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

RECTAL PROLAPSE IN THE SULAWESI CRESTED BLACK MACAQUE (MACACA NIGRA): MORBIDITY, MORTALITY, AND RISK FACTORS

Empirical data suggest that rectal prolapse (RP) is common in captive Sulawesi crested black macaques (Macaca nigra) in Europe, resulting in the euthanasia of animals that experience repeat occurrences. However, the prevalence, etiology, and risk factors of RP remain unidentified. The aims of this retrospective study were to assess the morbidity and mortality of RP, to provide an overview of management practices, and to identify risk factors for RP in this species. A questionnaire was sent to all European Ex situ Programme institutions that housed M. nigra between 01 January 2014 and 31 December 2020. Zoological Information Management System medical records and the studbook were used to obtain additional information. The questionnaire had a response rate of 65%, accounting for 204 animals. Of these animals, 25 (12.3%) suffered from at least one RP event during the study period and recurrence was noted in 72%. The majority of prolapses reverted naturally, but 28% of afflicted animals were euthanized for this ailment. Institutions with M. nigra with high frequencies of diarrhea (P= 0.035), those that provided diets of ≥90% vegetables and high-fiber pellet (P < 0.001), and those with more male than female M. nigra (P < 0.001) had increased odds of RP. Institutions that provided fruits daily (P < 0.002) had reduced odds of having RP cases. Although correlation of RP with diet was identified, confounding cannot be excluded, and a detailed dietary analysis needs to take place before altering feeding practices. Acute stressors and detection of protozoa in fecal samples were common findings before an RP event. Demographic analysis indicated that aged females, young males, and subordinate individuals were most affected by this condition. Where tested during an RP intervention, animals had low serum levels of vitamin D. Pedigree analysis hinted at genetic predisposition in this species and requires further investigation.

The Efficacy of Biofeedback Therapy in Patients with Solitary Rectal Ulcer and Dyssynergic Defecation

BACKGROUND

The treatment of solitary rectal ulcer (SRU) is challenging and controversial; generally, no response to conventional treatments can be obtained, particularly in patients with dyssynergic defecation (DD). We assessed the efficiency of biofeedback therapy (BFT) in patients who did not respond to conservative treatments and had coexistence of SRU and DD.

METHODS

BFT responses, as well as anorectal manometry and rectoscopy results of 20 patients with the coexistence of SRU and DD, were assessed.

RESULTS

Mean age was 32.5 years. Of the patients, 12 were female, and 8 of them were male. An average of 12 sessions of BFT was performed on the patients. Ulcer disappeared in 11 patients (55%) after BFT, and the ulcer size decreased in 3 patients (15%). However, ulcers healed in 9 (90%) of 10 patients whose DD pattern disappeared following BFT, and ulcers healed in only 20% of patients whose DD pattern continued (p = 0.005). The change in anal resting pressure after BFT was significant (p = 0.016). Ulcers were healed in 87.5% (7/8) of the patients whose anal resting pressure decreased after BFT and whose DD disappeared, while ulcers remained untreated in 85.7% of the patients whose anal resting pressure decreased, but the DD pattern continued (p = 0.005).

CONCLUSIONS

SRU patients with DD are typically unresponsive to medical treatments. Ameliorating anorectal dyssynergia should be the priority of treatment in these patients. BFT is an effective treatment for DD. BFT enhances the healing of ulcers in patients with SRU by restoring coordination of the pelvic floor.

Solitary rectal ulcer syndrome (SRUS): observational case series findings on MR defecography

OBJECTIVE

Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS.

MATERIALS AND METHODS

MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years' experience in pelvic floor imaging made the anatomical and functional measurements.

RESULTS

Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia.

CONCLUSION

MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications.

KEY POINTS

MRD can identify and grade both rectal intussusception and dyssynergia in patients with SRUS. MRD is an acceptable substitute to evacuation proctography in assessing anorectal dysfunctions when attempting to avoid ionizing radiation. SRUS influences the pelvic floor globally. MRD depicts associated anterior and/or middle compartment prolapse.

Meta-analysis of laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete rectal prolapse

OBJECTIVES

To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse.

METHODS

We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures.

RESULTS

We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR (n=160) or LPSR (n=147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P=0.009) but longer procedure time (MD: 23.93, P<0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: -1.02, P=0.50), CCCS (MD: -1.54, P=0.47), surgical site infection (OR: 1.48, P=0.71), and length of hospital stay (MD: -1.54, P=0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis.

CONCLUSIONS

LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

Solitary Rectal Ulcer Syndrome in Children: A Report of 140 Cases

OBJECTIVES

Solitary rectal ulcer syndrome (SRUS) is said to be rare in children (largest series so far; 55 in children, 116 in adults). We analyzed our experience to look at its clinical presentations, endoscopic appearance, and treatment outcome in a large cohort of children.

