Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus

Surgical management of the rectocele - An update

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes

BACKGROUND

The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results.

METHODS

Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6 months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis.

RESULTS

A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications.

CONCLUSIONS

The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.

Khubchandani’s procedure combined with stapled posterior rectal wall resection for rectocele

BACKGROUND

Obstructed defecation syndrome (ODS) is a widespread disease in the world. Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection (STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.

AIM

To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani’s procedure with stapled posterior rectal wall resection.

METHODS

A cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients (group A) underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 51 patients (group B) underwent the STARR procedure. Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.

RESULTS

In group A, 42 patients underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min (group A) vs 39.24 ± 6.53 min (group B). Mean hospital stay was 3.15 ± 0.70 d (group A) vs 3.14 ± 0.54 d (group B). Mean blood loss was 10.91 ± 2.52 mL (group A) vs 10.14 ± 1.86 mL (group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was 17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm (group A) vs 4.18 ± 0.95 cm (group B) preoperatively to 1.19 ± 0.43 cm (group A) vs 1.54 ± 0.82 cm (group B) one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients’ (30/34, 88.2%) final outcomes were judged as effective and 4 (4/34, 11.8%) as moderate in group A, whereas in group B, 30 (30/37, 81.1%) patients’ outcomes were judged as effective, 5 (5/37, 13.5%) as moderate, and 2 (2/37, 5.4%) as poor.

CONCLUSION

Khubchandani’s procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Prognostic and predictive value of interstitial cells of Cajal populations following stapled transanal rectal resection (STARR) in patients with obstructed defecation syndrome

Objective

The present study was designed to evaluate the functional outcome of stapled transanal rectal resection (STARR) and to examine the relationship between the population density of the interstitial cells of Cajal (ICC) and the efficacy of the STARR operation in the management of obstructed defecation syndrome (ODS) patients.

Methods

Full-thickness rectal samples were obtained from 50 ODS patients who underwent STARR. Samples were analysed using ICC immunohistochemistry. Clinical and functional parameters obtained with defecography and anorectal manometry were compared with 20 controls.

Results

ICCs were significantly decreased in patients in the submucosal (SM), intramuscular (IM) and myenteric (MY) regions when compared with the control group (P < 0.05). The mean pre-operative Cleveland Constipation Score (CCS) was 24.2 ± 4.1, whilst the CCS at 1, 2, 3, 4 and 5 years post-operatively decreased significantly (P < 0.05). At 3 post-operative years, 58.3% (28/48) of the patients reported a favorable outcome (CCS ≤ 10). On univariate analysis, the functional results were worse in those with pre-operative digitation (P = 0.017), a decreased ICC-MY cell population (P = 0.067), a higher resting anal canal pressure (P = 0.039) and a higher rectal sensory threshold (P = 0.073). Multivariate analysis showed the decreased ICC-MY cell population was an independent predictor for low unfavorable functional outcome (odds ratio = 0.097, 95% confidence interval: 0.012–0.766).

Conclusions

STARR achieved acceptable results at the cost of a slight deterioration over a more prolonged follow-up. Patients with a decreased ICC number in the rectal specimen showed an unfavorable functional outcome where pre-operative histological assessment of a full-thickness rectal sample might predict for the functional outcome following STARR.

Surgery for constipation: systematic review and practice recommendations: Results IV: Recto-vaginal reinforcement procedures

AIM

To assess the outcomes of recto-vaginal reinforcement procedures in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty-three articles were identified, providing data on outcomes in 3346 patients. Average length of procedures ranged between 20 and 169 min, and length of stay between 1 and 15 days. Complications typically occurred after 7-17% of procedures (range 0-61%). Post-operative bleeding was uncommon (0-4%) as well as haematoma or sepsis (0-2%). Fistulation did not occur in most studies. Two procedure-related deaths were observed for 3209 patients. Although inconsistent, 78% of patients reported a satisfactory or good outcome, with 30-50% experiencing reduced symptoms of straining, incomplete emptying or reduced vaginal digitation. About 17% of patients developed anatomical recurrence. Considering measures of harm and global satisfaction rating scales, there was insufficient evidence to prefer one type of procedure over another. There was no evidence to support better outcomes based on selection of patients with a particular size or grade of rectocoele.

CONCLUSION

Evidence supporting recto-vaginal reinforcement procedures is currently derived from observational studies and comparisons, with only one high quality study. Large trials are needed to inform future clinical decision making.

Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness

OBJECTIVE

This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients.

METHOD

From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction.

RESULTS

Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR.

CONCLUSIONS

The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR.

BRIEF SUMMARY

In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.

Treatment of obstructed defecation

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.

Transanal repair for treatment of rectocele in obstructed defaecation: manual or stapled

AIM

Our aim is to evaluate the results of transanal repair of rectocele, either manual or stapled, considering the anatomic, manometric and symptomatic improvement.

