Is a pre‑operative enema required for a patient undergoing sacrocolpopexy, and what postoperative bowel regimen should be implemented?

Preoperative Enema for Sacrocolpopexy

Routine preoperative mechanical bowel preparation or enema is NOT required for sacrocolpopexy and offers no clinical benefit while decreasing patient satisfaction. 1

Preoperative Bowel Preparation

The 2020 ERAS Society guidelines for vulvar and vaginal surgery specifically address this question for sacrocolpopexy. While one RCT showed that women undergoing minimally invasive sacrocolpopexy with mechanical bowel preparation (MBP) had improved postoperative defecatory function and better surgeon perceptions, enemas do not adversely affect recovery or electrolytes and may reduce stool burden, though they provide no infection reduction benefit 1.

However, the evidence strongly argues against routine use:

• A 2014 RCT in vaginal prolapse surgery (including apical suspension and posterior colporrhaphy) found that 85% of surgeons rated the operative field as "excellent or good" WITH bowel prep versus 90% WITHOUT prep (not statistically significant, p=0.30) 2
• Patients receiving bowel preparation were significantly LESS satisfied (OR 0.11,95% CI 0.04-0.35; p<0.001) and experienced more abdominal fullness, cramping, fatigue, anal irritation, and hunger 2
• A 2020 systematic review concluded that preoperative bowel preparation of any type should be omitted prior to minimally invasive and vaginal gynecologic surgeries 3

The ERAS guidelines for pelvic surgery reinforce that MBP should not be used routinely in pelvic surgery (strong recommendation, high evidence) 4. This applies to sacrocolpopexy, which does not involve bowel resection or anastomosis.

Postoperative Bowel Regimen

Implement a 7-day preoperative polyethylene glycol (PEG) regimen to reduce postoperative pain, NOT to speed bowel function.

A 2024 RCT provides the most recent evidence:

• Preoperative PEG for 7 days before robotic sacrocolpopexy did NOT reduce time to first bowel movement (2.32 vs 1.96 days, p=0.21) 5
• However, it significantly reduced pain with first postoperative bowel movement (median pain score 4 vs 1, p=0.0007) 5
• Postoperative day 1 pain was significantly lower (median 4 vs 2, p=0.0484) 5
• Average postoperative pain over 7 days was reduced by 1.88 units (95% CI 0.64-3.12, p=0.0038) 5

Recommended Protocol:

Preoperatively:

• Polyethylene glycol daily for 7 days before surgery (for pain reduction, not bowel prep) 5
• Regular diet until clear liquids 2 hours before anesthesia 4
• NO routine enema or mechanical bowel preparation 1, 2

Postoperatively:

• Continue polyethylene glycol postoperatively 5
• Early mobilization and oral intake per standard ERAS protocols

Important Caveats

Constipation is common after sacrocolpopexy: 43% of patients have preoperative constipation, and sacrocolpopexy is associated with increased rectal emptying difficulties, incomplete evacuation, and need for digital assistance or enemas compared to vaginal approaches 6, 7. However, overall constipation symptoms (PAC-SYM scores) do not significantly worsen at 6 weeks or 6 months postoperatively 6.

The exception: If intraoperative colonoscopy might be needed or bowel resection is anticipated, then MBP should be performed 4. This is not standard for sacrocolpopexy.