Keywords
pelvic organ prolapse - hemorrhoids - surgery - resistive index - venous flow
Introduction
A great number of women is affected by pelvic organ prolapse (POP), a condition characterized
by the descent of the pelvic organs, especially the uterus, into the vaginal canal.
Another common disorder, which affects more women than men is represented by hemorrhoids.[1] It has been observed that large uterine prolapse and hemorrhoids often coexist,
and we assume that there may be a cause-effect relationship that can explain this
association. Also, the surgical treatment of POP leads in most cases to clinical improvement
of the hemorrhoids, which further sustains this argument.
The exact pathophysiology of the hemorrhoidal development is not yet fully understood.
The sliding anal canal theory is widely accepted, and it sustains that the connective
tissue which composes the anal cushions deteriorate, therefore causing their descent
and venous dilatation.[2] In one of the few reviews concerning hemorrhoids, Zhifei Sun et al. described abnormal
venous dilatation in the anal cushions.[3]
Another take on the problem would be to consider venous dilatation of the anal cushions
not only as a structural problem concerning the connective tissue within their wall,
but also as a consequence of impaired blood flow. This would explain the rapid improvement
of the hemorrhoidal disease almost immediately after surgery for POP.
Other authors have described the effect that POP has on the pelvic vessels. In 1993,
Petros and Ulmsten explained that due to high laxity of the cardinal and uterosacral
ligaments, the uterus descends into the vaginal canal causing obstruction of the pelvic
vessels and venous dilatation.[4] Paradisi et al. mentioned, in 2010, that the protrusion of the anterior rectal wall
toward its lumen impairs rectal blood flow.[5] Another conclusion was taken by Abendstein, who stated that high laxity is one of
the main causes for hemorrhoids, which, combined with pelvic venous stasis, can explain
their high incidence in women with POP.[6] The same author published an article on the relationship between loose ligaments
involved in POP and rectal intussusception.[7]
In terms of symptomatology, large uterine prolapse and hemorrhoids have multiple similarities.
Pruritus can be due to irritation of the hemorrhoidal epithelium as well as the vaginal
epithelium. Bleeding is a common symptom of hemorrhoidal disease, but it can also
occur due to the erosion of the prolapsed uterus. Also, rectal fullness or the feeling
of incomplete evacuation can be explained by both pathologies.
Materials and Methods
We conducted a pilot study that consisted of two parts. First, we analyzed the impact
of prolapse surgery on the hemorrhoidal disease, from the patients' perspective. Second,
we tried to objectively assess how the reduction of the prolapse affects the hemorrhoids.
The sample consisted of 113 women, who had POP surgeries between 2011 and 2015 at
the hospital. The inclusion criteria of the patients involved high grade uterine prolapse,
associated with hemorrhoids. More exactly, the POP cases included degrees III and
IV, and, in addition, the condition needed to show a significant improvement of the
hemorrhoids after the POP surgery. However, since there is no standard classification
concerning hemorrhoids, we subjectively established which of the patients achieved
an improvement of over 75%, 50%, or less than 50%. Our subjectivity was based also
on the perceived hemorrhoidal symptomatology of the women before and after surgery.
As such, the patients were asked to fill in a questionnaire that measured their symptomatic
perception on a 5-point Likert scale, ranging from 1 - no symptomatology to 5 - high
symptomatology.
So, the symptomatic improvement after surgery was determined both clinically, after
surgery by the surgeon, as well as by the patient herself, in providing a perceived
efficiency of the surgery.
Despite taking into consideration the subjective method of assessing the improvement
of hemorrhoids after the POP surgery, we also looked for a potential mechanism that
may explain it in more objective terms. We believe that high grade uterine prolapse
impairs the pelvic venous blood flow, which contributes greatly to the hemorrhoidal
disease. The measurable parameter that may offer this possibility is the resistive
index (RI) of the arterial vessels, located within the anal canal, where, in fact,
the hemorrhoidal branches are located.
Taking into consideration the literature about RI, we have conducted ultrasound examinations
to women with POP degrees III and IV, before and after the reduction of prolapse.
Resistive index is a calculated flow parameter derived from the maximum, minimum and
mean Doppler frequency shifts during a cardiac cycle (RI = peak systolic velocity
– end diastolic velocity/peak systolic velocity). Peak systolic velocity is the maximum
speed, achieved during the cardiac systole and end-diastolic velocity is the minimum
speed, achieved during the diastole. As a vessel narrows and resistance to flow increases,
the RI will increase.
