such as hard stools, impaired evacuation, tenesmus, ano-rectal .... hysterectomy is often combined with a posterior repair which can affect ... damage to the related autonomic plexus and thus influ- ence rectal ... Most studies of the external anal sphincter have shown it to be ... To date physiological data are inconsistent and ...
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Bowel dysfunction following hysterectomy Introduction Opinions differ between patients and clinicians as to the definition of constipation. It would be simple but is probably not sufficient to define constipation purely in terms of defaecation frequency. Heaton et al. I found that a third of women defaecated less often than once daily and 1% of women once a week or less. As well as decreased stool frequency, many patients will include subjective observations when describing constipation, such as hard stools, impaired evacuation, tenesmus, ano-rectal discomfort, bloating and lower abdominal pain. The conclusions from Kumar et a1.* are pertinent in this respect: “in practice, constipation presents when the patient feels the situation to be unsatisfactory”.Consequently any analysis of constipation following hysterectomy needs to take account of such a broad spectrum of symptomatology. Constipation may result from a variety of underlying causes including slow transit, pelvic outlet obstruction or other mechanical, pharmacological, metabolic, endocrine, and neurogenic abnormalities’. This article reviews current literature on the topic of constipation. A literature search was carried out using Medline (1966-1999), and the keyword hysterectomy was cross referenced with colon, constipation, defaecation, anus, faecal incontinence, manometry, pressure, rectum and ano-rectal physiology to identify all published English language articles. The bibliographies of retrieved articles were searched manually.
Bowel dysfunction in gynaecological patients Hysterectomy is a common, comparatively safe procedure. Some women presenting with constipation or rectal dysfunction and loss of defaecatory urge relate the onset of their symptoms to previous hysterectomy. The mechanisms for these disturbances and any pelvic floor abnormalities following hysterectomy remain poorly understood. It is entirely plausible that hysterectomy itself has no significant influence on bowel function and that apparently ensuing motility disorders actually predate surgery. Gynaecological and gastroenterological complaints are frequently interrelated. The prevalence of irritable bowel syndrome in the general female popula1120
tion has been reported as between 13 and 22%4.5and women attending gynaecological clinics have a particularly high prevalence of symptoms indicating irritable bowel syndrome (Table 1). Several studies have addressed the question as to whether hysterectomy itself influences symptoms of constipation or irritable bowel syndrome. Gurnani et al.’O in a retrospective study of women who had previously undergone hysterectomy, found significantly more women reported new symptoms of constipation and a loss defaecatory urge following radical hysterectomy. No such increase was reported by women following nonradical surgery. In a cohort of women undergoing total abdominal hysterectomy for benign disease, symptoms of constipation were reported by 19% pre-operatively and by 16% at three months after hysterectomy”. There is no indication from this study whether some women complaining of constipation preoperatively improved after surgery or others without constipation developed new symptoms. A longitudinal study9 of 205 women awaiting hysterectomy reported more than 20% had symptoms of irritable bowel syndrome. In this cohort symptoms improved or resolved completely following hysterectomy in 60%. In the same study, however, 5 % of patients without symptoms developed symptoms of irritable bowel syndrome, of which constipation was the predominant subtype. Others have reported a similar incidence (6%) of new symptoms of constipation in women at six and twelve months following hysterectomy for benign disease”. In a comparative study, self reported constipation was more common in women who had had a previous hysterectomy and straining during defaecation was more frequent, particularly in older womenI3. Similarly, Taylor et al. 14, found that women who had undergone hysterectomy had less frequent bowel movements, harder stools, were more frequent users of laxatives and consulted a doctor about constipation more often than an age matched group of controls who had not undergone hysterectomy. In addition some patients with reduced bowel frequency also developed increased urinary frequency following hysterectomy, but this study has been criticised for its retrospective design, its use of a control group specifically without bowel symptoms, and its failure to consider the type of hysterectomy or the oestrogen status of the w ~ m e n I ~ Furthermore, -~~. vaginal 0 RCOG 1999 British J o u m l of Obstetrics and Gynaecology
