Did this rectocele require repair?

February 1, 2011

The patient was referred to the defendant ob/gyn by the codefendant urologist in December 2006 for evaluation of longstanding uterine prolapse with cystocele and rectocele.

THE FACTS

The patient was referred to the defendant ob/gyn by the codefendant urologist in December 2006 for evaluation of longstanding uterine prolapse with cystocele and rectocele. The urologist intended to repair the pelvic floor with mesh and consulted the defendant ob/gyn for evaluation of the extent of prolapse and a recommendation as to whether a hysterectomy was indicated to be performed either vaginally or abdominally. It was the codefendant urologist's position that the patient had "complete procidentia," including a "grade 4 rectocele" that required posterior repair. However, the patient had consulted with a nonparty urogynecologist during the previous month. She had been using a pessary until that point, and according to the urogynecologist's brief note the patient had a "marked cystocele, moderate uterine prolapse, and small rectocele."

Two years before, the patient had consulted with her nonparty private gynecologist, who documented a "moderate cystocele and a second-degree cervical uterine prolapse." She was referred to a nonparty urogynecologist, who evaluated her and documented a fourth-degree cystocele, second-degree vaginal apex prolapse, and third-degree uterine prolapse. He left the line for "rectocele" blank. She also was examined by a nonparty gynecologist, who documented a "large cystocele" without mentioning rectocele.

In mid-November 2006, the patient was seen by the defendant urologist and underwent cystoscopy secondary to urethrovesical angulation/procidentia. The record describes the patient as a 51-year-old with 5 children, who was noted to have urethral angulation, procidentia, and an incompetent bladder neck. Surgery was recommended. The diagnosis was many years of "complete procidentia," with a prolapsed vagina and uterus, and poor tone in the anus and perineum.

Defendant ob/gyn examined the patient preoperatively. His findings were that she had a grade 3 cystocele, grade 2 uterine prolapse, and a grade 1 rectocele.

The plaintiff was admitted on February 23, 2007, to the defendant hospital for a vaginal hysterectomy and an anterior-posterior repair. She signed a consent form for the repair of uterine prolapse, hysterectomy, cystocele, rectocele, and stress incontinence. The defendant ob/gyn performed the hysterectomy portion of the procedure first and his dictated operative report again reflects the presence of a "grade 1 rectocele," although the assisting resident documents it as "grade 2." After the hysterectomy, the mesh was placed by defendant urologist anteriorly to repair the cystocele and posteriorly to repair the rectocele. Adhesions were noted bilaterally and cystoscopy was performed to ensure that the bladder had not been perforated.