1. Studied population
Between March 2000 and January 2007, 104 retro-anal levator plate myorrhaphies (RLPM) were performed to treat levator plate sagging. To study the effect of RLPM, only 9 cases of isolated procedures were taken into account. The mean follow up was 16.1 months (extremes: 10–39 months). The mean age of patients was 44.3 years (extremes: 29–63) and mean parity 2.11 (extremes: 1–3). Five patients had a history of abdominal hysterectomy and 2 of surgery for prolapse. Five patients had difficult deliveries (2 vacuum extractors and 3 forceps). The approval for this study was granted by the CHC – Clinique Sainte Elisabeth Ethic Committee and each patient signed a written informed consent before surgery.
2. Pre-operative evaluation
In addition to the classical history and clinical examination of the three axes of the perineum (urological, gynecological and colo-proctologic), special attention was given to diagnose pudendal neuropathy and levator plate sagging.
History
-Urinary symptoms
Stress and urge urinary incontinences are evaluated according to a 4 level ordinal scale depending on the amount of the leakage: 0 = no incontinence, 1 = mild incontinence (few drops of urine), 2 = moderate incontinence (moderate amount) and 3 = severe incontinence (large amount). The number of pads used per day is included.
Daily frequency is based on the mean time (in minutes) between 2 micturitions. It is considered abnormal if this time is less than 90 minutes.
Nocturnal frequency is evaluated by the number of micturitions during the night. The patient suffers from nocturia if there is more than 1 micturition per night.
Urgency was evaluated according to a 3 level ordinal scale: 0 = no urgency, 1 = occasional urgency, 2 = constant urgency.
Dysuria is evaluated with the same 3 level ordinal scale.
- Colo-proctologic symptoms
For anal incontinence a four level ordinal scale was used: 0 = no incontinence, 1 = gas incontinence, 2 = liquid incontinence, 3 = solid incontinence.
The patient presents dyschesia if the defecation process is abnormal, including formation of plugs, the need for enemas, glycerin suppositories or digital manipulation to evacuate stool. The importance of dyschesia has been evaluated according to a three level scale: 0 = no dyschesia, 1 = occasional dyschesia and/or mild difficulties to defecate, 2 = continuous or severe.
- Dyspareunia and other perineodynia
The importance of dyspareunia has been evaluated according to a 3 level scale: 0 = no dyspareunia, 1 = mild dyspareunia, 2 = severe dyspareunia.
For perineodynia (perineal pain), the intensity of pain is evaluated using a classical visual analog scale going from 0 to 10. The different characteristics of pain are also studied.
Clinical examination
The entire examination is done in gynecological position (with the thighs flexed to 90 degrees).
- Basic examination
Cystocele, rectocele, enterocele and uterus descent have been graded from 0 to 3 according to the French classification [21, 22] during Valsalva's maneuver and with a speculum moving away the vaginal wall in front of the prolapse (0 = no descent, 1 = in the vagina, 2 = at the level of vulvae skin, 3 = outside the vagina).
In case of dyspareunia or perineodynia, the most prominent painful areas are explored by vaginal and rectal examination.
- Pudendal neuropathy
The three clinical signs of pudendal neuropathy (abnormal pinprick sensibility, pain over the pudendal nerve during rectal examination and positive skin rolling test) were searched in the 9 patients [20, 23].
- Levator plate sagging
To evaluate levator plate sagging, we have used 3 methods: rectal examination, the Perineocaliper® and retro-anal ultrasound.
During rectal examination, the position of the levator plate is evaluated with the index finger at rest and during Valsalva's maneuver. The two first phalanges of this finger are in the rectum in close contact with the levator plate. During straining, a small amount of traction on the finger is used. A three levels ordinal scale is used: 0 = no sagging of the levator plate (90° angle between anal canal and levator plate plane), 1 = moderate sagging of the levator plate (between 0 and 2) and 2 = complete levator plate sagging (180° angle between anal canal and levator plate plane).
The Perineocaliper
® (Duchateau SA, Liège, Belgium) has been developed to evaluate the position of anal margin with respect to the ischial tuberosities at rest and during a Valsalva's maneuver in the gynecological position (with thighs flexed to 90 degrees) (Figure 1).
If the anal margin is located higher than the ischial tuberosities the value is positive. If it is located below, the value is negative. Perineal descent corresponds to the difference between the position at rest and during straining.