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Table 1. Irritable bowel syndrome (IBS) in gynaecological patients. Reference
No. of patients
Hogston 19876 Prior et al. 1989' Longstreth et al. 1990R
50 768 86 172
Prior et al. 1992'
205
Patient group
Findings
60% symptoms of IBS 37.3% symptoms of IBS (27.7% controls) 47.7% symptoms of IBS 39.5% pre op symptoms of IBS (32%controls) 44.4% IBS improved by surgery 20% new symptoms after surgery Hysterectomy patients (pre & 6 months post) 22%pre op symptoms of IBS 60%IBS improved by surgery 10%new symptoms after surgery
Pelvic pain, negative laparoscopy New referrals to gynaecology clinic Pelvic pain Elective hysterectomy (pre & 1 year post)
hysterectomy is often combined with a posterior repair which can affect bowel symptoms and function". A more recent retrospective study'' reported that of women with normal defaecation pre-operatively, following hysterectomy 3 1% experienced a deterioration in symptoms, of which severe straining, incomplete evacuation and digital evacuation were predominant. A similar deterioration in symptoms was not reported in the control group undergoing laparoscopic cholecystectomy. Interestingly, fewer complaints about bowel dysfunction were reported with advancing age and no relationship was found between symptoms and type of hysterectomy, including radical and nonradical surgery. These latter observations would appear to be at variance with earlier reports '0,13. There are several mechanisms by which constipation may occur after hysterectomy, including neurological, anatomical, hormonal, pharmacological and psychological factors.
Neurological Dysfunction of the autonomic innervation of the hind gut has been suggested as a cause of constipation after radical hysterectomy2".". The parasympathetic supply to the sigmoid colon and ano-rectum derive from the 2nd 3rd and 4th sacral nerve roots and the sympathetic supply derives from the 2nd 3rd and 4th lumbar ganglia. Together, they form a plexus intimately related to the lateral aspect of the rectum, cervix, vaginal fornix and posterior aspect of the urinary bladder. Autonomic nerve fibres extend across the superior surface of the levator ani muscle within and below the cardinal ligamentszz and are here susceptible to division during the operation of radical hysterectomy. While it is understandable that radical hysterectomy, involving division of the entire cardinal ligament together with the autonomic nerves, may result in bladder dysfunction, the mechanism by which ano-rectal dysfunction may occur is less obvious. The so called lateral rectal ligaments contain autonomic nerve fibres23,and their division may influence rectal function24.However. these structures are not divided Q RCOG 1999 Br J Obstet Gynaecol 106,1120-1125
during the operation of radical hysterectomy. There is no clear anatomical explanation for an autonomic cause for constipation or ano-rectal dysfunction after simple hysterectomy. It has been suggested that excessive paravaginal dissection or removal of the cervix may result in damage to the related autonomic plexus and thus influence rectal function25.Postmortem studies suggest that there is little risk to the pelvic autonomic nerves during simple hysterectomy unless the cardinal ligaments or an unusually long cuff of vagina are removedzz.Goffeng et a1.26were unable to demonstrate a change in bowel symptoms in 42 women, 32 of whom underwent a subtotal hysterectomy, studied before and up to 18 months after their hysterectomy. It is conceivable that the risk of autonomic damage may be reduced by cervical conservation. Most studies of the external anal sphincter have shown it to be unaffected by hysterectomy. This finding is not surprising, since the muscle is innervated via the ventral rami of the 2nd, 3rd, and 4th sacral nerve roots via the pudendal nerve and not via the potentially vulnerable autonomic nerves (Table 2). A recent study has found reduced anal canal squeeze pressures following hysterectomy with pudendal nerve latencies reportedly unchangedz7.While this finding appears to be at variance with previous reports, it is worth noting that the observed post-operative changes were due to large pressure decreases recorded in a subgroup of women with five or more previous vaginal deliveries. Evidence of increased rectal compliance, rectal sensory threshold and maximum tolerated rectal distention have been demonstrated in women who have had a hysterectomy, compared with controls28.The same study reported reduced motility indices in the distal rectum and sigmoid colon, which suggests autonomic dysfunction in this group of patients. Others have not found such differences when comparing patients with idiopathic slow transit constipation with those who have developed constipation following hysterectomy2'. Prior et a1." studied patients before and six months after hysterectomy for benign disease. They reported significant increases in rectal sensitivity sustained at six months3".