We performed an ultrasound examination to a second sample of 51 patients with grades
III and IV POP admitted to our clinic between 2016 and 2019. The ultrasound examination
was performed using a Voluson E8 with a 5-mHz vaginal probe. The probe was transrectally
introduced, and the flow of the arterial vessels was measured between 3 and 9 o'clock,
vessels which we assumed to be hemorrhoidal branches. Pulse Doppler was used to measure
the RI mean values of the right and left arterial vessels. Consequently, the prolapse
was manually reduced, and a new mean of RI values was registered.
Data was collected and analyzed using the IBM SPSS Statistics for Windows, version
20.0 (IBM Corp., Armonk, NY, USA) The data collected included demographic information,
such as the age of the patients, as well as qualitative information about the classification
of the POP. The mean age of the patients and the mean RI values before and after the
POP reduction were determined. The RI values were checked for normal distribution
using the Shapiro-Wilk tests. To assess if there was a difference between the values
registered for the RI with the prolapse and the RI values after the POP reduction,
the paired t-test was used, as well as the size effect to measure the impact of the surgery on
the POP. According to Cohen (1988), effect values around 0.20 are considered low,
effect values around 0.50 are considered moderate, while effect values around 0.80
are high.
A repeated measure analysis of variance (ANOVA) was conducted so as to identify if
there were any differences between the RI values classified after the POP stage as
well as the effect of the interaction between POP and RI.
All tests were considered statistically significant at a p-value < 0.05.
Results
For the first part of our study, we had a total number of 253 patients who underwent
surgery for POP in our hospital between 2011 and 2015, including all grades of POP.
([Fig. 1])
Fig. 1 Total pelvic organ prolapse cases.
From the 114 patients who were diagnosed with grades III and IV POP, 90 of them were
also suffering from hemorrhoidal disease. ([Fig. 2])
Fig. 2 Hemorrhoids cases associated with grade-III and IV pelvic organ prolapse.
After prolapse surgery, the patients were asked to subjectively assess the grade of
improvement it had on their hemorrhoidal disease. The results showed that 40% felt
an improvement of more than 75% regarding their hemorrhoidal disease, 20% felt an
improvement of over 50%, and 20% showed improvement of less than 50%. ([Fig. 3])
Fig. 3 Grade of hemorrhoidal improvement after pelvic organ prolapse surgery.
We then continued with our second part of the study, trying to find a measurable parameter
to explain this improvement. Doppler measurements were performed on the hemorrhoidal
arterial branches within the rectal wall ([Figs. 4] and [5]).
Fig. 4 Resistive index before prolapse reduction.
Fig. 5 Resistive index after prolapse reduction.
The mean age of the patients was 67.43 (±10.67). There were 27 (52.9%) patients with
POP grade III and 24 (47.1%) patients with POP grade IV ([Fig. 6]).
Fig. 6 The distribution of the patients on different pelvic organ prolapse stages.
The RI with POP was 0.89 (±0.06), and the RI with POP reduction was 0.81 (±0.05) ([Fig. 7]).
Fig. 7 The distribution of resistive index with prolapse and with the prolapse reduction.
The Shapiro-Wilk tests of normality (p > 0.05) revealed that the RI with prolapse and the RI with prolapse reduction had
normal distributions ([Table 1] and [Fig. 8]).
Table 1
The Shapiro-Wilk normality tests
|
Shapiro-Wilk
|
|
Statistic
|
df
|
p-value
|
|
RI with prolapse
|
0.964
|
51
|
0.124
|
|
RI with prolapse reduction
|
0.978
|
51
|
0.458
|
Abbreviations: df, degrees of freedom; RI, resistive index.
Fig. 8 The histograms with the normal curve for resistive index of the patients with prolapse
and resistive index for the patients with prolapse reduction.
A paired t-test was conducted to assess whether there is a significant difference between the
before and after RI registered values. According to the results in [Table 2], there was a statistically significant difference between RI with a prolapse and
RI with a prolapse reduction, t (50) = 11,476, p = 0.001 ([Table 2]). This outcome also suggests that the mean RI of the POP reduction is smaller than
the RI of the POP before reduction (95% CI 0.07–0.10). The effect size of the reduction
was higher than 0.80, suggesting a significant improvement in the patients' conditions,
after the POP reduction ([Fig. 9]).
Fig. 9 The distribution of the resistive index with prolapse and resistive index with the
prolapse reduction.