METHODS

Clinical and endoscopic data were collected between 2000 and 2018. Children (18 years or younger) diagnosed to have SRUS on colonoscopy and confirmed by histopathology were included. All children with SRUS were treated with behavioral modification, bulk laxative. Most with ulcer received steroid enema and some sulfasalazine or sucralfate enema.

RESULTS

The median age of 140 children was 12 (interquartile range [IQR]: 10-14) years, 79% were boys. The median symptom duration was 21 (IQR: 9-36) months. Rectal bleeding was the presenting feature in 131 (93.6%); constipation in 38 (27%); and small, frequent stools in 79 (56%). Most children had features of dyssynergic defecation such as prolonged sitting in the toilet (131, 93.6%), excessive straining (138, 98.6%), a feeling of incomplete evacuation (130, 92.8%), and rectal digitation (71, 50.7%). Rectal prolapse was noted in 24 (17%) cases. Colonoscopy documented rectal ulcer in 101 (72%) [Single: 84]. Over a median follow-up of 6 (IQR: 4-18) months, 27 patients were lost to follow-up and of the remaining 113 cases, 71 (62.8%) showed clinical improvement (healing of ulcer documented in 36/82, 44%).

CONCLUSIONS

The majority of cases of SRUS presented in second decade with rectal bleeding and features of dyssynergic defecation. Ulcer was noted in three fourths of cases. The outcome of medical treatment with behavioral modification and local therapy was modest.

Perineal Rectosigmoidectomy Revisited

Objective

The aim of this study was to evaluate the long-term results of perineal rectosigmoidectomy.

Background

Multiple surgical options are available for rectal prolapse perineal rectosigmoidectomy (Altemeier procedure) is the procedure of choice in elderly patients and those with multiple comorbidities.

Methods

Retrospective review was performed of all patients undergoing perineal rectosigmoidectomy from 1998 to 2008.

Results

Of 128 patients, 125 (98%) were women; with mean age 74 years. Mean operating time was 76 minutes. Hemostasis was achieved using ultrasonic scalpel or clamp and tie technique in equal numbers. Ultrasonic scalpel use resulted in shorter operative times (57.9 versus 94.7 minutes, respectively, P &lt; 0.0001,) and estimated blood loss (18.8 versus 73 mL, respectively, P &lt; 0.0001) compared to clamp-tie technique. Recurrence was seen in 23 (18%) patients. Recurrence was more after a handsewn anastomosis compared to a stapled anastomosis. Complications occurred in 3 patients (2%: 1 experienced major bleeding, 1 experienced perineal abscess, and 1 experienced postoperative ileus).

Conclusions

Perineal rectosigmoidectomy is associated with low morbidity and mortality. In addition, the minimal discomfort to patient, short length of stay and improvement in quality of life makes this a suitable operation for the elderly.

A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018?

PURPOSE

To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy.

METHOD

A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed.

RESULTS

A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary.

CONCLUSIONS

The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed.

Solitary Rectal Ulcer Syndrome: A Paediatric Case Report

INTRODUCTION

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign rectal disease. Mostly young adults are affected, and it is rare in paediatric populations.

CLINICAL CASE

We present a 12-year-old girl with a 6-month history of tenesmus, frequent defaecation, and bloody stools with mucus. There was no previous history of constipation or other symptoms. At the first visit, physical examination and routine laboratory test results were normal. A stool examination for bacteria and parasites was negative. Colonoscopy revealed a single ulcer in the distal rectum 6 cm from the anal margin. SRUS was confirmed by biopsy. Despite conservative measures, the symptoms persisted. A defaecation proctography showed a small rectocele with no rectal mucosal prolapse. Because of its proximity to the anal sphincter, no surgical intervention was performed.

CONCLUSION

The present case illustrates how difficult the management of SRUS is. Multicentre studies are needed to establish treatment protocols for children.

Value and limits of stapled transanal rectal repair for obstructed defecation syndrome: 10 years-experience with 450 cases

BACKGROUND/OBJECTIVE

In the late's 90' a new surgical treatment, the stapled trans-anal rectal resection (STARR) was born to treat obstructed defecation syndrome (ODS). In this study we retrospectively analyze a series of 450 cases that underwent STARR in 10 years.

METHODS

Between January 2001 to December 2011, 450 patients, diagnosed with ODS syndrome caused by rectocele or intussusception, underwent to STARR procedure. The presence of rectocele and/or intussusception was verified by dynamic defecography. The preoperative evaluation was completed with anorectal manometry and colonoscopy. Follow-up visits were scheduled 1 week, 1 month, 3 months, 1 years, 3 years and 5 years after surgery.