Table 2. Hysterectomy and anorectal physiology. STC = slow transit constipation; PNMTL = pudendal nerve motor terminal latency. Reference
No. of patients
Roe et al. 1988”’
14
Smith et al. 19902’
14
Barnes et al. 1991”
Study type
9 P e of hysterectomy
Comparative 22 controls, 16 STC Comparative (14 controls)
Not specified
15
Longitudinal (pre & 1 week)
Radical
Prior et al. 19923”
26
Longitudinal (pre & 6 weeks)
18 vaginal 8 total abdominal
Goffeng et al. 1997?6
42
I0 total 32 subtotal
Kelly er al. 1998”
30
Comparative, longitudinal (20 controls) (pre 3 & 11-18 months) Longitudinal (pre & 16 weeks)
2 vaginal 12 abdominal
16 abdominal 14 vaginal
These changes were not always associated with the development of new gastroenterological symptoms and are the reverse of those expected after autonomic denervation. Indeed Kelly et al.” found no differences in rectal sensitivity between pre-operative recordings and those taken at 16 weeks following hysterectomy. Patients one week after radical hysterectomy have been found to have reduced rectal sensitivity and require increased rectal distention to elicit an ano-rectal inhibitory reflex3’.A number of other factors may have influenced the results of this particular study including analgesia, pelvic oedema or possible pelvic collections. Indeed, there was no uniformly consistent manometric abnormality after hysterectomy, and there was no strict correlation between patients’ symptoms and their manometric evaluation. Nevertheless, others have reported delayed transit in the left colon with chronic disabling constipation following radical hysterectomy. Good functional results in such patients may be achieved by left hemicolectomy”. To date physiological data are inconsistent and it is difficult to unravel putative abnormalities and their possible underlying causes. Given that autonomic dysfunction may be important as a causative factor of constipation following hysterectomy, it is interesting to consider the effect of hysterectomy on bladder function. The development of urinary symptoms after total abdominal hysterectomy is controversiaP. In a study of urinary symptoms before and after simple hysterectomy, 17% of women either developed new, or had worse symptoms, following their surgery. This must be considered against a background of a very high incidence of urinary symptoms found prehave operatively in this group of ~ o m e n ” ~ . failed to demonstrate the development of urinary symp-
Findings in hysterectomy patients No difference in anal canal pressures, rectosigmoid motility, ano-rectal inhibitory reflex or rectal sensitivity. No differences in anal canal pressures or PNMTL. Reduced rectal sensitivity, increased compliance. Reduced proximal to distal motility gradient. No differences in anal canal pressures. Reduced rectal sensitivity at 1 week. No differences in anal canal pressures, rectal compliance, ano-rectal inhibitory reflex or motility. Rectal sensitivity increased at 6 weeks. No differences in anal canal pressures, rectal sensation or whole gut transit time. Significantly reduced anal canal squeeze more pronounced in multiparous women. No differences in ano-rectal inhibitory reflex, rectal sensation or pudendal nerve latencies.
toms or sustained urodynamic changes after total abdominal hysterectomy for benign disease in women who were previously asymptomatic. Prior et al.”I found urinary symptoms arising de novo in six of 26 women following hysterectomy, though such symptoms were not always associated with the increases in vesical sensitivity found in this group of women at six months”. In summary, subjective and objective studies have failed to show a conclusive role for simple hysterectomy in the genesis of urinary dysfunction. Interestingly, in a longitudinal study Kilkku” described reduced urinary symptoms and incontinence in women undergoing subtotal hysterectomy, compared with those undergoing total hysterectomy, and suggested that conservation of the cervix may be beneficial. The situation is different following radical hysterectomy, where urinary complications are well documented and may vary from stress incontinence to urinary retentiod8. Modification of the technique of radical hysterectomy with preservation of autonomic nerves in the cardinal ligaments has been shown by some’’, but not all4’, to reduce the risk of postoperative urinary symptoms.