Table 2
The paired t-test results
|
Paired differences
|
t
|
Df
|
Sig. (2-tailed)
|
|
Mean
|
Std. deviation
|
Std. error of the mean
|
95% confidence interval of the difference
|
|
Lower
|
Upper
|
|
Pair
|
RI with prolapse - RI with prolapse reduction
|
0.08686
|
0.05406
|
0.00757
|
0.07166
|
0.10207
|
11,476
|
50
|
0.000
|
Abbreviations: df, degrees of freedom; RI, resistive index.
According to the POP classification, the mean age of the patients with POP grade III
was 64.52 years (±10.72) and for the patients with POP grade IV was 70.71 years (±9.81).
For POP grade III, the mean RI value for the patients with prolapse was 0.86 (±0.05),
and the mean RI value of the patients with prolapse reduction was 0.79 (±0.04), whereas
for POP grade IV, the mean RI values for the patients with prolapse was 0.93 (±0.04)
and the mean RI value of the patients with prolapse reduction was 0.83 (±0.04) ([Fig. 10]).
Fig. 10 The evolution of the resistive index for the patients with prolapse and with prolapse
reduction on types of pelvic organ prolapse.
As the previous results have showed, the repeated measures ANOVA confirmed there is
a statistically significant difference between the RI values with the prolapse and
the RI values with the prolapse reduction. However, the repeated measures ANOVA also
revealed there is a statistically significant difference between the POP stages (F
(1.49) = 26.55, p = 0.001), and the effect size was low (d = 0.35). Regarding the interaction POP x
RI, the repeated measures ANOVA indicated there is a statistically significant difference
in the evolution of POP stages and the RI values with the prolapse and with the prolapse
reduction (F (1.49) = 4.25, p = 0.04). In [Fig. 11], it may be observed that POP grade III has lower registered values for both RI with
prolapse and RI with prolapse reduction, suggesting that the patients with POP grade
III will have lower RI values after the POP reduction in comparison with the patients
with the POP grade IV.
Fig. 11 The evolution of the RI values on pelvic organ prolapse stages.
Conclusions
Vascular resistance within the rectal wall is significantly lowered after reduction
of POP; therefore, pelvic blood circulation is improved. Also, the greater the POP
grade, the greater the resistive index is improved, so the impact the prolapse has
on the pelvic circulation is proportional with the severity of the prolapse.
Clinical improvement of the hemorrhoidal disease after POP surgery can suggest that
POP is an etiological factor in the development of hemorrhoids and treatment of the
prolapse might be sufficient for both pathologies.
Age might also be an important prognostic factor. The higher the age, the more advanced
the POP disease might be.
Discussion
Concerning the patients' subjective perception on the clinical impact of the hemorrhoids,
our questionnaires showed that more than 50% of the patients that underwent surgery
for POP report significant symptom relief for the hemorrhoidal disease after anatomical
restoration of the prolapsed uterus.
One of our most important results is that the mean RI of the hemorrhoidal branches
is lower when the prolapse is manually reduced. The simple reduction of the prolapse
has a visible effect on the rectal arterial velocimetry. The difference has statistical
significance, leading to the assumption that, with the reduction of the prolapse,
there is significant improvement of the venous flow within the rectal wall. Furthermore,
a greater RI improvement is observed after the reduction of a grade IV POP than of
grade III. The arterial system is characterized by high degrees of pressure, as opposed
to the venous system, which is more distensible. Considering that we can influence
the arterial parameters by reducing the prolapse, we can only assume that the impact
on venous flow is at least as important.
The rapid improvement of the hemorrhoids suggests that there is an initial pathogenic
mechanism which is being reversed. We can, therefore, speculate that there is a dynamic
etiological factor involved in the development of the hemorrhoidal disease, which
can be represented by the pressure variation of the vascular system.
Surgical reduction of POP can reduce flow resistance within the pelvic circulatory
system and can alleviate hemorrhoidal disease. In such cases, we can assume that hemorrhoids
should be addressed only after excluding POP or after its correction. We can think
of hemorrhoids not only as a single disease, but also as a consequence of another
affliction. This can explain hemorrhoidal relapse after its correction, considering
that its etiological factor is not removed.
Our study was aimed only at grades III and IV POP. It might be of use to study the
impact of lower grades of POP on hemorrhoidal disease. Also, there are other clinical
situations that can increase flow resistance in the pelvic circulation, such as pelvic
tumors, which should be excluded as well.
