Rectocele: Clinical Guidelines

List of Abbreviations

BFBT — Biofeedback therapy

GIT - gastrointestinal tract

ZAPK — sphincter apparatus of the rectum

PFDS — Pelvic floor descent syndrome

ODS — Obstructive defecation syndrome

IBS — Irritable bowel syndrome

STARR — Stapled transanal rectal resection

PT – physical therapy

Ultrasound — ultrasound examination

Terms and Definitions

Pelvic floor descent syndrome - a set of disorders resulting from the descent or prolapse of pelvic organs. These conditions can occur as isolated nosological entities (rectocele, rectal prolapse, enterocele) or in combination with each other.

Obstructive defecation syndrome is a disorder of rectal evacuation caused by anatomical changes in the posterior pelvic floor, such as rectocele, internal intubation and rectal prolapse, enterocele, and sigmocele, combined with dyscoordination and/or atrophy of the pelvic floor muscles.

Dyssynergic defecation is a defecation disorder resulting from impaired coordination of the pelvic floor muscles.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Rectocele (rectocele: Lat. rectum - straight intestine; Lat. coele - hollow) is a diverticulum-like protrusion of the rectal wall toward the vagina (anterior rectocele) and/or along the posterior circumference of the rectum (posterior rectocele). Anterior rectocele may present as an isolated form or in combination with posterior rectocele and internal rectal intussusception [1, 59].

Synonym: descensus (prolapse) of the posterior vaginal wall.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Rectocele is the most common manifestation in coloproctology of pelvic floor prolapse syndrome, which develops in women over the course of life under the influence of various factors and is characterized by weakness of the ligamentous-muscular apparatus with descent or prolapse of the pelvic organs. Pelvic floor defects most commonly form in the rectovaginal septum area, which is accompanied by rectocele formation.

The risk of the disease increases with complicated pregnancy and childbirth, including surgical interventions, precipitous labor, perineal tears, and macrosomia [2].

The development of pelvic floor prolapse syndrome is facilitated by heavy physical labor and intensive sports, not limited to heavy lifting. The underlying mechanism of these factors involves an increase in intra-abdominal pressure as well as sharp vertical loads leading to pelvic organ displacement in the sagittal plane [3, 4, 60].

Chronic constipation, which provokes frequent and intensive straining, and persistent cough also lead to multiple sharp increases in intra-abdominal pressure and, consequently, overstretching of the musculo-fascial structures of the pelvic floor that ensure normal organ position [5].

Another factor predisposing to pelvic organ prolapse is hysterectomy. The uterine ligamentous apparatus is part of the system ensuring the correct position of the pelvic floor; therefore, after transection of the uterine ligaments during hysterectomy, pelvic floor support decreases, leading over time to pelvic organ prolapse [6, 7].

Obesity also has a negative impact on the condition of the ligamentous-muscular apparatus of the female pelvis [8].

Thus, the impact of these factors on the female body over the years leads to changes in pelvic organ position and impaired function. Therefore, pelvic floor prolapse syndrome is considered an age-related disease.

1.3 Epidemiology of the Disease or Condition

The prevalence of rectocele among women complaining of impaired rectal evacuation ranges, according to various authors, from 7.0% to 56.5% [9-11]. In women aged 18-83 years undergoing annual gynecological examination, the prevalence of pelvic floor prolapse increases by approximately 40% with each successive decade of life [9].

A study of the results of preventive check-ups conducted in Russia showed that 60% of women exhibit conditions such as rectocele, vaginal and uterine wall prolapse, and stress urinary incontinence [12]. There is also data that patients with perineal prolapse syndrome in our country account for 15% to 30% of all patients with gynecological diseases [13].

1.4 Features of Coding the Disease or Condition

ICD-10 Codes

Class - Diseases of the genitourinary system (XIV).

Block - Noninflammatory disorders of female genital tract (N81).

Code:

N81.6 - Rectocele

1.5 Classification of the disease or condition

1. According to the level of the rectovaginal septum defect, the following are distinguished [14]:

• lower rectocele - located in the lower third of the vagina;

• middle rectocele - located in the middle third of the vagina;

• high rectocele - located in the upper third of the vagina.