Anatomical The development of an enterocele or sigmoidocele following pelvic surgery is disappointing for all concerned, not least the patient. Enteroceles and sigmoidoceles, often described as a posterior vaginal hernia or a hernia of the pouch of Douglas, represent true hernias“. Although the contents of the hernial sac may be different, the aetiological factors responsible for their development are similar. Nichols4*has classified enteroceles according to their aetiology as being 0 RCOG 1999 Br J Obstet Gynaecol 106, 1120-1 125
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impaired rectal evacuation in constipated patients. Thus, congenital, pulsion, traction or iatrogenic. The failure care should be exercised before ascribing symptoms to to identify a deep pouch of Douglas during hysterecthe presence of an enterocele. tomy is commonly cited as a reason for the subsequent development of a posterior e n t e r ~ c e l e ~ ~Many . ~ ' . enteroceles follow abdominal or vaginal h y ~ t e r e c t o m y ~ ' . Hormonal Pulsion enteroceles may coexist with a vaginal vault ~ with constipation due to slow transit tend to prolapse following hysterectomy. Symmonds et ~ 2 1 . ~ Women have reduced levels of plasma oestradiol and urinary reported that of 190 patients with enterocele and vault oestrogen excretion and increased serum prolactin, prolapse, 91 had undergone abdominal, and 99 a vaginal, hysterectomy. It is likely that such herniation which are normal in women with irritable bowel syndromeSs.Others have shown a consistent reduction in occurring with vaginal vault prolapse results from a defect in the principle fascia1 supports of the upper adrenal steroids in constipated women, which may be vagina, the uterosacral-cardinal ligament complex49. pathogenically importanP9. The precise nature of hormonal influences in women with intractable constipaThe flap valve effect created by compression of the normally horizontal vagina against the pelvic floor tion remains uncertain; it is possible that altered may be lost when the long axis of the vagina is pulled hormone concentrations affect bowel function followvertically, thereby exposing the pouch of Douglas to ing hysterectomy, particularly in those women who intra-abdominal pressure"". This may result from hysalso undergo oophorectomy. Constipation may be part terectomy alone, but particularly if combined with anteof the climacteric syndrome per se and if occurring after hysterectomy may simply reflect diminished rior repair or colposuspension5',and may occur without oestrogen activity due to oophorectomy or ovarian failvault prolapse. Hernias of the pouch of Douglas prolapse through the we6', which occurs on average four and a half years posterior vaginal fornix and may dissect down between earlier after hysterectomy than in women with an intact the anterior wall of the rectum and the posterior wall of uterus6'. the vagina. The classical symptoms are said to be rectal and may include pressure in the rectum, tenesmus, a Pharmacological sense of rectal fullness or incomplete rectal emptyings2. Patients may describe normal onset of defecation, but Pre-operative symptoms can be caused by the underlying gynaecological conditions themselves or their treatinability to complete evacuation, often with the need for anal or vaginal digitation. This group of patients can be ment. Hormonal manipulation with progestogens and difficult to assess, as enteroceles and sigmoidoceles oestrogens pre- and post-operatively may be important may coexist with other conditions causing ano-rectal factors in the masking, or the development of, new dysfunction, such as rectocele, rectal prolapse or intussymptoms after hysterectomy. In addition, these women susception43.Both enteroceles and sigmoidoceles can may be receiving iron or nonsteroidal anti-inflammatory account for symptoms of obstructed defaecation. Jorge drugs, both of which can cause bowel dysfunction6'. et aLS3reported that 67% of women with demonstrable sigmoidoceles on cinedefaecography had impaired recPsychological tal emptying. Using defaecating proctography in combination with opacification of the small bowel and vagina, Psychological factors affect the development or presenWiersma et ~21.'~found a higher incidence of enteroceles tation of new symptoms. Patients with imtable bowel in women who had undergone hysterectomy (20%), syndrome commonly have psychological symptoms, compared with those who had not had this operation though the interrelationship between the bowel and the (4%). Others'' have suggested that enteroceles and sigpsyche is uncle&'. In an Australian study of 97 women nificant pelvic floor descent are more commonly seen in attending a gynaecological outpatient clinic, over half of women who have had a hysterectomy. Whether these those assessed were found to be probable 'psychiatric abnormalities are present before surgery or occur as cases' as measured by the General Health Questionresult of hysterectomy is not clear. Nevertheless, prenaireM.Hysterectomy can be associated with depression operative assessment of women with symptoms of anoin some women6', and the findings of Gorard et aLhhare rectal dysfunction could identify a subgroup who would consistent with the clinical impression that depressed benefit from a combined procedures6.On a cautionary patients tend to be constipated. Similarly, constipated note, deep rectogenital pouches appear to be common in patients have been found to have significantly higher constipated patients and just over half of these pouches Hospital Anxiety and Depression scores than controls67. fill with visceras7.Using combined evacuation proctogPsychological assessment is clearly important when raphy and peritoneography, Halligan et aLs7found that assessing constipated patients and careful consideration the presence of an enterocele was not associated with given to potential complicating factorP. 0 RCOG 1999 Br J Obsret Gynaecol 106,1120-1 125
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Summary While it does not seem unreasonable to suppose that autonomic dysfunction may be the main factor contributing to constipation after radical hysterectomy, its genesis following simple hysterectomy is poorly understood and likely to be multifactorial in origin. Currently available evidence suggests that constipation or evacuatory dysfunction affects a small group of women following simple hysterectomy. Interest has centered on surgical damage to autonomic pathways, yet anatomical factors relating to loss of vaginal support may be equally important. A well designed, prospective iongitudinal study trial is needed to clarify whether constipation or evacuatory dysfunction may be caused by hysterectomy. Such a trial should also take account of the type of hysterectomy, pre-existing pathologies, as well as the hormonal and psychological status of the women included in the study.