RESULTS

Mean operative time was 30,2 min. In 408 cases (90.7%) hospital discharge occurred 24 hours after surgery. Among postoperative complications urinary retention was observed in 35 patients (7.8%). Five (1.1%) patients presented an early rectal bleeding and 8 (1.8%) patients presented a late bleeding. In 5 (1.1%) patients a stable pelvic hematoma was found. Six (1.3%) patients presented pelvic sepsis due to subperitoneal perforation. An asymptomatic partial dehiscence of stapler row occurred in 19 patients (4.2%).125 patients (27.8%) reported defecation urgency that completely vanished at 3 months follow-up in 83 patients (66,4%) and in further 42 patients (33,6%) at 6-months. The average preoperative ODS score was 14.1; 3.1 at one year; 4.3 at 3 years and 6.4 after five years.

CONCLUSIONS

In expert hands, with right indications, STARR procedure is safe with good results in terms of improvement of the ODS score.

Magnetic resonance imaging of pelvic floor dysfunction - joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group

OBJECTIVE

To develop recommendations that can be used as guidance for standardized approach regarding indications, patient preparation, sequences acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for diagnosis and grading of pelvic floor dysfunction (PFD).

METHODS

The technique included critical literature between 1993 and 2013 and expert consensus about MRI protocols by the pelvic floor-imaging working group of the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) from one Egyptian and seven European institutions. Data collection and analysis were achieved in 5 consecutive steps. Eighty-two items were scored to be eligible for further analysis and scaling. Agreement of at least 80 % was defined as consensus finding.

RESULTS

Consensus was reached for 88 % of 82 items. Recommended reporting template should include two main sections for measurements and grading. The pubococcygeal line (PCL) is recommended as the reference line to measure pelvic organ prolapse. The recommended grading scheme is the "Rule of three" for Pelvic Organ Prolapse (POP), while a rectocele and ARJ descent each has its specific grading system.

CONCLUSION

This literature review and expert consensus recommendations can be used as guidance for MR imaging and reporting of PFD.

KEY POINTS

• These recommendations highlight the most important prerequisites to obtain a diagnostic PFD-MRI. • Static, dynamic and evacuation sequences should be generally performed for PFD evaluation. • The recommendations were constructed through consensus among 13 radiologists from 8 institutions.

Ventral mesh rectopexy versus conventional suture technique: a single-institutional experience

AIMS

Anterior mesh rectopexy is a novel surgical technique for the treatment of complete rectal prolapse, a common disorder in female elderly patients. Aim of the study was to evaluate functional outcomes after ventral mesh rectopexy and conventional suture rectopexy.

PATIENTS AND METHODS

Forty patients have been enrolled in this prospective study. Patients were divided into two groups: 20 patients (group A) had a conventional suture rectopexy with a standard technique and 20 patients (group B) underwent an anterior mesh rectopexy. Each patient had a clinic and defecographic diagnosis of full-thickness rectal prolapse, which was further investigated with manometry and clinical questionnaires (Wexner Constipation and Incontinence Score, Rome III criteria). Postoperative outcomes were evaluated through clinical questionnaires, a rigid rectosigmoidoscopy and a defecography, 1 year after surgery.

RESULTS

Preoperative Wexner constipation score was greater than 15 in all the patients (21 in group A and 22 in group B); median postoperative score was 15 in group A and 11 in group B, and the difference was significant. Median preoperative incontinence score was 11 in group A and 12 in group B; median postoperative score was 9 in group A and 6 in group B. Three patients experienced recurrence in group A and only 1 patient in group B.

CONCLUSION

Ventral mesh rectopexy is feasible, safe and effective for the treatment of full-thickness rectal prolapse in a well-fit geriatric population. Better functional results have been achieved compared with conventional suture technique with a trend toward a lower recurrence rate.

Methods of Evaluation of Anorectal Causes of Obstructed Defecation

Obstructed defecation is a complex disorder that results in impaired propagation of stool from the rectum. It is one of the major subtypes of functional constipation and can be secondary to either functional or anatomic etiologies. Patients with obstructed defecation typically present with symptoms of abdominal discomfort, a sensation of incomplete evacuation and rectal obstruction, passage of hard stools, the need for rectal or vaginal digitation, excessive straining, and reduced stool frequency. Evaluation of obstructed defecation is multimodal, starting with a thorough history and physical examination with focus on the abdominal, perineal, and rectal examination. Additional modalities to elicit the diagnosis of obstructed defecation include proctoscopy, colonic transit time studies, anorectal manometry, a rectal balloon expulsion test, defecography, electromyography, and ultrasound. The results from these studies should be taken in the context of each patient's clinical situation, as there is no single criterion standard for the diagnosis of obstructed defecation. Surgery is typically a last resort for these patients and the majority of patients will have good symptomatic management with diet and lifestyle changes. Patients who are found to have functional mechanisms behind their obstructed defecation also benefit from pelvic floor exercises and biofeedback therapy.