2. According to the severity of anatomical changes three degrees of rectocele are distinguished [1, 59]:

• Grade 1 - rectocele is detected only on digital rectal examination as a small pouch of the anterior rectal wall that does not reach the level of the vaginal introitus;

• Grade 2 - protrusion of the rectal wall into the vagina reaches the level of the vaginal introitus;

• Grade 3 - protrusion of the anterior rectal wall extends beyond the vagina.

3. According to the severity of radiological changes, the following are distinguished [1, 59]:

• Grade 1 - protrusion size does not exceed 2 cm;

• Grade 2 - 2-4 cm;

• Grade 3 - protrusion greater than 4 cm.

1.6 Clinical presentation of the disease or condition

In most cases, rectocele is asymptomatic. When symptoms appear, the clinical picture corresponds to obstructive defecation syndrome, which manifests as a sensation of incomplete rectal evacuation, difficulty with defecation, and the need for manual assistance by applying pressure to the posterior vaginal wall or perineum to empty the rectum [15].

In some patients, the only symptom of rectocele is the sensation of a "foreign body" in the vagina. In severe forms of rectocele, even after minor physical exertion, prolapse of the posterior vaginal wall beyond the genital hiatus may occur. Constant trauma to the vaginal mucosa leads to maceration with phenomena of itching and discomfort.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The patient's history and clinical examination data are sufficient to establish a preliminary diagnosis of rectocele; however, to identify concomitant signs of pelvic floor prolapse that may supplement the rectocele symptoms and to choose the correct treatment strategy, instrumental diagnostic methods must be used.

Principles of formulation of the diagnosis.

When formulating a diagnosis of rectocele, it is important to reflect the depth of protrusion of the anterior rectal wall. Examples of diagnosis formulations are given below:

• "Grade 1 rectocele";

• "Grade 2 rectocele";

• "Grade 3 rectocele".

2.1 Complaints and Anamnesis

Clinical manifestations of rectocele consist of impaired rectal evacuation with the development of obstructive defecation syndrome (ODS). This condition is characterized by the following signs [15]:

• difficulty in stool evacuation from the rectum, accompanied by prolonged straining;

• sensation of incomplete rectal evacuation;

• use of manual assistance to empty the rectum.

When taking the medical history, attention should be paid to the number of deliveries, the nature of labor (rapid labor, instrumental assistance), occupational hazards (heavy physical labor), and the presence of constipation or chronic pulmonary diseases [16].

In addition to impaired rectal evacuation, dyspareunia may occur, which impairs patients' sexual function. In this regard, it is important to determine the severity of dyspareunia before and after surgery in order to correctly evaluate the outcome of surgical treatment [17].

Women with rectocele may also complain of a sensation of pressure on the vagina and the presence of a rounded mass in this area [18].

Rectocele may be asymptomatic and detected during examination in patients who sought care for other diseases of the anal region or perineum.

2.2 Physical Examination

Comment: the examination is performed in the gynecological position with the patient on their back and legs maximally brought toward the abdomen, or, if impossible, in the lateral position. During external examination of the perineum and anus, attention is paid to changes in the perianal skin, the shape of the anus, its gaping, the presence of scarring and deformation, and the state of the inguinal lymph nodes.

Digital rectal examination determines the depth of protrusion of the anterior rectal wall toward the vagina. Patients are also asked to strain during the examination to determine the depth of protrusion upon increased intra-abdominal pressure. In addition, digital examination determines the folding and mobility of the rectal walls and identifies concomitant rectal diseases.

2.3 Laboratory Diagnostics

There is no specific laboratory diagnostics for rectocele. Laboratory diagnostic tests should be performed in patients during the preparation and planning of surgical intervention to rule out concomitant diseases and conditions, and when differential diagnosis is necessary.

