Knowles validated [15 (KESS) Score Constipation the using performed was constipation [13 (CCIS) Score Incontinence to according assessed was incontinence Fecal effort. during contraction a as defined was defecation dyssynergy Clinical recorded. were examination enterocele an of presence the and defecation dyssynergic Clinical consultation. diary, stool the using defined prociden genital or anal complaints anorectal following the on focused questionnaire The Accepted Article orectal manometry was performed as previously described [17 described previously as performed was manometry orectal . All patients had had their complaints for at least 6 months. Irritable bowel bowel Irritable months. 6 least at for complaints their had had patients All tia , an digita d n a hsca recorded physician a and ]. ] and was defined as CCIS CCIS as defined was and ]

ult o iewsqatfe sn vldtdsae for scale validated a using quantified was life of Quality tion. It also included included also It tion. mL/min with distilled water from an electrically an from water distilled with mL/min a

it the validated Cleveland Clinic Cleveland validated the stool diary using the Bristol Bristol the using diary stool – in the database during the the during database the in : Eccersley pelvic pain, bearing down, bearing pain, pelvic – ]. The subtype of IBS was was IBS of subtype The ]. ]. ]. >5 19 [14 ]. To record the mean mean the record To ]. ]. Assessment of of Assessment ]. – Scott Symptom Symptom Scott on clinical ], as as ], Study design Study design as theabsence enlargement ofdescentoran puborectalis musclestraining. during ofthe . significant several were there When analysis. multivariate for model regression logistic binary a into integrated were analysis univariate P a analysis, chi- non the and for variables test Wilcoxon the variables, distributed normally for tests t- using performed were enterocele without patients with enterocele with patients between the distributed. normally not if (range) medians or (SD) deviation standard ± means as expressed are Data retrospectively. studied and collected prospectively were Data analysisStatistical [15 by time. of period same the during observed were diagnosed enterocele with patients compared defecographywere consecutive investigations, these Following [2 defecation during line pubococcygeal quantified was descent [ described radiologic a p descent, perineal prolapse, high-grade , enterocele, of diagnosis the allowed examination radiologic before minutes 90 (Micropaque) barium of intake oral the via filled was The loop. sigmoid the materialize to sufficient was filling [20]. routes anal and vaginal, oral, via (Microtrast) Accepted Article ]. incontinencewasdefined Severe aradoxical puborectalis contraction puborectalis aradoxical 21 al - value < 0.05 was considered to be statistically significant. Items with p<0.05 by by p<0.05 with Items significant. statistically be to considered was 0.05 < value hernia of the small bowel into an enlarged rectovaginal space, as previously previously as space, rectovaginal enlarged an into bowel small the of hernia ]. and definitions and definitions

h svrt o te neoee a casfe a peiul [22]. previously as classified was enterocele the of severity The . qae ts o Fse’ eat et o categorica for test exact Fisher’s or test squared h mxml egh ht eaae te pe aa cnl ie and site canal anal upper the separated that length maximal the as with two age- with two age- as aCCIS 3 ]. Paradoxical puborectal Paradoxical and sex-matched patients without enterocele enterocele without patients and sex-matched and rectal emptying. Enterocele was defined as defined was Enterocele emptying. rectal and

and mutually dependent variables in univariate in variables dependent mutually and Constipation was defined was Constipation >8

, The bladder was not catheterized. Rectal Rectal catheterized. not was bladder The

as described previously as described previously al xmnto. hs radiologic This examination. is contraction was defined was contraction -n l variables. variables. l a KESS score > 9 > score KESS a as ral distributed ormally [14 Comparisons Comparisons ]. Perineal o each For who al

. with patients 135 the Of assistance. digital used frequently more enterocele with Patients 0.0033). p= (27.0%); 73/270 (IBS), syndrome bowel irritable from more complained enterocele with procidentia anal and down bearing or pain pelvic patients of frequently characteristics, clinical the to regard With with enterocele. associated not was hysterectomy the of approach surgical The hysterectomy. laparoscopic who patients 90 the Among enterocele. with patients in frequent more significantly was hysterectomy of history Past enterocele. with patients in frequent more significantly was surgeries pelvic history Past histories. medical to according differ not did groups two The surgery. bariatric <18. (BMI underweight were patients (6.2%) 24/385 Overall, enterocele. with patients than obese had enterocele without Patients The characteristicsof405 enterocele. the eligible. were entero with patients 135 of total A database. prospective the in recorded and registry the in included were visit single a during defecography and manometry, anorectal examination, physical questionnaires, self-administered underwent who patients 588 2015, to 2005 From Population RESULTS version JMP ProSoftware, (OR ratios multivariatethe analysis. wasonlyintegrated into one analysis, Accepted Article 5 kg/m 5 s