Age and cellular context influence rectal prolapse formation in mice with caecal wall colorectal cancer xenografts

In patients with rectal prolapse is the prevalence of colorectal cancer increased, suggesting that a colorectal tumor may induce rectal prolapse. Establishment of tumor xenografts in immunodeficient mice after orthotopic inoculations of human colorectal cancer cells into the caecal wall is a widely used approach for the study of human colorectal cancer progression and preclinical evaluation of therapeutics. Remarkably, 70% of young mice carrying a COLO320DM caecal tumor showed symptoms of intussusception of the large bowel associated with intestinal lumen obstruction and rectal prolapse. The quantity of the COLO320DM bioluminescent signal of the first three weeks post-inoculation predicts prolapse in young mice. Rectal prolapse was not observed in adult mice carrying a COLO320DM caecal tumor or young mice carrying a HT29 caecal tumor. In contrast to HT29 tumors, which showed local invasion and metastasis, COLO320DM tumors demonstrated a non-invasive tumor with pushing borders without presence of metastasis. In conclusion, rectal prolapse can be linked to a non-invasive, space-occupying COLO320DM tumor in the gastrointestinal tract of young immunodeficient mice. These data reveal a model that can clarify the association of patients showing rectal prolapse with colorectal cancer.

Advances in imaging diagnosis of rectocele

Rectocele is one of the common manifestations of outlet obstructive constipation. There are several imaging methods for evaluating rectocele including conventional defecography, dynamic nuclear magnetic resonance imaging (MRI) defecography and pelvic floor ultrasonography. These diagnostic techniques can identify the degree of rectocele and provide evidence for treatment. Defecography is still considered the gold standard for evaluating rectocele and guiding the operation, but it exposes patients to radiation. MRI defecography has the advantages of multi-dimensional imaging, excellent soft-tissue contrast and no radiation, and has broad prospects in the future, but it is expensive nowadays and has an unphysiological defecation way. Pelvic floor ultrasonography, especially endoanal and transperineal techniques, is able to identify all dysfunctions of the posterior pelvic floor compartment without radiation, but needs further studies.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Perineal rectosigmoidectomy for incarcerated rectal prolapse (Altemeier's procedure)

Perineal procedures have higher recurrence and lower mortality rates than abdominal alternatives for the treatment of rectal prolapse. Presence of incarceration and strangulation also influences treatment choice. Perineal rectosigmoidectomy is one of the treatment options in patients with incarceration and strangulation, with low mortality and acceptable recurrence rates. This operation can be performed especially to avoid general anesthesia in old patients with co-morbidities. We aimed to present perineal rectosigmoidectomy and diverting loop colostomy in a patient with neurological disability due to spinal trauma and incarcerated rectal prolapse.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

The PNEI holistic approach in coloproctology

The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloproctological disorders, by providing clinical cases and discussing them in light of this approach.

Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options

Chronic constipation is a considerable problem because it significantly affects the quality of a patient's life. Constipation can be diagnosed at every age and is more frequent in women and among the elderly. In epidemiological studies, its incidence is estimated at 2-27% in the general population. Chronic constipation may be primary or secondary. However, primary constipation (functional or idiopathic) can be classified into normal transit constipation, slow transit constipation, and pelvic outlet obstruction. In this review we make an attempt to present the current pathophysiological aspects and new therapeutic options for chronic idiopathic constipation, particularly highlighting the value of patient assessment for accurate diagnosis of the cause of the problem, thus helping in the choice of appropriate treatment.

Fecal Evacuation Disorder Among Patients With Solitary Rectal Ulcer Syndrome: A Case-control Study

Background/Aims

Data on frequency of fecal evacuation disorder (FED) among patients with solitary rectal ulcer syndrome (SRUS), hitherto an enigmatic condition, are scanty. Moreover, most such studies had limitations due to small sample size and lack of inclusion of healthy controls (HC).

Methods

Forty patients with SRUS underwent symptom assessments, sigmoidoscopy, anorectal manometry, defecography, balloon expulsion test (BET); endoscopic ultrasound (EUS) of anal sphincter complex was performed in a subgroup. Physiological tests (anorectal manometry and BET) were also performed in 19 HC.