2.4 Instrumental Diagnostics

Comment: during defecography, the position of the rectum relative to the pubococcygeal line is determined at rest and during voluntary contraction, along with its emptying time and residual volume. A caudal displacement of the rectum of more than 1 cm during a voluntary effort indicates a compensated phase of pelvic floor muscle function, while a displacement of less than 1 cm characterizes the decompensation phase. Evacuation disorders are diagnosed when the residual volume after contrast evacuation exceeds 20% of the initial volume, and the rectal emptying time exceeds 19 seconds.

In addition, the grade of rectocele is determined (see the classification by radiological criteria in section "1.5 Classification of the disease or condition (group of diseases or conditions)"), as well as concomitant manifestations of ODS — internal rectal intussusception and sigmocele.

Comment: prolapse of the rectal wall into the vaginal lumen is an ultrasound sign of rectocele. Transrectal ultrasonography makes it possible to detect signs of ODS manifestations concomitant with rectocele: cystocele, sigmocele, and internal rectal intussusception. The advantage of ultrasound in the diagnosis of internal rectal intussusception is the ability to determine the layers of the intestinal wall involved in the intussusceptum and to distinguish the excessive mobility of the mucosa, which creates a "flap" over the entrance to the anal canal during straining, from intussusception of the entire rectal wall. This method provides the opportunity to diagnose levator ani injuries, as well as to measure the thickness of the anal sphincter and identify breaches in its integrity [23].

Comment: comprehensive sphincterometry is used to determine pressure values in the anal canal at rest and during various functional tests. Indirect signs of defecation disorders are detected using the straining test. An increase in pressure in the anal canal or the absence of its decrease by more than 20% of the basal resting pressure may indicate a functional defecation disorder.

The evacuation test — is an examination that confirms the presence of impaired rectal evacuation. To perform this test, a latex balloon filled with 100-120 ml of fluid is inserted into the rectum. Afterward, while sitting on the toilet, the patient is asked to strain. If the balloon is expelled from the rectum, the test is considered positive, which is within the normal range. If the balloon remains in the rectum, the test is negative, indicating impaired rectal evacuation function and determining a conservative management strategy.

Deviations from normal values in comprehensive sphincterometry and the evacuation test may indicate functional defecation disorders.

• In patients with rectocele associated with prolonged constipation or the absence of spontaneous bowel movements, it is recommended to perform a colonic transit study to identify slow-transit constipation [27].

Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).

Comment: this study is performed to detect slow-transit constipation, which can be one of the triggering mechanisms for the development of rectocele. Various techniques for this study exist, including the use of radioisotope markers. However, they all follow the same protocol: after oral administration of a contrast agent, daily radiological monitoring of its progression through the large intestine is carried out, making it possible to assess the motor and evacuation function of its various segments. The study is conducted against the background of the patient's usual diet, and attention is also paid to the presence or absence of bowel movements during the diagnostic procedure. Normally, the colon completely empties of the contrast agent within 48-72 hours. A transit time exceeding 72 hours indicates impaired colonic function. In functionally compromised segments, contrast stasis may exceed 96 hours, which is determined by examining radiographs.

The interpretation of colonic transit data must be performed taking into account defecography findings. This allows for the determination of the functional characteristics of the colon — the predominance of slow-transit constipation or evacuation disorders.

2.5 Other Procedures

No.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. General principles of rectocele treatment

Treatment of rectocele involves [28, 29]:

1. Carrying out conservative measures aimed at improving rectal evacuation function.

2. Performing biofeedback therapy in the presence of concomitant functional defecation disorders.

3. Surgical correction of the rectovaginal septum defect with elimination of the rectocele when conservative measures fail.

Due to the polyetiological nature of the disease, the correction of disorders associated with rectocele requires an integrated approach. Treatment should begin with a course of conservative therapy aimed at strengthening the pelvic floor muscles and normalizing the evacuation and motor function of the colon. If functional defecation disorders are present, biofeedback therapy is performed. In the absence of an effect from conservative measures and persistent signs of obstructed defecation syndrome, the issue of surgical treatment for rectocele is raised.

3.2. Conservative therapy

Conservative measures are aimed at improving rectal evacuation function and eliminating functional defecation disorders.