METHODS

Forty-five female patients with obstructed defaecation due to anterior rectocele were operated on in the Colorectal Surgery Unit, Mansoura University Hospital, after history taking, detailed questionnaire analysis, barium enema, anorectal manometric studies, EMG studies, anal endosonography, balloon expulsion test, colonic transit time and defaecographic studies. Transanal manual repair was performed for 23 patients (group 1), and transanal stapled repair (group 2) was performed for 22 patients. Postoperative complications were recorded, and the patients were followed up for 1 year. Functional results were evaluated at 3, 6 and 12 months after surgery by questionnaire, anorectal manometry and evacuation proctography.

RESULTS

Time of operation and hospital stay were significantly shorter in group 2. Postoperatively, there was no mortality or major morbidity. Two patients in group 1 experienced temporary anal incontinence (A3 and B1 stages). There were no reported adverse effects on sexual life, but significant clinical improvement was observed in both groups after surgery. Manometrically, there was a significant improvement in MARP, FLAC, RS, UTDV and MTV in both groups (significantly better in the early postoperative period in the stapled group). Also, follow-up defaecographic findings showed a significant decrease in the rectocele size in all the patients.

CONCLUSION

Transanal repair of rectocele is a safe and effective technique in improving symptomatic rectocele. Stapled repair offers the advantage of short operative time, no comorbidity, and shorter hospital stay.

Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation

OBJECTIVE

The present study was designed to evaluate functional outcome of perineal repair with and without levatorplasty versus transanal repair of rectocele in obstructed defecation.

METHODS AND PATIENTS

A total of 48 multiparous women with obstructed defecation caused by a rectocele were randomly allocated to three groups: transperineal repair with levatorplasty (TPR-LP; n = 16); transperineal repair without levatorplasty (TPR; n = 16); and transanal repair (TAR; n = 16). The study included defecographic assessment, anal manometry, symptom improvement, sexual function, and score on a function questionnaire. Assessments were done preoperatively and 6 months postoperatively.

RESULTS

Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in both groups with transperineal repair but not in the group with transanal repair. Significant reductions in mean anal resting pressure, maximum reflex volume, and urge-to-defecate volume were observed only with the transperineal approach (with and without levatorplasty). Functional score improved significantly in the transperineal groups (with levatorplasty, P < 0.001; without levatorplasty, P < 0.01), but not in the transanal group (P = 0.142). Levatorplasty added to transperineal repair significantly improved the overall functional score compared with transperineal repair alone (P < 0.01) and transanal repair TAR (P < 0.001).

CONCLUSIONS

Rectocele repair appears to improve anorectal function by improving rectal urge sensitivity. Transperineal repair of rectocele is superior to transanal repair in both structural and functional outcome. Levatorplasty improves functional outcome, but potential effects on dyspareunia should be discussed with the patient.

Types of pelvic floor dysfunctions in nulliparous, vaginal delivery, and cesarean section female patients with obstructed defecation syndrome identified by echodefecography

PURPOSE

This study aims to show pelvic floor dysfunctions in women with obstructed defecation syndrome (ODS), comparing nulliparous to those with vaginal delivery or cesarean section using the echodefecography (ECD).

MATERIALS AND METHODS

Three hundred seventy female patients with ODS were reviewed retrospectively and were divided in Group I-105 nulliparous, Group II-165 had at least one vaginal delivery, and Group III-comprised of 100 patients delivered only by cesarean section. All patients had been submitted to ECD to identify pelvic floor dysfunctions.

RESULTS

No statistical significance was found between the groups with regard to anorectocele grade. Intussusception was identified in 40% from G I, 55.0% from G II, and 30.0% from G III, with statistical significance between Groups I and II. Intussusception was associated with significant anorectocele in 24.8%, 36.3%, and 18% patients from G I, II, and III, respectively. Anismus was identified in 39.0% from G I, 28.5% from G II, and 60% from G III, with statistical significance between Groups I and III. Anismus was associated with significant anorectocele in 22.8%, 15.7%, and 24% patients from G I, II, and III, respectively. Sigmoidocele/enterocele was identified in 7.6% from G I, 10.9% G II, and was associated with significant rectocele in 3.8% and 7.3% patients from G I and II, respectively.

CONCLUSION

The distribution of pelvic floor dysfunctions showed no specific pattern across the groups, suggesting the absence of a correlation between these dysfunctions and vaginal delivery.

The impact of stapled transanal rectal resection on anorectal function in patients with obstructed defecation syndrome

PURPOSE

A careful preoperative selection of patients was performed in order to identify those eligible for stapled transanal rectal resection to correct obstructed defecation syndrome. The aim was to assess the consequences of surgery on anorectal function and patient outcomes.