Results

Patients with SRUS (26/40 male, age 37 [18–80] years) more often had FED than HC (10/19 male, age 43 [25–72] years) as shown by weight needed to expel the balloon (300 [0–700] g vs. 100 [0–400] g; P = 0.006), a trend towards abnormal BET (need of > 200 g weight for expulsion) (21/40 [53%] vs. 5/19 [26%], P = 0.058) and impaired anal relaxation (14/40 [35%] vs 2/19 [10.5%]; P = 0.048). Using Rome III criteria, most patients with SRUS reported having chronic constipation (36/40 [90%]) in spite of having normal (Bristol stool type IV, 21/40 [53%]) and diarrheal (types V, VI, VII, 6/40 [20%]) stool forms (Asian classification). SRUS patients more often (17/40 [43%]) had functional defecation disorder (Rome III criteria). Patients with SRUS with abnormal BET had thicker internal anal sphincter than those without (3.9 [3.4–7.0] mm vs 2.8 [2.0–4.0] mm; P = 0.01).

Conclusions

FED was commoner among patients with SRUS as evidenced by abnormal BET and sphincter relaxation. Those with abnormal BET had thicker internal sphincter on EUS than those without.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Precipitous intussusception with anal protrusion and complete overt rectal prolapse presenting with intestinal obstruction and an associated rectal adenoma in a young man: a case report

Background

Intestinal obstruction secondary to intussusception, occurring simultaneously with complete rectal prolapse, is an unusual entity among young adults. When it occurs the intussusceptum may protrude per anus. Few cases are cited in literature; each with a unique clinical presentation. There is apparently no uniform trend in its clinical and pathological picture.

Case presentation

A 38-year-old, African-Ugandan man presented with sudden occurrence of rectal prolapse for one day. He had otherwise been in good health. Symptoms were precipitous. A clinical diagnosis of intussusception of the lower gut with rectal prolapse, and intestinal obstruction, was made. The intussusception was found to have a polyp as the ‘lead point’. He was treated by manual reduction of the intussusception and the prolapse under general anesthesia. Histopathologic examination of the polyp showed it to be an adenoma. Definitive surgical treatment of the patient was not completed due to socioeconomic challenges.

Conclusions

Rectal prolapse and intussusception are commonly childhood conditions. Rectal prolapse alone is commoner in the middle-aged and elderly; females in particular. The finding of this combined clinical entity in a young, adult male is therefore a unique condition with an unusual presentation. It is the first case of its kind reported in East Africa. It is also an example of an adenoma constituting a ‘lead point’ for an intussusception at the gastrointestinal tract’s terminus. Even in the presence of a pre-existing adenoma, a relatively common lesion, other differential diagnoses acting as ‘lead points’ ought to be considered in perspective. This characteristic, along with other features described in this case, is useful knowledge for colorectal surgeons, general surgeons, gastrointestinal pathologists, and gastroenterologists given their involvement in the diagnosis and management of anorectal disease of peculiar presentation.

Surgical correction is ineffective for improvement of dyssynergic defecation in patients with rectal prolapse

BACKGROUND/AIMS

The patients with rectal prolapse suffer from not only a prolapse rectum but also associated dysfunction. However, most surgical techniques are successful regarding the prolapse, but either do not solve or even worsen defecation dysfunction. The purpose of this study was to investigate the functional and physiological results after surgical correction in patients with rectal prolapse.

METHODS

This study is a retrospective review of a single-institution experience. Patients with rectal prolapse who underwent anorectal manometry before and after Delorme's procedure were included. The primary outcomes measured were improvement of clinical symptoms and physiologic study.

RESULTS

Consecutive 19 patients with rectal prolapse (17 females, mean age of 68.1 ± 10.8 years) underwent anorectal manometry before and after Delorme's procedure. The two most prevalent symptoms before operation were rectal tenesmus (15/19, 78.9%) and excessive straining (13/19, 68.4%). The two most prevalent symptoms after operation were rectal tenesmus (14/19, 73.6%) and excessive straining (13/19, 68.4%). No significant differences in resting anal pressure, squeezing anal pressure, defecation index, and rectal sense were found postoperatively. However, vector asymmetry index before surgery was higher than that after surgery (35.0 vs. 32.0, P = 0.018). Ten patients (52.5%) had type I dyssynergic defecation before surgery. No improvement of dyssynergic pattern occurred after surgery.

CONCLUSIONS

In conclusion, dyssynergic defecation was not improved after reduction of rectal prolapse in patients with rectal prolapse. Further study about combination treatment with biofeedback therapy in these subgroups may be necessary.