Comment: the patient diet should include foods rich in plant fiber and a large amount of fluid. It has been proven that a daily intake of 25 grams of dietary fiber increases stool frequency in patients with chronic constipation. Fluid intake up to 1.5-2 liters per day increases stool frequency and reduces the need for laxatives in patients following a high-fiber diet. In our country, wheat bran, kelp, and flaxseed are traditionally used as sources of dietary fiber, both in their natural form and as pharmaceutical preparations. Additionally, bulk-forming laxatives or osmotic laxatives with high water-holding capacity are used to normalize gastrointestinal tract function, allowing the patient to avoid straining during defecation. Drug dosages are selected individually.

Comment: to improve colonic function, plant-based bulk laxatives are used, for example, ispaghula (plantago ovata) seed husks. These medications increase the volume of chyme, which has a beneficial effect on intestinal peristalsis. Polyethylene glycol-based osmotic laxatives form hydrogen bonds with water molecules in the intestinal lumen, increase fluid content in the chyme, stimulate mechanoreceptors, and improve intestinal peristalsis. Prokinetics (serotonin receptor antagonists) are prescribed in combination with laxatives. In addition to the aforementioned drugs, other laxatives such as sodium picosulfate and bisacodyl** may be used to improve colonic function.

Comment: Biofeedback (BF) therapy is based on the feedback principle, which involves providing the patient with audiovisual information about the state and changes of certain physiological processes of their own. It is performed using sensors placed in the anal canal, on the perineal skin, or on the abdominal wall, and projecting the indicators of the pelvic muscle state from them onto a screen placed in front of the patient's eyes. Depending on the received signals, the patient can voluntarily alter muscle contractions and improve pelvic floor muscle function.

3.3 Surgical treatment of rectocele

Indications for surgical treatment of rectocele are determined individually [31].

It is advisable to establish indications for surgical treatment in patients with rectocele in the following clinical situations:

1. The patient is troubled at rest by a sensation of pressure in the perineum and a feeling of a "bag" in the vagina.

2. Defecation is achieved only with manual assistance, and even then, it does not bring a sense of complete evacuation.

3. According to defecography data, the vector of fecal flow is directed toward the rectocele, and the residual contrast volume in the rectum exceeds 20%.

4. All measures undertaken to improve bowel evacuation (dietary modification, laxatives, BF therapy) have failed to yield positive results.

Methods of surgical treatment

All surgical interventions for rectocele aim to strengthen the anterior rectal wall and eliminate the diverticulum-like protrusion. The operations are performed using transvaginal, transperineal, transrectal, and transabdominal approaches [32-34].

Comment: the posterior vaginal wall incision is made longitudinally. The anterior wall of the rectum and the edges of the levator muscles are mobilized. The defect of the rectovaginal fascia is sutured.

Native tissue repair is performed by approximating the edges of the levator muscles (tension-based repair).

Mesh repair is performed by placing a wound-adapted fragment of synthetic or biological mesh over the repaired rectovaginal fascia defect (tension-free repair).

Possible complications:

1. Dyspareunia (more common after tension-based repair).

2. Vaginal erosion (most typical for synthetic mesh repair).

3. Wound inflammatory process (possible with any repair method).

This method achieves elimination of the diverticulum-like vaginal protrusion in 80% of patients and eliminates the need for manual assistance during defecation in 67% of operated patients [39].

Comment: the incision is made transversely at the junction of the vaginal mucosa and perineal skin. Then, the rectovaginal septum is dissected, and the anterior rectal wall and anterior portions of the levator muscles are mobilized. Rectovaginal septum repair is performed in the same manner as with the transvaginal approach. If an anal sphincter defect is present, the sphincter edges are sutured after excision of the scar tissue replacing it.

The results of this method are comparable to those after transvaginal rectocele repair.

Comment: using a single-use fenestrated tube, two mucomuscular half-purse-string sutures are placed on the anterior semicircle of the rectum — the first suture 3 cm above the dentate line, the second 2 cm proximal to the first. The working part of the circular stapler with the head maximally extended is introduced into the rectum. The traction sutures pulling the rectal wall are tied on the shaft of the instrument, after which the head is closed against the main body. Pressing the stapler handle resects the segment of the rectal wall captured by the instrument, forming a double-row staple line. The applied mechanical suture creates a connective tissue-muscular framework of the anterior rectal wall, thereby reinforcing the rectovaginal septum. Resection of the intestinal wall along the posterior semicircle is performed in the same manner.