METHODS

From January 2004 to June 2007, 33 female patients (median age, 56.3 years; range, 27-77 years) eligible for stapled transanal rectal resection completed standardized questionnaires for the assessment of constipation (constipation scoring system), quality of life (Patient Assessment of Constipation-Quality of Life Questionnaire), and patient satisfaction (visual analogue scale). A complete clinical reassessment including anorectal manometry and defecography was performed after one year.

RESULTS

At a median follow-up of 18 months, significant improvement in constipation scoring system, quality of life, and visual analog scale (P < 0.0001) was observed. Postoperative defecography confirmed the correction of internal rectal prolapse (P < 0.01) and rectocele (P < 0.0001) with an increase in rectal sensitivity (P < 0.0001). Significant correlations were observed between rectocele correction and rectal sensitivity, as evidenced by a decrease in rectal sensory threshold volumes (P = 0.017; Phi = 0.7), increased rectal sensitivity, and patient's satisfaction index (P = 0.011; Phi = 0.64).

CONCLUSIONS

Stapled transanal rectal resection allowed for the correction of rectocele and intussusceptions. These corrections increased rectal sensitivity, diminished symptoms of obstructed defecation syndrome, and improved the quality of life of patients.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.

Functional disorders: rectocele

The baseline prevalence of rectocele is not well defined as many women are asymptomatic and do not seek medical help. Gynecologists tend to perform posterior wall repairs more commonly than colorectal surgeons because they also address patients with vaginal symptoms in addition to those with defecatory dysfunction. Overall, surgical correction success rates for rectocele correction are quite high when using a vaginal approach. Vaginal dissection, as opposed to transrectal or transperineal approaches, results in better visualization and access to the endopelvic fascia and levator musculature, allowing for more firm anatomic correction. In addition, the maintenance of rectal mucosal integrity may reduce the risk of postoperative complications such as infection and fistula formation. With the rapidly growing popularity of synthetic and biologic implant kits in the field of pelvic reconstruction, outcomes data reporting is increasing and allowing surgeons to better understand the effect of various surgical techniques on vaginal, sexual, and defecatory symptoms.

Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation

PURPOSE

Obstructed defecation may be treated by stapled transanal rectal resection, but different complications and recurrence rates have been reported. The present study was designed to evaluate stapled transanal rectal resection results, outcome predictive factors, and nature of complications.

METHODS

Clinical and functional data of 123 patients were retrospectively analyzed. All patients had symptoms of obstructed defecation before surgery and had rectocele and/or intussusception. Of them, 85 were operated on by the authors and 38 were referred after stapled transanal rectal resection had been performed elsewhere.

RESULTS

At a median follow-up of 17 (range, 3-44) months, 65 percent of the patients operated on by the authors had subjective improvement. Recurrent rectocele was present in 29 percent and recurrent intussusception was present in 28 percent of patients. At univariate analysis, results were worse in those with preoperative digitation (P<0.01), puborectalis dyssynergia (P<0.05), enterocele (P<0.05), larger size rectocele (P<0.05), lower bowel frequency (P<0.05), and sense of incomplete evacuation (P<0.05). Bleeding was the most common perioperative complication occurring in 12 percent of cases. Reoperations were needed in 16 patients (19 percent): 9 for recurrent disease. In the 38 patients referred after stapled transanal rectal resection, the most common problems were perineal pain (53 percent), constipation with recurrent rectocele and/or intussusception (50 percent), and incontinence (28 percent). Of these patients, 14 (37 percent) underwent reoperations: 7 for recurrence. Three patients presented with a rectovaginal fistula. One other patient died for necrotizing pelvic fasciitis.

CONCLUSIONS

Stapled transanal rectal resection achieved acceptable results at the cost of a high reoperation rate. Patients with puborectalis dyssynergia and lower bowel frequency may do worse because surgery does not address the causes of their constipation. Patients with large rectoceles, enteroceles, digitation, and a sense of incomplete evacuation may have more advanced pelvic floor disease for which stapled transanal rectal resection, which simply removes redundant tissue, may not be adequate. This, together with the complications observed in patients referred after stapled transanal rectal resection, suggests that this procedure should be performed by colorectal surgeons and in carefully selected patients.

Bowel, bladder and sexual function in women undergoing laparoscopic posterior compartment repair in the presence of apical or anterior compartment dysfunction

OBJECTIVE

The aim of the study was to analyse the functional outcome of women undergoing a laparoscopic posterior compartment repair in the presence of anterior or apical compartment dysfunction.

DESIGN

Prospective cohort study.

METHODS

Forty women, median age 65 years (41-78), with symptoms of genital prolapse 31 (78%), urinary dysfunction 32 (80%) and bowel dysfunction 40 (100%), underwent laparoscopic posterior compartment repair in conjunction with an anterior compartment repair. Pre-operative and postoperative bowel and bladder function was prospectively assessed with a Wexner continence score, Vienna constipation score and a urinary dysfunction score. Twenty-eight (70%) and 24 patients (60%) had pre-operative urodynamics and anorectal manometry. Post-operatively all women were also assessed with a Watt's sexual dysfunction score and a linear analogue patient satisfaction score. Twelve women (30%) had postoperative anal manometry.