Solitary rectal ulcer syndrome in children: a literature review

Solitary rectal ulcer syndrome (SRUS) is a benign and chronic disorder well known in young adults and less in children. It is often related to prolonged excessive straining or abnormal defecation and clinically presents as rectal bleeding, copious mucus discharge, feeling of incomplete defecation, and rarely rectal prolapse. SRUS is diagnosed based on clinical symptoms and endoscopic and histological findings. The current treatments are suboptimal, and despite correct diagnosis, outcomes can be unsatisfactory. Some treatment protocols for SRUS include conservative management such as family reassurance, regulation of toilet habits, avoidance of straining, encouragement of a high-fiber diet, topical treatments with salicylate, sulfasalazine, steroids and sucralfate, and surgery. In children, SRUS is relatively uncommon but troublesome and easily misdiagnosed with other common diseases, however, it is being reported more than in the past. This condition in children is benign; however, morbidity is an important problem as reflected by persistence of symptoms, especially rectal bleeding. In this review, we discuss current diagnosis and treatment for SRUS.

Rectal prolapse

CASE REPORT

A 56-year-old male presented to the emergency department with a feeling of heaviness and a protruding mass at the anal verge associated with pruritus in this area. The patient did not feel any pain and did not report experiencing faecal incontinence. Physical examination resulted in the visual diagnosis of a total rectal prolapse. Immediate manual repositioning through gentle pressure succeeded and the patient was scheduled for an elective laparoscopic ventral rectopexy.

DISCUSSION

Total rectal prolapse, or full-thickness rectal prolapse (procidentia), is defined as protrusion of the rectum beyond the anus. The entire rectal wall can be palpated in the externalized tissue exhibiting circular plication. Thus, a less distinct rectal prolapse can be distinguished visually from an anal mucosal prolapse as the latter shows stellate plication. Symptomatic patients having difficulties in reduction, substantial incontinence or obstructed defecation are to be referred for consideration of surgery.

Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients

AIM

Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence.

METHOD

The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate.

RESULTS

Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years.

CONCLUSION

The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions

CONTEXT

The correlation between vaginal delivery, age and pelvic floor dysfunctions involving obstructed defecation is still a matter of controversy.

OBJECTIVES

To determine the influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions in women with obstructed defecation syndrome.

METHODS

Four hundred sixty-nine females with obstructed defecation syndrome were retrospectively evaluated using dynamic 3D ultrasonography to quantify posterior pelvic floor dysfunctions (rectocele grade II or III, rectal intussusception, paradoxical contraction/non-relaxation of the puborectalis and entero/ sigmoidocele grade III). In addition, sphincter damage was evaluated. Patients were grouped according to age (≤50y x >50y) and stratified by mode of delivery and parity: group I (≤50y): 218 patients, 75 nulliparous, 64 vaginal delivery and 79 only cesarean section and group II (>50y): 251 patients, 60 nulliparous, 148 vaginal delivery and 43 only caesarean section. Additionally, patients were stratified by number of vaginal deliveries: 0 - nulliparous (n = 135), 1 - vaginal (n = 46), >1 - vaginal (n = 166).

RESULTS

Rectocele grade II or III, intussusception, rectocele + intussusception and sphincter damage were more prevalent in Group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001). The stratified groups (nulliparous, vaginal delivery and cesarean) did not differ significantly with regard to rectocele, intussusception or anismus in each age group. Entero/sigmoidocele was more prevalent in the vaginal group <50y and in the nulliparous and vaginal groups >50y. No correlation was found between rectocele and the number of vaginal deliveries.

CONCLUSION

Higher age (>50 years) was shown to influence the prevalence of significant rectocele, intussusception and sphincter damage in women. However, delivery mode and parity were not correlated with the prevalence of rectocele, intussusception and anismus in women with obstructed defecation.

Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature

BACKGROUND

Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there are few long-term follow-up and functional outcome data available. Using meta-analysis techniques, this study was designed to evaluate long-term results of open and laparoscopic abdominal procedures to treat full-thickness rectal prolapse in adults.

METHODS

A literature review was performed using the National Library of Medicine's PubMed database. All articles on abdominal rectopexy patients with a follow-up longer than 16 months were considered. The primary end point was recurrence of rectal prolapse, and the secondary end points were improvement in incontinence and constipation. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.

RESULTS

Eight comparative studies, consisting of a total of 467 patients (275 open and 192 laparoscopic), were included. Analysis of the data suggested that there is no significant difference in recurrence, incontinence and constipation improvement between laparoscopic abdominal rectopexy and open abdominal rectopexy. Considering non-comparative trials, the event rate for recurrence was similar in open and laparoscopic suture rectopexy studies and in open and laparoscopic mesh rectopexy trials. Improvement in constipation after the intervention was not statistically significant except for open mesh repair; postoperative improvement in incontinence was statistically significant after laparoscopic procedures and open mesh rectopexy.

CONCLUSIONS

Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regard to recurrence, incontinence and constipation. However, large-scale randomized trials, with comparative, strong methodology, are still needed to identify outcome measures accurately.

Functional and morphologic outcome after stapled transanal rectal resection for obstructed defecation syndrome

BACKGROUND

Stapled transanal rectal resection is a novel surgery for obstructed defecation syndrome. Few data on the functional and morphologic outcome after the surgery have been reported.