S. Radley, Senior Lecturer & M. R. B. Keighley, Professor (Surgery) University Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham S. C . Radley, Senior Registrar Department of Obstetrics and Gynaecology, Central Shefield Hospitals Trust, Shefield C. H. Mann, Professor/SpecialistRegistrar Department of Obstetrics and Gynuecology, Birmingham Women’s Hospital, Edgbaston, Birmingham References 1 Heaton KW, Radvan J, Cripps H, Mountford RA, Braddon FEM, Hughes AO. Defecation frequency and timing, and stool form in the general population: aprospective study. Gut 1992; 33: 818-824. 2 Kumar D, Bartolo DC, Devroede G et al. Symposium on constipation. Inr J ColorectalDis 1992; 7: 47-67. 3 Lennard-Jones JE. Clinical management of constipation. Pharmacol 1993; 47: 216223. 4 Jones R, Lydeard S. Imtable bowel syndrome in the general population. BMJ 1992; 304: 87-90. 5 Heaton KW, O’Donnell L, Braddon F, Mountford R, Hughes AO, Cripps PJ. Symptoms of irritable bowel syndrome in a British urban community: consulters and nonconsulters. Gasrroenterol 1992; 102: 1962-1 967. 6 Hogston P. Imtable bowel syndrome as a cause of chronic pain in women attending a gynaecology clinic. BMJ 1987; 294: 934-935. 7 Prior A, Wilson K, Whonvell PJ, Faragher EB. Imtable bowel syndrome in the gynecological clinic. Dig Dis Sci 1989; 34: 1820-1824. 8 Longstreth GF, F’reskill DB, Youkeles L. Imtable bowel syndrome in women having diagnostic laparoscopy or hysterectomy. Dig Dis Sci 1990; 3 5 1285-1290. 9 Prior A, Stanley KM, ARB Smith, Read NW. Relation between hysterectomy and the irritable bowel: a prospective study. Gut 1992; 33: 81&817. 10 Gumarni M, Mazziotti F, Corazziari E et al. Chronic constipation after gynaecological surgery: a retrospective study. Ira1 J Gasrroenterol 1988;20: 183-186. 11 Clarke A, Black N, Rowe P,Mott S, Howle K. Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study. B r J Ohstet Gynuecol1995; 102: 611420. 12 Carlson KJ, Buell A, Miller A, Fowler FJ. The Maine womens health
study: 1 outcomes of hysterectomy. Obsrer Gynecol 1994; 83: 556-565. 13 Heaton KW, Parker D. Cripps H. Bowel function and imtable bowel symptoms after hysterectomy and cholecystectomy: a population based study. Gur 1993; 34:1108-1111. 14 Taylor T, Smith AN, Fulton PM. Effect of hysterectomy on bowel function. BMJ 1989; 299 300-301. 15 Shafi MI, Constantine G, Samra JS, Obrai M. Effect of hysterectomy on bowel function. BMJ 1989; 299: 680. 16 Stanton SL. Effect of hysterectomy on bowel function. BMJ 1989; 299: 680. 17 Versi E. Effect of hysterectomy on bowel function. BMJ 1989; 299: 680. 18 Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obsrer Gynaecoll994; 104: 28. 19 Van Dam JH, Gosselink MJ, Drogendijk AC, Hop WCJ, Schouten WR. Changes in bowel function after hysterectomy. Dis Colon Recrum 1997; 40: 1342-1347. 20 Stanhope CR. Chronic constipation following simple hysterectomy is rare. Gynecol Oncol1991; 42: 114-1 15. 