On 5-29-2024, Pt with Stage III pelvic organ prolapse and urinary incontinence undergoes Sacrospinous Ligament Hysteropexy, Anterior and Posterior Colporrhaphy with Enterocele
Repair, Partial Vaginectomy, Single Incision Midurethral Sling, and Cystoscopy. In the Op note it is also reported that " the posterior muscularis was plicated in the midline using O Vicryl sutures thus reducing the rectocele." From this surgery forward the patient reported significant "outlet obstruction constipation". The patient thereafter tried pelvic floor therapy without effect. Anorectal manometry revealed:
Anal Sphincter length (3.8-4.5cm) Short
Mean Resting Pressure (6-13mmHg)
Max Resting Pressure (61-83mmHg)
Max Squeeze (164-233mmHg)
Cough Reflex present
Push unchanged
RAIR not present
Volume 1st sensation (35-50cc) low
Urge to defecate (88-97) low
Max Tol Volume (135-160cc) low
Impressions nonrelaxation of the puborectalis
no RAIR present
low resting and squeeze pressures
decreased sensory thresholds and low tolerated volumes
Balloon Expulsion Study : Failed-unable to expell balloon after 3 minutes.
defecography revealed normal anatomic position and appearance of the colon, rectum and anus. Her defecography shows appropriately evacuation of the liquid contrast but this does not require strong straining. Her anorectal angle does not change and there is minimal movement in the pelvis with
straining and evacuation. This is consistent with obstructive defecation from pelvic floor dyssynergia.
The patient eventually underwent an elective ileostomy due to pain and distress.
I do believe that there may be a functional component to her situation as well.
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No questions yet!
Do you believe there might have been medical error?
It's not clear actually if there is medical negligence from the information given because the vignette does not tell us if there was defecatory dysfunction and/or a symptomatic rectocele prior to the surgery. Nor do I know if the doctor disclosed possible rectocele in his/her consent discussion nor if rectocele repair was included on the consent. The information that was provided does reflect the following: The manometry and defecography strongly suggests that: The rectocele was not the primary driver of symptoms and the patient’s obstruction is functional, not structural. If the patient had pelvic floor dyssynergia BEFORE the surgery, then the surgery failed to address it and potentially worsened neuromuscular coordination or compliance. This is a classic scenario of persistent or worsened outlet obstruction after rectocele repair due to unrecognized pelvic floor dyssynergia. Since you did not provide sufficient pre-operative information, only post-operative, a medico-legal decision of negligence cannot be rendered.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The information that was provided does reflect the following: The manometry and defecography strongly suggests that: The rectocele was not the primary driver of symptoms and the patient’s obstruction is functional, not structural. If the patient had pelvic floor dyssynergia BEFORE the surgery, then the surgery failed to address it and potentially worsened neuromuscular coordination or compliance. This is a classic scenario of persistent or worsened outlet obstruction after rectocele repair due to unrecognized pelvic floor dyssynergia. Since you did not provide sufficient pre-operative information, only post-operative, a medico-legal decision of negligence cannot be rendered.
What makes you a good expert for this case?
I am fellowship trained in urogyneocology and perform these procedures. I order anorectal manometry or obtain colorectal consultation when patients demonstrate bowel dysfunction. Bottom line is that more background information is needed to determine if negligence occurred for an "unauthorized rectocele repair".
How often do you encounter cases similar to this one in your practice?
I encounter these types of cases intermittently and will co-manage them with colorectal surgery.
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