Retro-anal ultrasound has been done with an end-fire transvaginal probe (Hitachi®) emitting at 6.5 MHz [24] The patient is lying in gynecological position (with the thighs flexed to 90 degrees). The probe must be perfectly horizontal with its tip located in the midline 1 or 2 cm in front of the coccyx to obtain a sagittal section (Figure 2).
The practitioner has to be very cautious to avoid any lifting or supportive effect of the levator plate with the probe at rest and during straining. The angle between the levator plate ("ano-coccygeal raphe" in the midline) and the vertical plane has been measured at rest and during Valsalva's maneuver. The angle of sagging corresponds to the difference between these 2 values.
- Anti-sagging tests
The aim of the "anti-sagging tests" is to reduce the sagging of the levator plate, which simulates the effect of retro-anal levator plate myorrhaphy (Figure 3).
For dyschesia and dysuria, the patient has to move back as much as possible on the toilet seat during defecation and micturition to support the levator plate (between coccyx and anus).
For dyspareunia, if vaginal examination reproduces the classical pain induced by intercourse (usually at the level of the pubo-rectalis muscle, utero-sacral ligaments, transverse muscle or vaginal scar), the test consists of lifting the posterior perineum (between coccyx and anus) with two or three fingers and to evaluate the effect on pain. The patient can also try this test during intercourse (or use sexual positions where the buttocks are higher than the head).
The anti-sagging test can be tried by the practitioner and taught to the patient while standing for urinary urgency or perineodynia. During urodynamic exploration, it is possible to try the effect of this test on the urgent need to urinate, on bladder capacity or even on urinary stress incontinence.
The "anti-sagging test" is positive if there is a very clear improvement of the symptom studied during this maneuver.
3. Indication for surgery
When diet, drugs and physiotherapy fail, surgery is indicated when the anti-sagging test dramatically improves the resistant symptoms associated with complete levator plate sagging on rectal examination (180° angle between anal canal and levator plate plane) and/or a perineal descent of more than 1 cm (measured with the Perineocaliper®).
4. Surgical procedure
During the 48 hours before surgery, the patient has to eat a residue free diet and must take paromomycine 2 g per day. To complete the intestinal preparation, an enema is done the evening before surgery.
The patient is installed in a gynecological position with hyperflexion of the thighs. The surgical procedure begins with a sagittal incision 4 cm long between anus and coccyx (Figure 4a). The two ischio-rectal fossae are opened with the tip of the scissors laterally to the ano-coccygeal ligament (also called "intermediate loop of the external anal sphincter" [25]). The space between the ano-coccygeal ligament and the levator plate is opened with the finger. The scissors are passed from left to right over the ano-coccygeal ligament to isolate this ligament (Figure 4b). It is cut after having marked its two extremities with a suture (Figure 4c).
The levator plate myorrhaphy began in front of the coccyx. Before putting stitches, it is necessary to "clean" the muscle with the finger by removing the adherent grease as much as possible. This step is necessary to be sure to put the stitches into the muscle. The first stitch is very important. It is located just in front of the coccyx. It must take a good bit (1 cm; with a dexon® 2, needle GS-21) of the levator plate on each side to tighten the muscle but without excessive tension not to tear it. Traction on this stitch to the rear checks the solidity of this first point of myorrhaphy and presents the two edges of the levator plate to be sutured. Usually two to four stitches of dexon® 2 (with some "figure of eight" if possible) are necessary to suppress completely the sagging (Figure 4d). To avoid rectal injury, the stitches can be put with a finger in the rectum to check the position of the needle. The last stitches must remain behind the level of the anal canal to avoid damage to the rectal branches of the pudendal nerves.
At the end of the procedure, rectal examination confirms the absence of sagging of the levator plate (90° angle between anal canal and levator plate plane). The ano-coccygeal ligament is repaired with two to three stitches of dexon® 2 (Figure 4e). A Y-shaped multi-tubular drain is put into the two ischio-rectal fossae and exits through the posterior edge of the initial incision. The subcutaneous tissue is then closed followed by closure of the skin with simple stitches of vicryl rapide® 2.0 (Figure 4f). The drains are usually removed the 5th day after surgery. Antibiotic coverage is continued for 5 days.
After surgery, the patient is told to avoid heavy lifting, constipation (use of soft laxatives), and chronic cough and to move back on the toilet seat to support her posterior perineum during defecation and voiding, for a minimum of two months and ideally for the rest of her life.
5. Evaluation of the procedure
The effects of RLPM have been evaluated more than 9 months after surgery by using the same history, clinical examination and retro-anal ultrasound as before the operation.