RESULTS

At 20 months median follow-up, 30 (97%), 20 (62%) and 12 (31%) women reported improvement in their prolapse, urinary and bowel symptoms, respectively. Post-operatively, one woman reported denovo faecal incontinence, four worsening obstructive defecation and three denovo urinary dysfunction. Nine women (35%) reported denovo dyspareunia. The mean time to clinical deterioration following surgery was 11 months. Bowel function improvement was the only factor to significantly correlate with postoperative patient satisfaction.

CONCLUSION

The functional outcome of laparoscopic posterior compartment repair in the presence of anterior compartment dysfunction is disappointing. Preoperative counselling is important to ensure that patients have reasonable and realistic expectations from repair surgery, and an understanding that anatomical improvement might not be followed by long-term functional improvement.

Clinical and physiologic outcomes after transvaginal rectocele repair

PURPOSE

This study was designed to evaluate the clinical and physiologic outcomes after transvaginal rectocele repair.

METHODS

Between June 2000 and January 2003, 30 females (mean age, 62 (range, 45-78) years) with a symptomatic large rectocele (>3 cm) underwent transvaginal rectocele repair (anterior levatorplasty). Six months after surgery, a physiologic evaluation was performed by using defecography (depth of rectocele) and anorectal manometry (maximum resting pressure, maximum squeeze pressure, rectal threshold, and maximum tolerable volume). Using a questionnaire, a clinical evaluation was performed one year after surgery to analyze symptoms, including difficult evacuation, digital support, sexual discomfort, as well as patient satisfaction. Follow-up of all patients was conducted during a median duration of 38 (range, 23-54) months.

RESULTS

There were no operative complications, such as hematoma, wound infection, or rectovaginal fistula. Difficult evacuation improved in 27 of 30 patients (90 percent) and completely disappeared in 9 patients. Postoperatively, digital support was no longer necessary during evacuation in 15 of 21 patients (71 percent). Overall patient satisfaction reached 25 of 30 (83 percent). Although mild sexual discomfort was observed in nine patients, it disappeared gradually and only one patient complained of persistent symptoms. No patient reported symptomatic recurrences at the end of the follow-up. The radiologic mean depth of the rectocele was significantly reduced: preoperative, 3.9 cm; postoperative, 0.5 cm. None of the physiologic parameters significantly changed after surgery.

CONCLUSIONS

Transvaginal rectocele repair can provide excellent long-term symptomatic relief and a high rate of patient satisfaction without any alteration in anorectal physiologic function.

Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation

BACKGROUND

Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty.

PATIENTS AND METHODS

Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression.

RESULTS

Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05).

CONCLUSIONS

Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.

[Surgical treatment of rectocele and enterocele: an integrated view of disorders of the posterior vaginal compartment]

Genital prolapse, whether associated or not with urinary, anal or sexual dysfunction, should be evaluated globally to select the appropriate treatment. Rectocele and enterocele are defects of the posterior vaginal compartment, although they can be secondary to abnormalities of the central compartment, since lesions of the perineal raphe and rectovaginal septum can occur in isolation or accompanied by others that also affect the tissues involved in pelvic support. The various surgical approaches to rectocele alone or associated with other defects are reviewed. Likewise, the distinct pathogenic types of enterocele are discussed. Laparoscopic sacrocolpoperineopexy is a promising intervention for the simultaneous correction of defects of the posterior and central compartments. New and better designed studies are required to evaluate the distinct surgical approaches and interventions for genital prolapse.

A Three-Year Prospective Assessment of Rectocele Repair Using Porcine Xenograft

OBJECTIVE

To prospectively evaluate clinical outcome of rectocele repair using xenograft 3 years after surgery.

METHODS

Twenty-three patients who completed evaluation preoperatively and 1 year after surgery were assessed at a 3-year follow-up. Clinical examination was performed preoperatively, and at the 1- and 3-year follow-ups, with the pelvic organ prolapse quantification system. Symptom assessment was performed with a validated bowel function questionnaire including questions on sexual function.

RESULTS

There were no graft-related complications during the 3 years following surgery. Preoperatively, all patients had stage II prolapse of the posterior vaginal wall and a rectocele verified at defecography. At the 1-year follow-up, 11 of 29 patients (38%) had rectocele of stage II or more, and 4 patients were reoperated. At 3-year follow-up 7 of 23 patients (30%) had rectocele of stage II or more. When including the 4 early anatomical recurrences, a total of 11 of 27 patients (41%) had rectocele of stage II or more at 3-year follow-up. Preoperatively, all patients reported varying degrees of rectal emptying difficulties and symptoms of bowel dysfunction. There was a significant decrease in rectal emptying difficulties (P < .01), sense of incomplete evacuation (P < .01), need for manually assisted defecation (P < .05), and symptoms of pelvic heaviness (P < .001) at the 3-year follow-up compared with preoperatively. Cure of rectal emptying difficulties was reported by fewer than 50% of patients. There were no significant changes in anal incontinence scores or symptoms of sexual dysfunction at the 3-year follow-up compared with preoperatively.

