Prevalence of rectocele in young nulliparous women

Background: It is generally assumed that fascial defects in the rectovaginal septum are the result of childbirth. However, rectoceles do occur in women who have never delivered vaginally. Aims: To determine the incidence of rectocele in a cohort of asymptomatic, young nulliparous women. Methods: Observational cohort study on 178 nulliparous caucasian women (aged 18-24) recruited for a twin study of pelvic floor dysfunction. All women were interviewed and examined by translabial ultrasound, supine and after voiding. In 52 women, 3D imaging was obtained and 171 datasets were complete and available for analysis. Ultrasound findings were reviewed for rectovaginal septal integrity by an assessor blinded against interview and demographic data for rectovaginal septal integrity. Results: A discontinuity of the anterior rectal wall with extrusion of rectal mucosa or contents (depth of ! 10 mm) was observed in 21/171 (12%). The depth of this herniation ranged from 10 to 25 mm and was filled with stool (n = 10) or rectal mucosa (n = 11). Defects were associated with a higher BMI (P = 0.049), with the complaint of constipation (P = 0.049) and non-significantly with straining at stool (P = 0.09). Descent of the ampulla to beyond the level of the symphysis pubis without fascial defect, that is, significant perineal relaxation, was observed in 23/171 (13%). Conclusions: Twelve percent of 171 young nulligravid caucasian women showed a defect of the rectovaginal septum. Associations were observed with higher body mass index and a history of constipation. It is hypothesised that in some women defects of the rectovaginal septum and perineal hypermobility may be congenital in nature.

National audit of post-operative management in spinal surgery

Background: There is some evidence from a Cochrane review that rehabilitation following spinal surgery may be beneficial. Methods: We conducted a survey of current post-operative practice amongst spinal surgeons in the United Kingdom in 2002 to determine whether such interventions are being included routinely in the post-operative management of spinal patients. The survey included all surgeons who were members of either the British Association of Spinal Surgeons ( BASS) or the Society for Back Pain Research. Data on the characteristics of each surgeon and his or her current pattern of practice and post-operative care were collected via a reply-paid postal questionnaire. Results: Usable responses were provided by 57% of the 89 surgeons included in the survey. Most surgeons (79%) had a routine post-operative management regime, but only 35% had a written set of instructions that they gave to their patients concerning this. Over half (55%) of surgeons do not send their patients for any physiotherapy after discharge, with an average of less than two sessions of treatment organised by those that refer for physiotherapy at all. Restrictions on lifting, sitting and driving showed considerable inconsistency both between surgeons and also within the recommendations given by individual surgeons. Conclusion: Demonstrable inconsistencies within and between spinal surgeons in their approaches to post-operative management can be interpreted as evidence of continuing and significant uncertainty across the sub-speciality as to what does constitute best care in these areas of practice. Conducting further large, rigorous, randomised controlled trials would be the best method for obtaining definitive answers to these questions.