Pelvic Floor

Question 1

Pros and cons of transvaginal vs transanal repair of rectocele?

Answer 1

Transanal = lower recurrence but higher dyspareunia

Transanal = higher recurrence but lower dyspareunia

Question 2

For adult Hirschsprung, which operation is best and why?

Answer 2

Duhamel
.superior for preventing post-op impotence and anastomotic dehiscence

Also has a reservoir so it can minimize soiling

Question 3

Three major groups for pelvic pain and how to tell them apart?

Answer 3

1) levator syndrome
- tender
- chronic and recurrent rectal pain lasting 20 minutes or longer
- all other causes such as IBD, fissure, hemorrhoids ruled out

2) unspecified Anorectal pain
- not tender

3) proctalgia fugax
- localized to proximal rectum, not related to defecation
- lasts seconds to minutes but no more than 30 minutes

Treatment is biofeedback first line.

Question 4

In Hirschsprung,

• acetylcholinesterase is [increased/decreased]
• nerve trunks are [hypertrophic/hypotrophic]
• ganglion cells are [absent/present]

Answer 4

• acetylcholinesterase is [increased]
• nerve trunks are [hypertrophic]
• ganglion cells are [absent]

Question 5

For Hirschsprung, when to do pull through/Duhamel vs myomectomy?

Answer 5

For short segment disease, <5cm then myomectomy okay

Question 6

How much neostigmine to give?

How much atropine?

Answer 6

2mg IV over 2-5 min. Can be repeated 3 times every 3 hrs

Atropine 0.5mg

Question 7

Fecal incontinence. Failed medical mngmt, SNS.

what makes you decide against artificial bowel sphincter and magnetic sphincter?

Answer 7

Artificial bowel sphincter: pt must have extensive sphincter destruction to be indicated

Magnetic sphincter: can’t use in thin perineal body pts.

Question 8

Rectocele sizes. Which ones need surgery?

Answer 8

<2cm : small
2-4cm: moderate
>4cm: large

Pts who digitize to empty should be considered for surgery