OBJECTIVE

This study aimed to evaluate the functional and morphologic outcome after stapled transanal rectal resection.

DESIGN

This is a prospective study of consecutive patients undergoing transanal rectal resection.

SETTING

The study was conducted at a tertiary referral hospital, Beijing, China, from May 2007 to May 2009.

PARTICIPANTS

Eighty-six consecutive female patients with obstructed defecation syndrome were carefully selected.

INTERVENTIONS

All patients underwent stapled transanal rectal resection.

MAIN OUTCOME MEASURES

The main outcome measures were patients' symptoms, obstructed defecation syndrome score, Wexner incontinence score, anorectal manometry and defecography before and 1 year after surgery.

RESULTS

The occurrence of all symptoms were significantly reduced after the procedure (P < .0001). Obstructed defecation syndrome score was decreased from 18.17 ± 4.68 preoperatively to 7.36 ± 3.52 postoperatively (P < .0001) with the Wexner incontinence score unchanged. Maximum tolerable rectal volume was significantly decreased (236.08 ± 50.00 vs 205.25 ± 29.60, P < .0001) after surgery with anal sphincter pressures unchanged. Postoperative defecography was performed in 64 patients. Rectocele disappeared in 40 of 62 patients. The depth of rectocele was reduced from 35.40 ± 4.58 mm preoperatively to 19.77 ± 9.19 mm postoperatively (P < .0001). Incomplete evacuation disappeared in 41 of 51 patients. Intussusception was completely corrected in 39 of 56 patients. The reduction of obstructed defection syndrome score was greater in patients with both rectocele and intussusception corrected than others (12.75 ± 2.24 vs 9.17 ± 3.47; P < .0001).

LIMITATIONS

This study was limited owing to the lack of a control group and the medium-term results.

CONCLUSIONS

Stapled transanal rectal resection is an effective procedure for obstructed defecation syndrome. The functional outcome is good with the preservation of sphincter function and continence postoperatively. The morphologic outcome confirmed its efficacy in correcting rectocele and intussusception, and correlated well with clinical improvement.

Rectal hyposensitivity is uncommon and unlikely to be the central cause of obstructed defecation in patients with high-grade internal rectal prolapse

BACKGROUND

There are several causes of obstructed defecation one of which is thought to be internal rectal prolapse. Operations directed at internal prolapse, such as laparoscopic ventral rectopexy, may improve obstructed defecation symptoms significantly. It is not clear whether the obstructed defecation with internal prolapse is a mechanical phenomenon or whether it results changes in rectal sensitivity. This study aimed to evaluate rectal sensory function in patients with obstructed defecation and high-grade internal rectal prolapse.

METHODS

This study represents a retrospective review of a prospectively collected database of patients attending a tertiary referral pelvic floor unit. Patients with high-grade (recto-anal) intussusception formed the basis of this study. Rectal sensory function was determined by intrarectal balloon inflation. Three parameters (sensory threshold, urge to defecate and maximum tolerated volumes) were recorded. Abnormal sensitivity was defined as partial (one or two parameters abnormal) or total (all three abnormal).

KEY RESULTS

Four hundred and eight patients with high-grade internal rectal prolapse both with and without obstructed defecation symptoms were studied. Two hundred and forty one (59%) had normal sensation. Eighteen (4%) had total hyposensitivity and three (1%) total hypersensitivity. A further 96 (24%) had partial hyposensitivity whilst 50 (12%) had partial hypersensitivity. Neither hypersensitivity nor hyposensitivity differed between patients with and without symptoms of obstructed defecation.

CONCLUSIONS & INFERENCES

Rectal hyposensitivity is relatively uncommon in patients with high-grade internal rectal prolapse and obstructed defecation. Internal rectal prolapse may cause obstructed defecation through a mechanical process. It does not appear that rectal hyposensitivity plays a significant part in the pathological process.

Solitary Rectal Ulcer Syndrome: Exploring Possible Management Options

Solitary rectal ulcer syndrome (SRUS) is a rare condition with various causes that results in ischemic injury. The aim of this study was to assess the clinical findings, diagnosis, and outcomes of treatment in patients with SRUS. Between 1992 and 2006, a retrospective review was undertaken for all patients diagnosed with SRUS. Fifty-eight patients were diagnosed with SRUS. Among patients with paradoxic rectal spasm (PRS), lesions disappeared in 1 of 3 given applied biofeedback treatment, and in 2 of 4 injected with Botulinum toxin (BotoxTM). Twenty-three patients underwent appropriate surgical treatment. Overall, postoperative improvement was seen in 18 patients (78.2%). In conclusion, every patient with SRUS must be assessed for causative disease. Treatment should include conservative approaches such as Botox injection; in patients with pelvic floor disorders, surgical treatment should be considered.