CONCLUSION

Rectocele repair using porcine dermal graft was associated with an unsatisfactory anatomical cure rate and persistent bowel-emptying difficulties in the majority of patients 3 years postoperatively.

LEVEL OF EVIDENCE

II-3.

Treatment of obstructed defecation

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve optimal outcomes. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. It must be remembered that the pelvis contains many structures and that defects of pelvic support or function frequently affect other pelvic organs. Optimal outcomes can be achieved only by selecting appropriate treatment modalities that address all of the components of an individual patient's problem.

Laparoscopic or transanal repair of rectocele? A retrospective matched cohort study

PURPOSE

The aim of the study was to analyze the functional and physiologic outcome of patients undergoing laparoscopic rectocele repair compared to a matched cohort undergoing transanal repair.

METHODS

Forty patients with a rectocele who had undergone laparoscopic pelvic floor repair by a laparoscopic gynecologist were matched for age and rectocele size with 40 patients who had undergone a transanal repair by a colorectal surgeon. All patients had clinical evidence of a symptomatic rectocele. All patients were assessed postoperatively with a quality of life (SF-36) score, a modified St. Mark's continence score, a urinary dysfunction score, a Watt's sexual dysfunction score, and a linear analog patient satisfaction score. Fifteen patients in each group had also undergone preoperative and postoperative anal manometry.

RESULTS

At 44 months median follow-up, the transanal approach resulted in significantly more patients reporting bowel symptom alleviation (P < 0.002) and higher patient satisfaction (P < 0.003). The bowel symptom improvement was also sustained over a significantly longer period (P < 0.03). Only 11 patients (28 percent) in the laparoscopic group reported more than 50 percent improvement in their bowel symptoms compared to 25 patients (63 percent) in the transanal group. On univariate analysis of 50 percent bowel symptom improvement, a larger rectocele (P < 0.009), transanal repair (P < 0.02), and presenting with obstructive defecation rather than fecal incontinence (P < 0.03) were statistically significant. Rectocele size (P < 0.012) and treatment cohort (P < 0.006) remained significant on multivariate analysis. Postoperatively, bowel symptom alleviation correlated with patient satisfaction in both groups (P < 0.015). Although not statistically significant, five patients (13 percent) in the transanal group developed postoperative fecal incontinence, which was associated with a low maximum anal resting pressure preoperatively that was further diminished postoperatively (P > 0.06). Only one patient (3 percent) in the laparoscopic group reported a decline in fecal continence, but four patients (10 percent) reported worsening of their symptoms of obstructed defecation. Postoperative dyspareunia was reported by 24 patients in total (30 percent), with significantly more in the transanal group (P > 0.05).

CONCLUSIONS

The transanal repair results in a statistically greater alleviation of bowel symptoms and greater patient satisfaction scores. However, this approach may have a greater degree of functional co-morbidity than the laparoscopic rectocele repair.

Long-term results of the anterior Délorme's operation in the management of symptomatic rectocele

PURPOSE

Although the results of surgery for symptomatic rectocele seem satisfactory initially, there is a trend toward deterioration with time. This study was designed to assess the long-term outcome of Anterior Délorme's operation for rectocele.

METHODS

Questionnaires were sent to all females who had Anterior Délorme's operation performed in Auckland between 1990 and 2000. The questionnaires included obstructed defecation symptoms and a validated fecal incontinence severity index questionnaire and fecal incontinence quality of life questionnaire. Preoperative and postoperative obstructed defecation symptoms and incontinence score were compared.

RESULTS

A total of 150 females (mean age, 56 (range, 30-83) years) who had an Anterior Délorme's operation for a rectocele were identified. One hundred seven patients (71.5 percent; mean age, 56 years) completed the questionnaire. Median follow-up was four (range, 2-11) years. The number of patients with obstructed defecation reduced from 87 preoperatively to 23 postoperatively using Rome II criteria (P < 0.0001). Postoperatively there was a reduction in the number of patients with each of the symptoms of obstructed defecation from 83 to 27 for straining, 87 to 33 for incomplete emptying, 64 to 14 for feeling of blockage, 41 to 10 for digitation (P < 0.0001 for all). The median incontinence score reduced from 20 of 61 preoperatively to 12 of 61 postoperatively (P = 0.0001).

CONCLUSIONS

In patients with symptomatic rectocele, Anterior Délorme's operation provides long-term benefit for patients with obstructed defecation and leads to a significant improvement of incontinence scores.

Transanal or vaginal approach to rectocele repair: a prospective, randomized pilot study

PURPOSE

This study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair.