Potential complications [45, 46]:

1. Bleeding from staple lines.

2. Anal sphincter insufficiency.

3. Perianal pain syndrome.

4. Rectovaginal fistula.

5. Inflammatory process in the pararectal tissue (abscess, phlegmon).

In the early postoperative period following transanal proctoplasty, increased defecation frequency may be observed (34–40%), the incidence of which drops to 10% by 3 or more months postoperatively [47]. Long-term treatment results range from 90% good results in the first months after the intervention to a decrease in treatment efficacy and return of symptoms in 52% of patients 18 months postoperatively [48].

Comment: the surgery is performed using an open or laparoscopic approach. To the right of the rectum at the level of the sacral promontory, the pelvic peritoneum is incised. The incision is extended downward onto the rectouterine pouch. During this, the rectum is mobilized along the right semicircle to the lateral ligament and anteriorly down to the anal sphincter. At this level, the edge of the mesh implant, shaped like a 3x15 cm ribbon, is fixed to the anterior wall of the rectum. The posterior vaginal fornix is also fixed to this implant. The opposite end of the polypropylene mesh is sutured to the sacral promontory. The peritoneum is closed with a continuous suture incorporating the edge of the implant. This reduces the depth of the pouch of Douglas.

This method allows for simultaneous correction of rectocele (as a result of deep rectal mobilization with rectovaginal septum splitting), fixation of the rectum to the sacrum, and pelvic floor reinforcement [49]. This technique achieves elimination of anatomical defects of the rectovaginal septum and pelvic floor, as well as improvement of rectal evacuation function in more than 80% of cases [50, 51].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comment: preventive management of constipation and performing gymnastic exercises aimed at strengthening the pelvic floor muscles can help improve the outcomes of surgical rectocele treatment in the long-term postoperative period.

5. Prevention and Dispensary Observation

5.1 Prevention

5.2 Follow-up observation

Comment: the use of specialized questionnaires makes it possible to determine colonic evacuation disorders and comprehensively assess the symptoms of pelvic organ prolapse. Long-term radiological defecography following surgical interventions for rectocele allows for the detection of recurrence, as well as the identification of internal rectal intussusception and sigmoidocele, which contribute to the development of obstructed defecation syndrome.

6. Organization of Medical Care

Medical care, with the exception of medical care provided as part of clinical trials, in accordance with Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 28, 2024) "On the Fundamentals of Public Health Protection in the Russian Federation", and Government Decree of the Russian Federation No. 1968 dated November 17, 2021 "On Approval of the Rules for the Phased Transition of Medical Organizations to the Provision of Medical Care Based on Clinical Guidelines Developed and Approved in Accordance with Parts 3, 4, 6 - 9 and 11 of Article 37 of the Federal Law 'On the Fundamentals of Public Health Protection in the Russian Federation'", is organized and provided:

1) in accordance with the regulations on the organization of medical care by types of medical care, approved by the authorized federal executive body;

2) in accordance with the procedure for the provision of medical care in the specialty of "coloproctology", which is mandatory for implementation throughout the Russian Federation by all medical organizations;

3) based on these clinical guidelines;

4) taking into account the standards of medical care approved by the authorized federal executive body.

Hospitalization of patients with rectocele is carried out on a scheduled basis for the purpose of performing surgical intervention. Treatment of this category of patients is carried out in a specialized coloproctology inpatient facility. Medical care for patients with rectocele is provided by coloproctologists.

Indication for hospitalization:

• confirmed diagnosis of rectocele.

Indications for patient discharge:

• upon persistent improvement, when the patient can continue treatment on an outpatient basis under the supervision of a coloproctologist without detriment to their health;

• in the absence of indications for further inpatient treatment;

• if there is a need to transfer the patient to another medical institution;

• at the request of the patient or their legal representative;

• in cases of non-compliance by the patient with prescriptions or the internal regulations of the hospital, provided this does not threaten the patient's life or the health of others.