) with 95% confidence intervals [CIs]. intervals confidence 95% with ) 2 ), a hseetm,3 ptet hd aia hysterectomy, vaginal had patients 30 hysterectomy, had The and 9/127 (7.1%) patients with enterocele were underweight. were enterocele with patients (7.1%) 9/127 and se patients were case-matched in age and gender with 270 with gender and age in case-matched were patients se a 13.0.0 radiological enterocele, the diagnosis was clinically suspected in suspected clinically was diagnosis the enterocele, radiological a

(SAS InstituteInc.,Cary, NC, USA). higher body mass index (BMI) and were more frequently frequently more were and (BMI) index mass body higher particularly constipation-IBS (56/135 (41.5%) vs. vs. (41.5%) (56/135 constipation-IBS particularly

patients patients are depictedare inTable 1.

Statistical analyses were performed using using performed were analyses Statistical and more frequently suffered suffered frequently more and

The results are shown as odd asshown results The are

and 60 patients had patients 60 and patients without patients

No patient had had patient cele of s h rsls f hs rsetv cs mthd td dsrb te lncl and clinical the describe study matched . case prospective this of results The DISCUSSION prolapseand overt rectal [1.95-4.92],p= 0.0001). (OR=3.10 0.0007) p= [1.60-5.84], 3.06 (OR= down bearing and/or pain pelvic 0.0056), p= [1.23-3.27], 2.00 (OR= surgery pelvic of history past were enterocele with associated significantly factors the that revealed prolapse rectal overt and 9 > score KESS IBS, assistance, digital down, bearing and/or pain pelvic surgery, pelvic of history past including analysis multivariate A withFactors associated enterocele less frequent. Complete also rectal emptying was descent perineal and resting have to likely more were addition in and, enterocele, without patients to compared rectal overt and rectoceles frequent more had enterocele with 0.0014). p= 10/65, vs (26/64 enterocele II Grade than III Grade with patients in common more was Procidentia assistance. prociden genital down, bearing pain, pelvic with associated not was severity 64(49.6%) and II grade a had (50.4%) 69 enterocoele, a having as confirmed patients 129 the In groups. two the between comparable was function Anorectal 2. Table in depicted are defecography and manometry anorectal the of results The function Anorectal suffered constipationaccording Kesssevere frequently tothe score. more enterocele an with Patients GIQLI, enterocele. without and and with patients CCIS between comparable to according life, of quality and incontinence fecal of Severity to diagnose were 100% respectively. enterocele and 74.6%, (31.8 patients 43 only Accepted Article

and %) associated associated floor pelvic disorders . The positive and negative predictive values of clinical examination clinical of values predictive negative and positive The .

No enterocele containing sigmoid loop was identified. Patients identified. was loop sigmoid containing enterocele No

a rd II neool. Enterocele enterocoele. III grade

tia or digital digital or were n . . in respectively). 27.4%, and (60.7 high were rectocele and enterocele and prolapse rectal overt and enterocele between associations The hysterectomy. for guidance for questions raises point m This hysterectomy. the to anterior dehiscence hysterectomy, and enterocele between association The severe more with patients to symptoms. predispose might and disorders that center anorectal tertiary in a specializes to was recruitment as typical be not may pain. population improves our enterocele Thirdly, an of treatment surgical if know don't we and evaluations up data, some and prospectively collected data of analysis retrospective a was it Firstly, reasons. several for caution with o Nonetheless, procedure. same the following [13,15,16 performed scales validated and classifications recommended includ it that are study this of strengths main The suspect of diagnosis the aid not do data Manometric enterocele. with prolapse patients in rectal event Overt associated rectocele. a of development the to predispose that suggest results Our physiopathologic

