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Vascular and Interventional Radiology |
1 From the Departments of Radiology (D.M.H., J.R.S., C.S.S., E.S.M.) and Surgery (D.M.H., E.S.M.), Washington University Medical Center, Mallinckrodt Institute of Radiology, 510 S Kingshighway Blvd, St Louis, MO 63110. From the 1997 RSNA scientific assembly. Received July 27, 1998; revision requested August 27; revision received October 22; accepted December 21. Address reprint requests to D.M.H. (e-mail: hovsepian@mirlink.wustl.edu).
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: From July 1993 to August 1997, 22 male and 40 female patients (mean age, 41 years; age range, 4–80 years) underwent transrectal or transvaginal aspiration or drainage. Fifty-seven drainages were performed. In a follow-up survey, patients were asked to score pain experienced during the procedure and afterward on a scale of 1–10 and to rate the effect of the catheter on their activities of daily living.
RESULTS: Twenty-two patients participated in the telephone survey. For those able to recall the insertion procedure, the mean pain score was 3.2 for transrectal and 5.9 for transvaginal drainage. Mean indwelling catheter pain was 1.6 for transrectal and 4.8 for transvaginal drainage. Pain after removal was 1.4 for transrectal and 2.3 for transvaginal drainage. Only one patient with a transrectal catheter reported severe limitation (bowel movement), with no reports of any serious effect on urinating, bathing, sitting, or walking. Transvaginally placed catheters caused marked limitation in all categories and were more painful than transrectal catheters (P < .05).
CONCLUSION: Of the transrectal and transvaginal approaches, transrectal is better tolerated.
Index terms: Abscess, drainage, 757.1263, 791.1263, 855.1263 • Abscess, US, 857.12986 • Interventional procedures, 757.1263, 791.1263, 855.1263 • Pelvic organs, abscess, 85.211 • Pelvic organs, interventional procedures, 757.1263, 791.1263, 855.1263 • Pelvic organs, US, 757.12986, 791.12986, 855.12986
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Introduction |
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Despite the claim that transvaginal drainage is well tolerated (2), our impression has been that patients tolerate both the transvaginal catheter insertion procedure and indwelling transvaginal catheters less well than they do the placement of transrectal catheters. The purpose of this study was to evaluate patients' perceptions of transrectal and transvaginal abscess drainage and the effect of the catheter on their activities of daily living. We conducted a telephone interview of patients treated with transrectal or transvaginal catheter drainage at our institution to determine which route may be most appropriate and which subsets of patients may tolerate these approaches.
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Patients were treated by using the standard ultrasonographically (US) guided techniques that have been described by other authors in detail (2,4). Briefly, only with use of intravenous conscious sedation, access into the pelvic collection was attained by using endoluminal US, with a biopsy guide in most cases (transrectal, n = 42; transvaginal, n = 16). Fluoroscopy (transvaginal, n = 6), transabdominal US guidance (transrectal, n = 2), and digital palpation (transrectal, n = 2) were used for guidance in the remaining cases. The collections were then opacified with water-soluble contrast material, and the procedures were converted to fluoroscopic control for tract dilation and drainage.
No specific bowel preparation was used prior to transrectal drainage, and no patient received an enema prior to the procedure. No effort was made to sterilize the vaginal canal prior to transvaginal drainage. Collections were not lavaged with saline or povidone iodine, nor were antibiotics administered in the cavity. All patients were receiving antibiotics intravenously prior to drainage, and in most cases antibiotics were continued afterward. Drainage catheters were self-retaining (locking-loop type) and were 8–16 F (median size, 10 F for both transrectal abscess drainage and transvaginal abscess drainage), and all were placed to drain only by means of gravity.
At the request of the institutional review board, patients were first contacted by mail and then by telephone by medically trained research assistants who were not present during the original procedures. After explaining the purpose of the study, the assistants asked the patients for permission to conduct the interview. The 53-question telephone survey was used to gather demographic data; quantify patients' perceived pain or discomfort levels during and after the procedure (on a scale of 1–10); and evaluate the effect of the indwelling catheter on activities of daily living, employment, and sexual activity.
Five specific aspects of activities of daily living were investigated: bathing, bowel movements, urinating, sitting, and walking. The effect on activities of daily living was evaluated both for the time that catheters were in place and also after they were removed. Responses were classified as "very limited," "somewhat limited," or "not limited at all." Patients were also asked to assess whether they thought the informed consent process accurately prepared them for the procedure and the effect that the catheter would have on their activities of daily living.
The data were tabulated and analyzed by using statistical software (Statview; Abacus Concepts, Berkeley, Calif). Comparisons of pain scores were made by using the Student t test or Fisher exact test. Contingency tables were analyzed to determine the relative effect on activities of daily living. A P value less than .05 was considered to indicate a statistically significant difference.