7. Additional Information

Factors negatively affecting the outcome of surgical treatment:

1. Development of infectious complications.

2. Stool disorders (diarrhea or constipation) in the postoperative period.

3. Non-compliance by the patient with physical activity restrictions in the postoperative period.

Criteria for Evaluating the Quality of Medical Care

Quality assessment criteria for primary health care provided to adults with rectocele (ICD-10 codes: N81.6)

Quality of care assessment criteria for specialized medical care in adults with rectocele (ICD-10 codes: N81.6)

References

Appendix A1. Working Group Composition

Most working group members are members of the Association of Coloproctologists of Russia. There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

1. Coloproctologists.

2. Surgeons.

3. Gastroenterologists.

4. Obstetrician-gynecologists.

5. General practitioners.

6. General practitioners (family physicians).

7. Endoscopists.

8. Nursing staff.

9. Medical students, residents, postgraduate students.

Table 1. Level of Evidence (LoE) rating scale for diagnostic methods (diagnostic interventions).

Table 2. Level of Evidence (LoE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions).

Table 3. Grade of Recommendation (GoR) rating scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines.

The guideline revision mechanism provides for their systematic updating at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 24, 2024) "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation".

2. Decree of the Government of the Russian Federation No. 1968 dated November 17, 2021 "On Approval of the Rules for the Phased Transition of Medical Organizations to the Provision of Medical Care Based on Clinical Guidelines Developed and Approved in Accordance with Parts 3, 4, 6–9, and 11 of Article 37 of the Federal Law 'On the Fundamentals of Protecting the Health of Citizens in the Russian Federation'."

3. Order of the Ministry of Health of the Russian Federation No. 206n dated April 2, 2010 (as amended on February 21, 2020) "On Approval of the Procedure for Providing Medical Care to the Population with Diseases of the Colon, Anal Canal, and Perineum of the Coloproctological Profile".

4. Order of the Ministry of Health of the Russian Federation No. 168n dated March 15, 2022 "On Approval of the Procedure for Conducting Dispensary Observation for Adults".

5. Order of the Ministry of Health of the Russian Federation No. 1363n dated December 23, 2020, "On approval of the Procedure for referring insured persons to medical organizations, the functions and powers of the founders of which are exercised by the Government of the Russian Federation or federal executive authorities, for the provision of medical care in accordance with the uniform requirements of the basic compulsory medical insurance program".

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Disease information. Rectocele is a disease characterized by the protrusion of the anterior wall of the rectum toward the vagina. The risk of developing the disease increases with complicated pregnancies and deliveries, heavy physical labor, and intensive sports activities. An important risk factor is also chronic constipation, which provokes frequent and intense straining, leading to multiple sharp increases in intra-abdominal pressure and, consequently, overstretching of the musculo-fascial structures of the pelvic floor that ensure the normal position of the organs. A factor predisposing to pelvic organ prolapse is hysterectomy.

Most often, patients with rectocele are disturbed by a feeling of incomplete rectal evacuation, obstructed defecation, and the need for digital assistance to empty the rectum. Treatment for patients with rectocele begins with conservative therapy, which consists of regulating stool consistency with diet, using laxatives, and performing gymnastic exercises. If conservative therapy is ineffective, the issue of surgical treatment is considered.

Information required in the postoperative period. In the postoperative period, it is important to regulate the frequency and consistency of stool. It is necessary to achieve regular daily soft stools. It is also necessary to avoid increased physical exertion associated with lifting weights and elevated intra-abdominal pressure.

A course of exercise therapy for patients with perineal descent syndrome (a set of exercises aimed at strengthening the pelvic floor muscles):

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Colonic Evacuation Dysfunction Scoring System

To objectify the degree of disorders of the motor and evacuatory function of the colon, the State Research Center of Coloproctology named after A.N. Ryzhikh of the Ministry of Health of Russia developed a scoring system including nine parameters (main symptoms) with several response options having point scores.