Accepted Taken investigations. preoperative extensive our reflect may rectal overt with patients Article ed ed a large cohort of patients. The data were prospectively recorded in a d a in recorded prospectively were data The patients. of cohort large a enterocele. a be peiul dsrbd [4,6,2 described previously been has al

features encountered in patients with enterocele. features encountered patients enterocele. in with a These data are data These past history of pelvic surgery and pelvic pain and/or bearing down down bearing and/or pain pelvic and surgery pelvic of history past especially BMI, especially comparable with the literature [2 literature the with comparable a ay past history of surgery, floor pelvic of history past xli te curne f neoee after enterocele of occurrence the explain

we wa re lacking. Secondly, we had had no follow- no had had we Secondly, lacking. re s a nonsurgical nonsurgical a s 4 – 2 6 ] r eut sol b interpreted be should results ur . h ceto o a anatomic an of creation The . l eaiain were examinations All ]. case mthd td that study -matched 6 wa ]. Our higher rate higher Our ]. a frequent a s atabase using atabase in particular in ly

effect of enterocele repair on symptoms [30 symptoms on repair enterocele of effect the evaluated studies Few enterocele. with patients in pain pelvic explain partially also may damage Neuropathy pain. postoperative prevents surgery early Indeed, hernia. inguinal with . the to attention draw should features These prolapse. rectal and pain pelvic of complaints conclusion In enterocele areneeded to confirm hypothesis. this change the assessing studies Prospective complainedimproved longterm ofpain inthe but10/54 [30 term long the in discomfort pelvic of symptoms recurrent encounters patients four of one but beneficial is repair enterocele that to related be may hernia [2 neuropathy inguinal compressive in pain of mechanism the that demonstrated hernia inguinal with patients in pain of pathophysiology the on studies Recent descent. perineal partial be may pain Pelvic literature. the in discussed extensively been not has enterocele and pain pelvic between association The Whether constipation is anetiologic [2 literature the with consistent is result This enterocele. and disorders evacuation rectal and constipation between association an suggest data These often. more assistance digital use to needed and frequently more emptying rectal incomplete experienced and score, Kess the to according symptoms constipation-IBS severe experienced with Patients for investigated be should enterocoele floordisorder. pelvic posterior concomitant an with patients all that suggests this together, Accepted Article , patients with enterocele more frequently had frequently more enterocele with patients 8 ,2 9 ] . These data are likely to change the management of pain pain of management the change to likely are data These al

factor or a consequence of the enterocele is notfactor ora consequenceis oftheenterocele clear. ly explained by the mechanical stresses induced by by induced stresses mechanical the by explained ly ,3 1 ]. Regarding to the pain, half of the patients were patients the of half pain, the to Regarding ]. in ,3 pcfc ypos fe sria creto of correction surgical after symptoms specific 1]. Short-term follow Short-term 1]. after surgery after surgery a past history of pelvic surgery, surgery, pelvic of history past -up (3 months) has shown has months) (3 -up [3 1]. 7 ] . . Longstreth WG,GF,WD, Thompson F,Spiller RC. LA,Mearin Chey Houghton Functional bowel . disorders. 2006;130:1480 12. Motil incontinence. OffGastrointest Soc.2016;with fecal Neurogastroenterol Motil JEur Morcet J, et al. A,Mallet C,Bouguen A-L, Bodère A,Ropert Brochard G, Prospective studycohort variation ofphenotypic sphincterbased onan anal function in adults 11. Dis OffAssoc J C,Siproudhis L, Eleouet Favreau M, BouguenG,Bretagne J-F. maybowel disorder patient explain dissatisfaction haemorrhoidal after surgery. Colorectal 10. and long- short- prolapserectal rectopexy tothepromontory forfull-thickness patients:in 175consecutive 9. 2016;18:1010Irel. DisOffenterocele: arandomized JAssoc controlled trial. Coloproctology G B Colorectal laparoscopicassisted vs ventral rectopexy for orinternal external rectal and prolapse 8. J Int ofventral results successful rectopexyforsurgical enterocele aboutcorrection, 138patients. 7. techniques.operative J Reprod Med.1992;37:323 withposthysterectomy Evolutionin 163women vault of vaginal prolapseandenterocele. 6. 2008;32:953 ahistorywithout ofhysterectomy defecography studies). (303 GastroenterolClin Biol. 5. vaultvaginal prolapse. Am 1981;140:852 Gynecol. JObstet 4. ColorectalDisprolapse. GB 2017;19:O46 Off Irel. JAssocColoproctology contrast conventionalforrectal and floor defaecography posterior pelvic compartment V,etal.BGF, Sreetharan Comparison dynamic of magneticdefaecography resonance with 3. Coloproctology GB 2014;16:O240-247. Irel. floorpelvic ofaprospectivedisorders: results study.Colorectal Dis Off Assoc J cystocolpoproctography to is superior pelvic functional ofposteriorMRI inthediagnosis 2. Rectum. 1993;36:430 inagroupprospective study of 50patientscomplaining ofdefecatory Dis difficulties. Colon accurate isclinicalexamination in 1. REFERENCES for considered. be should defecography conventional and enterocele, of possibility

