Commentary

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Coexistence of advanced genital and rectal prolapse can be quite challenging to evaluate and treat. This is especially true in the younger, reproductive-age woman. As compared with the elderly woman presenting with very evident exteriorized vaginal and rectal prolapse who may be readily treated with a perineal proctosigmoidectomy and vaginal obliterative colpocleisis, the reproductive-age woman frequently presents with a complaint of rectal prolapse that is intermittent. This type of patient may now typically show up to the clinic with "Polaroid in hand." The advent of digital photography has facilitated demonstration of the maximum extent of rectal prolapse.

Although this patient did not demonstrate paradoxical contraction of the puborectalis muscle during defecogra-phy, she did demonstrate significant levator hypertonicity on vaginal and rectal examination. This likely contributed to her rectal prolapse because of the need to perform intense Valsalva efforts for bowel evacuation. Providing further evidence of increased pelvic floor tone is the rather elevated urethral closure pressure at 195 cm H2O. This may have provided her protection from developing stress urinary incontinence.

This patient carried a diagnosis of multiple sclerosis. The detrusor overactivity demonstrated on multichannel cystometrogram is likely related to her underlying neurologic problem, because it is otherwise uncommon to find idiopathic detrusor overactivity in a young woman. She only takes anticholinergic medications on a p.r.n. basis.

Planning a combined reconstructive pelvic surgery in a patient such as this requires excellent communication among the involved surgeons (Figure 8-8.1). For example, the abdominal resection rectopexy was performed first, with care being taken to not contaminate the operative field. Appropriate sharing of the sacral promontory to achieve both rectal and vaginal elevation requires a methodical surgical approach. We have found that performing the rectopexy to the mid sacral region before using the upper sacral segments for the vaginal elevation allows for a smooth surgical flow. If there is no operative field con-tamination,we will use bone anchors for suture attachment to the sacral promontory, as we normally do during a non-

combined procedure. If there is contamination, copious irrigation should be performed and monofilament sutures used on the sacral promontory. We use polypropylene mesh for the colpopexy. This mesh tends to not get infected or cause tissue reaction. We have not had graft-related problems when performing combined procedures such as this one.We opted to leave the uterus in place because of patient preference, and also because the uterus provides a strong structure for graft attachment, and the likelihood of graft erosion at the vaginal apex is reduced. The rectopexy is performed without a graft, using bilaterally placed monofilament sutures. We have not had any cases of life-threatening periosteal bleeding.

This patient has done very well over the last 3 years of follow-up,with no evidence of prolapse recurrence. She has performed pelvic floor exercises regularly, as we recommend to any patient who undergoes pelvic reconstructive surgery.

Section IX

Pain and Irritative Syndromes Therapy

Section IX

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