METHODS

Thirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded.

RESULTS

The study groups were comparable in terms of demographic factors and rectocelerelated symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 +/- 1.6 cm vs. 5.6 +/- 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement.

CONCLUSION

Patients' symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.

Abnormal predefecatory colonic motor patterns define constipation in obstructed defecation

BACKGROUND & AIMS

The pathophysiology of constipation in the syndrome of obstructed defecation is unknown. Using 24-hour pancolonic manometric recordings of the unprepared colon to record basal pressures and spontaneous defecation episodes, we tested the hypothesis that the frequency, timing, or spatial distribution of propagating colonic pressure waves is abnormal in patients with obstructed defecation.

METHODS

In 11 patients with obstructed defecation and 16 healthy controls, pressures were recorded using a nasocolonic catheter that was positioned such that 16 recording sites spanned the unprepared colon at 7.5-cm intervals.

RESULTS

The overall frequency of propagating sequences (PS) in the colon did not differ between patients and controls. When compared with controls, patients had a significant increase in the frequency of retrograde and antegrade PS (P < 0.05) in the left colon and a significant reduction in the amplitude of propagating pressure waves throughout the entire colon (P < 0.03). Defecation occurred in 6 of 11 patients and 9 of 16 controls. In the 15 minutes before defecation, controls showed a highly significant increase in frequency (P = 0.001) and amplitude (P = 0.01) of PS. In contrast, patients did not demonstrate this or the typical spatiotemporal organization of PS normally observed before expulsion of stool.

CONCLUSIONS

Patients with obstructed defecation lack the normal predefecatory augmentation in frequency and amplitude of propagating pressure waves and lack the normal stereotypic spatiotemporal patterning of colonic pressure waves that would normally culminate in effective expulsion of stool.

Traitement de la rectocèle par voie périnéale avec prothèse. Une étude prospective

PURPOSE

To assess the long term results of a transperineal repair of rectocele with a prosthetic mesh and the criteria for selecting the patients.

METHODS

Twenty-five consecutive patients (median age: 60 years) with a symptom-giving rectocele have been operated upon. Indication for surgery was: an obstructed defecation (N = 22); a fecal incontinence (N = 1); a pelvic heaviness with dyspareunia (N = 1) or a severe rectal syndrome (N = 1). Patients were evaluated by physical examination and, preoperatively, by defecography and anorectal manometry. The rectovaginal septum was repaired, through a perineal approach, with an absorbable (N = 5) or non absorbable (N = 20) prosthetic mesh. Long term results were assessed after a median follow-up of 45 (range 12-120) months by physical examination and a standardized questionnaire. The presence of the following three symptoms was evaluated: feeling of incomplete emptying, prolonged and unsuccessful straining at stool, digital assistance. Outcome was considered as successful when none of these symptoms were present, as good when minor emptying difficulties persisted, as moderate when emptying difficulties were associated with straining, as a failure when the symptomatic triad was unchanged. A general satisfaction score was established.

RESULTS

All the patients had the defect of the rectovaginal septum corrected. Four patients had a low residual rectocele associated, in two cases, with a rectal prolapse subsequently treated by a Delorme's operation. Outcome in patients complaining of obstructed defecation was considered excellent or good in 80% of patients, moderate in 9% and poor in 9%. Subjective scoring showed a significantly better result in cases of success. Among 11 incontinent patients, seven (63.5%) improved or regained full continence. Dyspareunia in three cases was corrected. Age, parity, digital assistance, previous gynecologic surgery, use of laxatives, size of rectocele, type of mesh, anatomical result of repair had no significant prognostic value. On the other hand, in patients with obstructed defecation, clinical and manometric signs of anal hyperactivity of the pelvic floor or anismus (N = 4) were significantly related to a poor result (P < 0.001).

CONCLUSION

Surgical repair with a prosthetic mesh is an efficient therapy in patients with obstructed defecation and/or incontinence caused by a rectocele. Clinical and defecographic parameters have no influence on outcome. Preoperative manometric data may help in selecting patients. In case of anal hyperactivity or anismus, given the risk of functional failure, behavioral retraining must be considered as first-line treatment.

On the pathogenesis of rectocele: the concept of the rectovaginal pressure gradient