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9 8 7 M-G,Henry X,MellierMion Lapalus L,Barth [Enterocele: G,GautierF, etal. G, 6. 5 4 3

Accepted. Wrigh Gynecol HolleyRL.Enterocele: a review. Obstet Surv.1994;49:284 . . ChouQ,Weber AM,Piedmonte Clinicalof presentation MR. enterocele. Obstet . A,Johansson Mellgren C, DolkAnzénB,Bremmer A, S, NilssonBY,etal. . S, ShorvonPJ,McHugh Diamant Somers S,StevensonGW.in NE, Defecography . Article Wright DE,D’Souza N,Hurd R,Born R,Wright L,Gill Why hernia D.do inguinal t R, Born DE,D’Souza N,Hurdt R,Born R,Wright compression L,Gill and D.Pain ‑ 82.

‑ 97. ‑ 603. patients. Int J Colorectal Dis.1992;7:102 ‑ 6. ‑ 4.

‑ 22.

‑ defecation block 600. ‑ 26.

‑

49. ‑ 7.

» exist? AJR» exist? Am J ‑ 7. ‑ 93.

‑

Surgery. Surgery. 54. ‑ ‑ 14. 22. Pelvic pain and/or bearing pain downPelvic and/or Enterocele (clinicexamination) Surgery of posterior colopocele Hysterectomy (amongHysterectomy women) Clinical dyssynergicClinical defecation Female/ malesex (ratio F/M) Female/ Surgery colopocele of anterior Depression/ Antidepressant Obesity Kgs/m (BMI>30 Clinical c 2002; 4: 321 2002; 4: . byabdominal enterocele colporectosacropexy 3 symptoms discomfort. pelvic of abdominal of obliteration thepelvic inlet:on obstructed defaecationand long-term outcome WR. Schouten vanDijl OomVR, MP,vanWijk Gosselink DM, JJ, 30. Table 1 Table 1

Neurological diseaseNeurological Genital procidenGenital 1. Jean F, Tanneau Y, Le Blanc-Louvry I, Leroi F. Y,LeBlanc-Louvry I, JeanF,Tanneau AM, DenisP,Michot Treatment of 1. Digital assistanceDigital Past treatments Cholecystectomy Anal prociden Accepted rectalSyndrome Article Pelvic surgeryPelvic BMI (Kgs/mBMI Bearing down Bearing CCIS score >8 Age (years) Pelvic painPelvic treatment treatment Variable IBS (yes)IBS Diabetes Scores h : aracteristics Details ofPatients

– 2

tia

) 5. tia

#

2 )

N(%) or N(%) 375/30 (92.6/7.4) All (N=405)All 57.5 (15.1) 126 (31.1) 157 (38.8) 214 (52.8) 154 (40.2) 24.2 (4.6) 53 (13.1) 90 (24.0) 50 (12.3) 71 (17.5) 55 (13.6) 44 (10.9) 43 (10.6) 54 (13.3) 57 (14.1) 83 (20.5) 26 (6.4) 29 (7.2) 18 (4.4) 39 (9.6) 11 (2.7) 32 (7.9) Colorectal Dis. 2007;9:845- Dis. Colorectal mean (SD)

– Enterocele (N=135)Enterocele N (%)or N (%)or 125/10 (92.6/7.4)

efficacy pressure. on pelvic 57.6 (15.1) 23.1 (4.0) 55 (40.7) 43 (31.9) 14 (10.4) 83 (61.5) 59 (46.1) 22 (16.3) 37 (27.4) 17 (12.6) 42 (33.6) 51 (37.8) 21 (15.6) 16 26 (19.3) 17 (12.6) 29 (21.5) 10 (7.4) 13 (9.6) 8 (5.9) 2 (1.5) 7(5.2) (11.9) mean

(SD)

50 .