21 Varma JS. Autonomic influences on colorectal motility and pelvic surgery. WorldJSurg 1992; 16:811-819. 22 Mundy AR. An anatomical explanation for bladder dysfunction following rectal and uterine surgery. B r J Urol1982; 54: 501-504. 23 Rutegkd J, Sandztn B, Stenling R, Wiig J, Heald RJ. Lateral rectal ligaments contain important nerves. Br JSurg 1997; 84: 1544-1545. 24 Speakman CT, Madden MV, Nichols RJ, Kamm MA. Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomixd study. Br JSurg 1991; 78: 1431-1433. 25 Thakar R, Manyonda I, Stanton SL, Clarkson P, Robinson G. Bladder, bowel and sexual function after hysterectomy for benign conditions. B r J Ohstet Gynaecoll997; 104: 983-987. 26 Goffeng AR, Andersch B, Antov S, Bemdtsson I, Oresland T,Hulten L. Does simple hysterectomy alter bowel function? Ann Chir et Gyynaecoll997; 8 6 298-303. 27 Kelly JL, O’Riordan DS, Jones E, Alawi E, ORiordan MG, Kirwan WO. The effect of hysterectomy on ano-rectal physiology. Inr J ColorectDis 1998; 13: 116118. 28 Smith AN, Vama JS, Binnie NR. Papachrystomou. Disordered colorectal motility in intractable constipation following hysterectomy. Br J S U 1990;77: ~ 1361-1366. 29 Roe AM, Bartolo DCC, Mortensen NJ. Slow transit constipation comparison between patients with or without previous hysterectomy. Dig DisSci 1988;33 1159-1163. 30 Prior A, Stanley KM,ARB Smith, Read NW. Effect of hysterectomy on anorectal and urethrovesical physiology. Gut 1992; 33: 264-267. 31 Barnes W, Waggoner S, Delgardo G. Maher K, Potkul R, Barter J, Benjamin S. Manometric characterization of rectal dysfunction following radical hysterectomy. Gynecol Oncol 1991; 42: 1 1 6 1 19. 32 Vierhout ME, Schreuder HWB, Veen HE Severe slow transit constipation following radical hysterectomy. Gynecol Oncol1993 51: 401403. 33 Hanley HG. The late urological complications of total hysterectomy. BrJ Urn1 1969;41: 682-684. 34 Jequier AM. Urinary symptoms and total hysterectomy. Br J Urol 1976; 48:437-441. 35 Wake CR. The immediate effect of abdominal hysterectomy on intravesical pressure and detrusor activity. Br J Obsrer Gynnaecol 1980; 87: 901-902. 36 Langer R, Neuman M, Ron-El R, Golan A, Bukovsky I, Caspi E. The effect of total abdominal hysterectomy on bladder function in asymptomatic women. Obsrer Gynecoll989; 74: 205-207. 37 Kilkku P. Supravaginal uterine amputation versus hysterectomy with reference to subjective bladder symptoms and incontinence. Acra Obster Gynecol S c a d 1985; 64: 375-379. 38 Zanolla R, Monzeglio C. Campo B, Ordesi G, Balzarini A, Martino G. Bladder and urethral dysfunction after radical hysterectomy: rehabilitative treatment. JSurg Oncol 1985; 28: 190-194. 39 Fomey JP. The effect of radical hysterectomy on bladder physiology. Am J Obstet Gynecoll980; 138 374-382. 40 Scotti RJ, Bergman A, Bhatia NN, Ostergard DR. Urodynamic changes in urethrovesical function after radical hysterectomy. Obsret Gynecol1986; 6 8 111-119.