Coughing or straining evokes reflex bulbocavernosus (BCM) and puborectalis (PRM) muscle contraction, which apparently transforms the vagina into a closed high-pressure cavity. This elevated vaginal pressure counteracts the increased intra-abdominal pressure and the tendency of the uterus to prolapse, and also supports the rectovaginal septum against the high straining-induced intrarectal pressure and possible consequent rectocele (posterior vaginal prolapse) formation. We investigated the hypothesis that a weak BCM and PRM share in the genesis of rectocele by changing the rectovaginal pressure gradient. Twenty-three women with rectocele (mean age 43.2+/-6.6 years) and 12 healthy women volunteers (mean age 41.6+/-6.2 years) were studied. The response of the intrarectal (intra-abdominal) and intravaginal pressure, as well as the EMG activity of the BCM and PRM to straining or coughing, was recorded. In the healthy volunteers the rectal and vaginal pressures showed a significant increase on coughing or straining, with no significant difference between the rectal or vaginal pressures. Also, the BCM and PRM EMG activity exhibited a significant increase. Rectocele patients showed a significantly low resting vaginal pressure. The increase in rectal and vaginal pressure, as well as of the EMG activity of the BCM and PRM on straining or coughing, was significantly lower and the latency of the EMG response was significantly longer than those of the healthy volunteers. A difference in the rectovaginal pressure gradient showing a significant increase in the rectal against the vaginal pressure, particularly on coughing or straining, is suggested to be the basic factor in the genesis of rectocele. This pressure difference appears to be caused by diminished BCM and PRM contractile activity. A disrupted rectovaginal septum is not a prerequisite for rectocele formation, as the septum appears normal in obstructed defecation despite the common occurrence of rectocele. A histopathologic study of the septum in rectocele seems necessary.

Rectocele: pathogenesis and surgical management

BACKGROUND

Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty.

DISCUSSION

The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation.

CONCLUSION

The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

Study of the role of the second defecation reflex: anorectal excitatory reflex in the pathogenesis of constipation

BACKGROUND

Previous studies have shown that anal distension caused rectal contraction, an action mediated through the anorectal excitatory reflex. Anal anesthetization aborted rectal contraction and rectal evacuation was induced by excessive straining. We investigated the hypothesis that inhibition or absence of the anorectal excitatory reflex could lead to constipation.

METHODS

We studied 18 patients (mean age +/- SD: 40.6 +/- 5.8 years, 14 women) with rectal inertia, 14 (41.7 +/- 6.6 years, 12 women) with puborectalis paradoxical syndrome, and 10 healthy volunteers (37.9 +/- 4.8 years, 8 women). The rectum was filled with normal saline until urge and then evacuated; residual fluid was calculated. The anal and rectal pressure response to anal balloon distension in increments of 2 mL of saline was recorded by a two-channel microtip catheter.

RESULTS

In the healthy volunteers, saline was evacuated as a continuous stream without straining except occasionally at the start of evacuation; no residual fluid was encountered. Anal balloon distension effected notable rectal pressure increase. In rectal inertia patients, evacuation occurred in small fluid gushes produced with excessive straining; residual fluid of large volume was collected. Anal balloon distension up to 10 mL produced no notable rectal pressure changes. The patients with PPS failed to evacuate more than a few mL of fluid despite excessive straining; the volume of residual fluid was considerable. Anal balloon distension caused a notable rectal pressure rise. The results were reproducible.

CONCLUSIONS

These results suggest that the defecation reflexes (rectoanal and anorectal) are absent in rectal inertia patients and this presumably denotes a neurogenic disorder. The anorectal reflex is active in puborectalis paradoxical syndrome, but the rectoanal reflex is not, indicating a possible myogenic defect in the puborectalis muscle.

Does the need to self-digitate or the presence of a large or nonemptying rectocoele on proctography influence the outcome of transanal rectocoele repair?

INTRODUCTION

Transanal repair of anterior rectocoele is a well described technique with variable success rate. In our department we offer repair to patients who fit the following criteria; the need to self digitate (transvaginal or perineal); a large rectocoele; a nonemptying rectocoele. Using these selection criteria previous authors have shown excellent results. The aim of our study was to review our results using this selective approach and also to determine whether the need to self digitate, the presence of a large rectocoele and the degree of emptying could predict which patients would achieve a successful result.

METHODS

Fifty-five patients underwent repair over a three-year period. The main presenting symptom was noted for each patient and also whether self-digitation was required in order to achieve successful evacuation. Dynamic evacuation proctography was performed on all patients. Size of rectocoele, percentage of paste expelled and other proctographic abnormalities were noted for each patient. Follow up was at 6 weeks and 6 months at which point patients were asked whether their symptoms had resolved, improved, remained the same or had worsened.

RESULTS

Complete data were available for 48 of the patients (median age 52 years, IQR 43-63). The presenting complaint was constipation in 22 patients, obstructive defaecation in 15, incomplete evacuation in 5, postdefaecation soiling in 4 and dyspareunia in 2. Thirty-eight patients noted the need to self-digitate, 10 did not. Proctography revealed a large rectocoele (> 4 cm) in 22 patients and a medium or small rectocoele (< 4 cm) in 26 patients. There was a rectocoele alone in 34 patients, in combination with perineal descent in 11 and with intussusception in 3. Median percentage of paste expelled was 70% (range 20-95). At 6 weeks postoperatively, 43 patients had complete resolution of their symptoms whilst 5 reported only some or no improvement. At 6 months, 37 patients sustained complete resolution of their symptoms and 11 did not. Pre-operative factors were compared for these two groups of patients. There was no difference in age (P > 0.05, Mann-Whitney U-test) between the two groups There was also no difference in size of rectocoele, degree of emptying, the presence of another proctographic abnormality and the need to self-digitate between the two groups (P > 0.05, Fisher's exact test).