No enterocele (N=270)No enterocele N (%) or N (%) 250/20 (92.6/7.4) Enterocele repair by Enterocele 57.4 (15.1) 102 (37.8) 131 (48.5) 24.7 (4.8) 36 (13.3) 40 (14.8) 95 (37.3) 35 (12.9) 46 (17.0) 48 75 (27.8) 29 (10.7) 45 (16.7) 38 (14.1) 22 (8.1) 24 (8.9) 13 (4.8) 12 (4.4) 11 (4.1) 23 (8.5) 0 (0.0) 9 (3.3) Colorectal Dis (19.2) mean (SD)

P 0.0001 0.003 0.003 0.002 0.001 - 0.56 0.21 0.01 0.09 0.79 0.36 0.01 0.06 0.04 0.61 0.16 0.28 0.52 0.68 0.28 0.02 1.00 0.91 value

Lower partLower resting pressure Upper pressurepart resting Abdominal pressureduring tolerableMaximum volume Mean squeeze duration (s)Mean squeezeduration Resting perinealdescent Perineal descent during Perineal descent during Anal canal length (mm) Anal length canal Rectal emptying ≥80% Threshold perception Overt rectal prolapseOvert rectal Constant perception perception Constant . Table 2 bowel syndrome irritable Constipation GIQLI= Symptom Score; KESS=Knowles-Eccersley-Scott : Abbreviations Rectal emptying (s)

defecation effort Defecography Acceptedeffort Article volume (ml) volume (ml) volume Kess score >9 Rectocele score GIQLI Variable (mmHg) (mmHg) Variable (ml) : Anorectal defecography manometry and (mmHg)

SD= Standard deviation; deviation; SD= Standard

N (%) or N (%) 188.4 (83.3) All (N=405)All 42.1 (26.6) 81.1 (53.2) 18.1 (19.4) 25.8 (11.7) 47.7 (25.2) 32.4 (17.9) 231 (57.2) 279 (69.2) 115 174 (43.0) 176 (47.8) 30.1(30.4) 22.6 (6.3) 91 (30.8) N(%) or N(%) (28.5) mean (SD) All (N=405)All 89.5 (23.8) 286 (70.6)

mean (SD)

BMI= Mass Body Index

Enterocele (N=135)Enterocele N (%) or N (%)

190.8 (86.9) 27.3 (23.9) 44.5 (25.1) 80.6 (54.5) 17.8 (19.9) 25.3 (11.0) 47.7 (18.9) 31.0 (18.7) 111 (82.8) 22.3 62 (45.9) 53 (39.6) 82 (60.7) 60 (48.8) 37 (27.4) mean (SD) Enterocele (N=135)Enterocele (6.8) N (%)or N (%)or 90.0

104 (77.0)

; CCIS= mean (26

Gastrointestinal Quality IBS= Index; Life of

No enterocele (N=270)No enterocele .1) Cleveland Clinic IncontinenceCleveland Clinic Score

(SD)

N(%) or N(%)

31.5 (32.8) 40.9 (26.4) 81.4 (52.7) 18.6 (18.5) 26.8 (12.4) 28.9 (13.0) 33.0 (17.5)

169 (62.8) 168 (62.5) 116 (47.4) 187 (81.7) 22.7 (6.1)

92 (34.1) 54 (20.0) 62 (23) mean (SD) No enterocele (N=270)No enterocele

N (%) or N (%)

89.3 (22.6) 182 (67.4)

mean (SD)

P 0.0001 0.0005 0.0001 0.001 -

0.19 0.79 0.09 0.19 0.07 0.88 0.70 0.23 0.97 0.32 0.59 value ;

P - 0.77 0.04 value

Paradoxical . Accepted Article contraction Variable puborectalis

N (%) or N (%) All (N=405)All 113 (28.0) mean (SD)

Enterocele (N=135)Enterocele N (%) or N (%) 38 (28.4) mean (SD)

No enterocele (N=270)No enterocele N(%) or N(%) 75 (27.8) mean (SD)

P - 0.90 value