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RESULTS |
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Twenty-two (39%) of the 57 patients who had undergone placement of a drainage catheter agreed to participate in the telephone survey: five male patients who underwent transrectal procedures and 17 female patients, seven of whom underwent transrectal procedures and 10 of whom underwent transvaginal procedures. Three patients had undergone two procedures, so 25 questionnaires were completed. The remaining 35 patients were unable to complete the questionnaire process owing to refusal (n = 2), death (n = 3), lost to follow-up (n = 18), failure to return multiple messages (n = 8), inability to recall having undergone the procedure (n = 2), and serving a jail sentence (n = 2).
Transrectal aspiration or transrectal abscess drainage accounted for 46 procedures, with an even distribution of male patients (n = 23) and female patients (n = 23), and an additional 22 procedures were performed by means of the transvaginal route (Fig 2). Only one patient underwent both transrectal and transvaginal procedures, which were unsuccessful aspiration attempts. Therefore, our clinical success rate, defined as those patients adequately treated with one or more radiologic procedures (drainage or aspiration), was 89% (55 of 62 patients). The mean catheter duration was 5.7 days for transrectal abscess drainage and 6.5 days for transvaginal abscess drainage (mode, 3 days; median, 4 days for both transrectal abscess drainage and transvaginal abscess drainage).
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Pain
In our questionnaire, procedural pain was graded on a scale of 1–10, with 10 being the highest. Patients who received a transrectal catheter were sufficiently sedated to be unable recall the procedure during nine (64%) of 14 procedures. Therefore, no pain score was given, and the means reflect only those who recalled the procedure.
Pain-scale measurements were recorded for the insertion of the catheter, the time while the catheter was indwelling, and the period after the catheter was removed. Mean scores (± SD) for transrectal catheters were as follows: insertional pain, 3.2 ± 3.9; indwelling pain, 1.6 ± 1.5; and postremoval pain, 1.4 ± 1.3. There were no differences in the pain scores of men and women undergoing transrectal abscess drainage for these three parameters (P = .67, P = .29, and P = .62, respectively). The patients who underwent transrectal drainage and who recalled the experience rated the pain during insertion as only 3 or less, with only one patient complaining of severe pain with a score of 10. Respondents also reported a similar level of pain while the transrectal catheter was indwelling: 13 of 14 procedures were given a pain score of 4 or less (mean, 1.6 ± 1.5). The one patient who reported a pain score of 10 during catheter insertion complained of a pain score of 6 while it was indwelling. Pain resolved in all patients on catheter removal.
Mean pain scores (± SD) for transvaginal catheters were as follows: insertion, 5.9 ± 3.5; indwelling, 4.8 ± 3.9; and postremoval, 2.3 ± 2.8. In contrast to the relative ease of sedating patients undergoing transrectal abscess drainage to the point that the procedure was not recalled, in four (36%) of 11 cases, patients undergoing transvaginal abscess drainage reported that they did not recall the procedure. In four cases, patients scored the pain of insertion as 5 or greater. Perception of pain with an indwelling catheter was higher for patients with transvaginal catheters; there were five scores for pain of 5 or greater (mean, 4.8 ± 3.9; P =.01). Again, all respondents reported that the pain resolved after the transvaginal catheter was removed.
Analysis of women undergoing transvaginal abscess drainage versus transrectal abscess drainage showed higher transvaginal abscess drainage pain scores for all three parameters, but these trends did not approach statistical significance (P > .99, P = .32, and P > .99), mainly owing to the small sample size. This observed trend also applied to the entire patient population; women receiving transvaginal catheters generally experienced greater pain as compared with both male and female patients receiving transrectal catheters, but this observation, too, did not reach statistical significance (P = .24).
Effect on Activities of Daily Living
The effects of both transrectal and transvaginal catheters on activities of daily living are summarized in Figure 3. The majority of patients reported that the indwelling transrectal or transvaginal catheter either did not limit or only somewhat limited their activities of daily living. Activities of daily living were limited in only one patient who underwent transrectal drainage, which was in the movement of her bowels.
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Employment
Eleven of the 22 respondents were employed full time prior to the drainage procedure, two were part-time workers, and one was a student. One full-time worker returned to work while her transvaginal catheter was in place. Seven full-time workers and both part-time workers returned to work within 60 days of catheter removal (mean, 35 days; median, 28 days). Three patients had not returned to work at the time of follow-up. Concurrent illness was often the major influence on hospital course, discharge date, and the time taken before returning to work.