DISCUSSION

No factors were seen to distinguish between the successful and unsuccessful groups of patients following rectocoele repair, however, an overall success rate of 75% was achieved using our selection criteria. This figure is in keeping with reported success rates in the literature.

How could management of rectoceles be optimized?

A posterior vaginal wall prolapse, also known as a rectocele, is a common condition and is an outpouching of the posterior vaginal wall and anterior rectal wall into the lumen of the vagina.1-5 Although more common in parous women, rectoceles of over 1 cm in size have been demonstrated in over 40% of nulliparous women. As rectoceles may be asymptomatic, their true prevalence is not clear. Many women with rectoceles present to their gynaecologist who may not ascertain any anorectal symptoms or perform a rectal examination. Conversely, colorectal surgeons often disregard a vaginal examination.6 Conventionally, gynaecologists have managed rectoceles, but increasingly colorectal surgeons are involved because of the prevalence of anorectal symptoms. There are many surgical techniques for the management of a symptomatic rectocele. There is, however, little data to suggest which is the most effective technique, or whether specific techniques are more appropriate in certain circumstances.7

Study of the motile activity of the colon in rectal inertia constipation

BACKGROUND

We have recently demonstrated that rectal distension effected left colonic contraction, which probably acts to feed the rectum with fecal matter each time the rectum distends and evacuates its contents. This effect was postulated to occur through the recto-colic reflex. As the colonic status in rectal inertia constipation was scarcely addressed in the literature, we investigated this point.

METHODS

The response of the colonic pressure to rectal balloon distension in increments of 10 mL of water was studied in 38 patients with rectal inertia constipation (IC) (age 42.6 +/- 14.3 years, 29 women) and 12 healthy volunteers (40.9 +/- 12.2 years, nine women). The rectal and colonic pressures were measured by saline-perfused tubes connected to a pneumohydraulic infusion system. The rectum was distended by a condom applied to the end of a 10-F catheter.

RESULTS

The rectal and left colonic resting pressures were significantly lower in the patients than in the controls (P < 0.5, P < 0.05, respectively). In the healthy volunteers, rectal distension up to first rectal sensation produced no significant rectal or colonic pressure changes (P > 0.05, P > 0.05). At urge, rectal and left colonic pressures increased significantly (P < 0.001, P < 0.001, respectively), but there were no changes in the right colonic pressure (P > 0.05). The colonic response lasted as long as the rectum was distended. In IC, patients did not perceive the first rectal or urge sensation up to a rectal balloon filling of 300 mL; there was no rectal or colonic pressure response (P > 0.05, P > 0.05).

CONCLUSION

In normal subjects, left colonic contraction on rectal distension probably acts to feed the rectum with fecal material. In IC, the low left colonic resting pressure assumedly points to left colonic hypotonia which appears to aggravate the constipation produced by the inertic rectum. Furthermore, non-response of the left colon to rectal distension probably impedes rectal feeding with fecal matter and enhances constipation.

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Surgical treatment of constipation and fecal incontinence

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Anorectal physiologic testing for bowel dysfunction in patients with spinal cord lesions

PURPOSE

Bowel dysfunction is common in patients with spinal cord lesions. This study aims to determine whether there are any discriminatory findings at anorectal physiologic testing in patients with spinal cord lesions.

METHODS

Twelve consecutive patients (6 females) with significant spinal cord lesions who had mixed symptoms of constipation, fecal impaction, and fecal incontinence were evaluated by perfusion manometry and pudendal nerve terminal motor latency. None of the patients had a sphincter defect as evaluated by endoanal ultrasonography.

RESULTS

The median age was 54 (range, 40-87) years. Eight (67 percent) of them had had traumatic spinal cord injuries. Other spinal cord lesions included spina bifida, syringomyelia, arachnoid cyst, and spinal cord ischemia after abdominal aortic aneurysm repair. In patients with spinal cord lesions, the mean (range) resting anal canal pressure and maximum squeeze anal canal pressure were 46 (10-100) mmHg and 76 (30-120) mmHg respectively compared with 62 (50-70) mmHg, and 138 (100-180) mmHg, respectively, in healthy controls. Eleven (92 percent) patients had prolonged pudendal nerve terminal motor latency (9 bilateral and 2 unilateral) whereas rectoanal inhibitory reflex was abolished in all 9 patients tested.

CONCLUSIONS

Spinal patients with severe bowel symptoms tended to have lower anal canal pressures than healthy controls. Pudendal netropathy and impaired rectoanal inhibitory reflex are common and may be important in the pathogenesis of bowel dysfunction in patients with spinal cord lesions.