0 RCOG 1999 Br J Obstet Gynaecol 106,1120-1125
REVIEW 41 Fenner DE. diagnosis and assessment of sigmoidoceles. Am J Obsrer Gynecoll996; 175: 1438-1442. 42 Nichols DH. Types of enreocele and principles underlying choice of operation for repair. Obsrer Gynecoll972;40 257-263. 43 Read CD. Enterocele. Am J Obster Gynecol 195 I ; 62: 743-757. 44 Weed JC. Curtiss T. Enterocele. Am J Obster Gynecol 1950; 60: 324-332. 45 Phaneuf LE. Posterior vaginal enterocele. Obsrer Gynecol 1953; 1: 257-262. 46 Austin RC. Damstra EF. New fascia plastic repair of enterocele. Surg G.yneco1 Obsrer 1955; 101: 297-304. 47 Kinzel GE. Enterocele. Am J Obsrer Gynecoll961;81: 1166-1173. 48 Symmonds RE, Williams TJ. Lee RA, Webb M. Post hysterectomy enterocele and vaginal vault prolapse. 1981; 140: 852-859. 49 De Lancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am JObsrer GynecoZ1992;166: 1717-1728. 50 Nichols DH, Milley PS, Randall CL. Significance of restoration of normal vaginal depth and axis. Obstet Gynecol1970;36: 25 1-256. 5 1 Stanton SL. Williams JE, Ritchie D. The colposuspension operation for urinary incontinence. Er J Obstet Gynaecoll976;83: 890-895. 52 Holley RL. Enterocele: a review. Obster Gynecol Surv 1994; 49: 284-293. 53 Jorge JMN, Yang YK,Wexner SD. Incidence and clinical significance of sigmoidoceles as determined by a new classification system. Dis Colon Rectum 1994; 37: 1112-1117. 54 Wiersma TG, Werre AJ, Den Hartog G et al. Hysterectomy: the anorectal pitfall. Scand J Gasrroenteroll997: 223 (Suppl): 3-7. 55 Karasick S, Spettell CM. The role of panty and hysterectomy on the development of pelvic floor abnormalities revealed by defecography. Am JRadioll997; 169: 1555-1558. 56 Lee RA. Vaginal hysterectomy with repair of enterocele, cystocele
0 RCOG 1999 Br J Obstet Gynuecol 106,1120-1 125
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and rectocele. Clin Obstet Gynecol 1993; 3 6 967-975. 57 Halligan S, Bartram C, Hall C, Wingate J. Enterocele revealed by simultaneous evacuation proctography and peritoneography: does ‘defecation block’ exist? A J R 1996; 167:461 4 6 6 . 58 Preston DM. Rees LH, Lennard-Jones JE. Gynaecological disorders and hyperprolactinaemia in chronic constipation. Gut 1983; 24: A480. 59 Kamm MA, Lennard-Jones JE, Farthing MJG, McLean A, Perry L, Chard T. Women with intractable constipation have an abnormality of adrenal steroids. Gut 1989; 30:A751. 60 Studd JWW, Baber R. The menopause. In: Shaw RW, Boulter WP, Stanton SL, editors. Gynaecology. London: Churchill Livingstone, 1982; 341-354. 61 Siddle N, Sarrel P. Whitehead MI. The effects of hysterectomy on the age of ovarian failure. Ferril Steril 1987;47: 94-100. 62 British National Formulary. British Medical Association and Royal Pharmaceutical Society of Great Britain. 1997; 34. 63 Whitehead WE, Crowell MD. Psychologic considerations in the imtable bowel syndrome. GastroentemlClin North Am 1991; 20: 249-267. 64 Worsley A, Walters WAW, Wood EC. Screening of psychological disturbance amongst gynaecology patients. Aust NZ J Obster Gynuecol 1977; 17: 21&219. 65 Oates M, Gath D. Psychological aspects of gynaecological surgery. Ballieres Clin Obstet Gynecol1989;3: 729-749. 66 Gorrard DA, Gomborone JE, Libby GW, Farthing MJG Intestinal transit in anxiety and depression. Gur 1996; 3 9 551-555. 67 Fisher SE, Breckon K, Andrews HA, Keighley MRB. Psychiatric screening for patients with faecal incontinence or constipation referred for treatment. Br J S u r g 1989; 76: 352-355. 68 Hasegawa H. Radley S, Fatah C, Keighley MRB. Long term results of colorectal resection for chronic constipation. Colorectol Disease 1999; 1: 141-145.