Sexual Function
Twenty-one of the respondents were over the age of 18. Thirteen were sexually active prior to the procedure and agreed to answer questions in this area. Nine transrectal and six transvaginal drains were placed in this subgroup, as two patients underwent two procedures. Of the nine transrectal catheters, three were in patients who were in the hospital the entire time the catheter was in place and there was no opportunity for sexual activity. Three transrectal catheters were associated with no sexual limitation at all, one was said to be somewhat limiting, and in two patients the catheter was thought to be very limiting. Normal sexual function was reported by all patients after the transrectal catheter was removed, except in one male patient who stated that he remained somewhat limited sexually.
Four of the six patients who had transvaginal catheters reported the catheters were very limiting to their sexual activity (P = .31). The remaining two patients were in the hospital the entire time and had no opportunity for sexual activity. Three patients reported the return of normal sexual function after removal of the catheter, but the fourth believed she remained somewhat limited at the time of follow-up.
Informed Consent
Twenty-one of the 22 respondents reported that the procedure was explained well to them prior to the initiation of treatment. Patients' expectations of the effect of the procedure and indwelling catheter, however, often differed from what they experienced. Six patients believed that they underestimated the amount of pain that would be involved, and eight thought they were more limited in their activities of daily living than they thought they would be. None stated that this reflected a deficiency in the informed consent process.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The most commonly used alternative to these technically challenging fluid collections is to approach them transgluteally, usually under computed tomographic guidance (11–13). However, transgluteal catheters are often accompanied by prolonged pain and discomfort (11), which may not subside until the catheter is removed. There is also a potential for transgluteal catheter insertion to injure large blood vessels, with resultant severe hemorrhage (14), which has not been reported in any transrectal or transvaginal series, to our knowledge.
Nevertheless, there remains some apprehension on the part of patients, referring physicians, and radiologists regarding use of the transrectal and transvaginal approaches. The reasons for this are uncertain but may include unfamiliarity with the techniques involved or a concern over the amount of pain and discomfort that the patient might experience. Transrectal and transvaginal drains are frequently anticipated by patients as awkward or unusual. Patients who are treated and discharged home in their own care may not express concerns over maintenance of hygiene and other factors. Interventional radiologists have assumed responsibility for the care and follow-up of patients, so it is imperative that they understand the issues involved in patients' acceptance of these types of catheters.
The effect of pelvic surgery, for instance, on body image, quality of life, and activities of daily living has been well described (8,9). We sought to obtain similarly objective data regarding the effect of radiologically placed transrectal and transvaginal catheters on patients and their activities of daily living by rating pain on a linear scale and asking questions about activities of daily living that would elicit discrete, quantifiable responses.
We found that despite a trend for greater pain during the insertion of transvaginal as compared with transrectal catheters (5.9 vs 3.2, P = .24), only the pain level while the transvaginal catheters were indwelling proved to be significantly greater (4.8 vs 1.6, P = .01). Pain resolved in every case after the catheter was removed.
Transrectal catheters had minimal effect on the patients' activities of daily living, whereas transvaginal catheters appeared to have a greater effect on walking, bathing, and bowel habits, with a significant (P < .05) effect on urination and sitting. Describing patients' limitations in general terms (eg, somewhat limited, very limited) does not allow identification of specific problem areas, such as pain on urination versus urinary incontinence. However, the purpose of this study was to determine if there was an overall greater negative effect with the transvaginal approach, and the data support this hypothesis. While we would have preferred to include very specific details, the small number of patients presented here often included too few data points for statistical validation of a number of interesting observations.
Ideally, the issue should be studied prospectively, with inclusion of patients undergoing transgluteal, transabdominal, and transperineal pelvic abscess drainage for comparison of all methods. This would necessitate studying a very large number of patients with close follow-up intervals, because many patients are unable to recall the precise details of distant events. Statistical analysis of specific complaints related to each type of approach would require many times the number of patient responses gathered in this study.
Limited as this study might otherwise be, there were no obvious predictive factors for those patients who would or would not tolerate transvaginal or transrectal drainage. There was no apparent correlation between the size of the catheter, the age of the patient, the duration of the catheter placement, the cause of the collection, the time from catheter removal to the date of the interview, or the physician placing the catheter with the amount of pain experienced or the effect on activities of daily living. Patients thought that they were properly informed, and, therefore, tolerance of the procedure or the effect of the indwelling catheter on activities of daily living is influenced by a variety of factors unrelated to the informed consent process.
In summary, given the increased pain and inconvenience associated with transvaginal drainage catheters, we prefer to use the transrectal approach. However, for female patients who are postmenarchal, we still opt for the transvaginal approach in three clinical settings: when the transrectal approach is no longer available (eg, following abdominoperineal resection), when there has been dehiscence of a vaginal cuff (no transvaginal needle or tract dilation is needed), and in patients with active inflammatory bowel disease.
Prior to pelvic abscess drainage, especially by means of the transvaginal route, patients and referring physicians should be made well aware of the potential for discomfort and severe limitations on activities of daily living.
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Acknowledgments |
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Footnotes |
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References |
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