Russian title:

Original name (if applicable): Colon Evacuatory Function Disorders Scoring System

Source (official developer website, validation publication): https://new.gnck.ru (2003); Surgical treatment of patients with rectocele via the perineal-anal approach: Candidate of Medical Sciences dissertation: / Mudrov Andrey Anatolyevich. – M., 2003. – 147 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: identification and dynamic assessment of obstructed defecation syndrome manifestations

Content (template):

Key (interpretation): 1 to 4 points – minor defecation disorders;

5 to 15 points – moderately expressed defecation disorders;

16 points or more – severe defecation disorders.

Notes: the maximum score on the scale is 22 points and indicates the most pronounced disorders of the motor and evacuatory function of the colon. This scale makes it possible to objectify the degree of motor and evacuatory dysfunction of the colon, determine the algorithm for conservative therapy, and predict treatment results.

Scoring system for the degree of colon evacuatory function disorders

Appendix G2. PFDI-20 (Pelvic Floor Distress Inventory)

To assess the quality of life of female patients with perineal descent syndrome, the questionnaire PFDI-20 (Pelvic Floor Distress Inventory) is used

Russian name: Pelvic Floor Distress Inventory

Original name (if applicable): PFDI-20 (Pelvic Floor Distress Inventory)

Source (official developer website, validation publication): Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005 Jul;193(1):103-13.

Validation: Peshkov N.O. Surgical treatment of cystocele using the tension-free vaginal mesh technique for synthetic endoprosthesis implantation. Candidate of Medical Sciences dissertation. 2017.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: assessment of symptoms arising from pelvic organ prolapse

Content (template):

Key (interpretation): the PFDI-20 questionnaire contains 20 questions and has a maximum score of 300 points, indicating the worst symptoms of pelvic organ prolapse. When calculating the score, the arithmetic mean is calculated for each group of questions (range from 0 to 4), the value is multiplied by 25, while the range of indicators is 0-100 points. Missing answers are treated as the arithmetic mean for this questionnaire.

To calculate the PFDI-20 questionnaire score, 3 scales must be added together (the range of indicators is 0-300 points).

Notes: PFDI-20 is divided into 3 sections. The first (Pelvic Organ Prolapse Distress Inventory – POPDI-6) consists of 6 questions dedicated to assessing the symptoms of pelvic organ prolapse. The second (Colorectal-Anal Distress Inventory – CARDI-8) consists of 8 questions that assess symptoms associated with defecation disorders. The third section (Urinary Distress Inventory – UDI-6) makes it possible to assess symptoms associated with urination disorders.

Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6)

1. Do you usually experience a feeling of pressure in the lower abdomen?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

2. Do you usually experience heaviness in the pelvic area?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

3. Does something fall out of your vagina that you can feel or see?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

4. Do you need to reduce the vagina or part of the rectum to completely empty your bowels?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

5. Do you usually experience a feeling of incomplete bladder emptying?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

6. Have you ever needed to reduce the vagina to initiate urination or empty your bladder completely?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

Colorectal-Anal Distress Inventory 9 (CRAD-8)

7. Do you feel the need to strain hard to empty your bowels?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

8. Do you have a feeling of incomplete bowel evacuation after defecation?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

9. Do you have episodes of fecal incontinence with well-formed stool?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

10. Do you have episodes of fecal incontinence with loose stool?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

11. Do you have episodes of gas incontinence?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

12. Do you experience pain during defecation?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

13. Do you experience an unbearable, strong urge to defecate?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

14. Has a part of your rectum ever prolapsed through the anus?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

Urinary Distress Inventory 6 (UDI-6)

15. Do you experience frequent urination?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

16. Do you experience urinary incontinence due to a strong urge to urinate?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

17. Do you experience urinary incontinence when coughing, sneezing, or laughing?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

18. Do you lose urine in small amounts (dribbling)?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

19. Do you experience difficulty emptying your bladder?

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always

20. Do you experience pain or discomfort in the lower abdomen or genital area

□No 0; □Yes

If yes, how often does this bother you?

□ 1 □ 2 □ 3 □ 4

Never Rarely Often Always