Complete rectal prolapse in adults: clinical and functional results of delorme procedure combined with postanal repair

This study has been performed at the Department of General Surgery, Zagazig University Hospital and King Saud Hospital, Oniza, KSAduring the period from November 1998 to September 2008.Twentyadult patients (6 males and 14 females with a mean age of 55 years) with complete rectal prolapse were eligible for the study, Where Delorme's procedure and postanal repairwere combined. All patients presented with complete rectal prolapse at least 5 cm in length. The associated disorders included constipation (4 patients, 20%), variable degrees of incontinence (15 patients, 75%). Only one patient had no associated functional problems. The median follow up period was 65 months. There was no mortality and immediate postoperative complications developed in 4 patients (20%). Recurrence of the prolapse occurred in two patient. Eleven patients (73.3%) (11/17) with faecal incontinence showed postoperative improvement and 4 patients failed to improve. The 4 patients presented with constipation were all improved postoperatively. We conclude that the combination of Delorme's procedure and postanal repair in the treatment of complete rectal prolapse in adults is a safe procedure that corrects the anatomical defects and improves the functional outcome. We recommend use of this method in the treatment of complete rectal prolapse especially in the elderly who are complaining of faecal incontinence.

Rectal prolapse

Despite the innovation of more than 100 surgical procedures for the treatment of complete rectal prolapse, no one procedure is best and applicable to all patients. Traditionally, procedures have been divided into abdominal and perineal approaches. The application of the laparoscopic approach to colon and rectal disease has allowed an additional less invasive method of therapy to treat rectal prolapse successfully. In comparison with conventional approaches, laparoscopy has achieved similar functional results and recurrence rates while reducing postoperative pain and hospital length of stay.

Functional anorectal disorders

Functional anorectal disorders include solitary rectal ulcer syndrome, rectocele, nonrelaxing puborectalis syndrome, and descending perineal syndrome. Patients usually present with "constipation," but the clinical picture of these disorders includes rectal pain and bleeding, digitalization, incomplete evacuation, and a feeling of obstruction. Diagnosis is difficult because many findings can be seen in normal patients as well. The diagnosis is made by using a combination of clinical picture, defecography, pathology, and occasionally anometry and pudendal terminal motor nerve latency. These disorders are generally treated medically with dietary changes and biofeedback. Surgical intervention is reserved for patients with intractable symptoms and has not been universally successful.

Perineal rectosigmoidectomy for gangrenous rectal prolapse

Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse. Even more rarely, it becomes strangulated, necessitating emergency surgery. We describe an extremely rare case of incarcerated acute rectal prolapse, without a relevant previous history or symptoms of predisposing pathology. The patient underwent emergency perineal proctosigmoidectomy, the Altemeier operation, combined with diverting loop sigmoid colostomy. The postoperative course was quite uneventful with an excellent final result after colostomy closure. The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual case scenario of bowel incarceration.

Open vs laparoscopic repair of full-thickness rectal prolapse: a re-meta-analysis

OBJECTIVE

A re-meta-analysis of available data within the published literature comparing laparoscopic rectopexy (LR) with open repair (OR).

METHOD

We searched MEDLINE, EMBASE, CINAHL, PubMed and the Cochrane databases from January 1990 to October 2008. We searched the following MESH terms: 'laparoscopy', 'prolapse' and 'rectal prolapse'. We used the following text words: 'rectopexy', 'haemorrhoids', 'minimally invasive' and 'keyhole surgery'. The bibliography of selected trials and a Cochrane review was scrutinized and relevant references obtained. Selected trials were analysed to conduct a meta-analysis.

RESULTS

Twelve comparative studies on 688 patients qualified for the review. There were 330 patients in LR group and 358 in the OR group. LR takes longer to perform compared with OR. This difference was statistically significant [random effects model: standardized mean difference (SMD) 1.63, 95% CI (1.14-2.12), z = 6.56, P < 0.001]. There was a significant reduction in hospital stay between LR vs OR [random effects model: SMD -1.75, 95% CI (-2.45 to -1.05), z = -4.90, P < 0.001]. There was no statistical difference relating to morbidity, constipation, incontinence or mortality between the two groups.

CONCLUSION

Laparoscopic rectopexy is a safe and effective modality and is comparable to OR, however, there is still a paucity of randomized controlled trials within the literature regarding this subject. Until these trials are conducted, we would advise caution in deriving absolute conclusions.

Systematic review on ventral rectopexy for rectal prolapse and intussusception

OBJECTIVE

This systematic review assesses the effectiveness of ventral rectopexy (VR) surgery for treatment of rectal prolapse (RP) and rectal intussusception (RI) in adults. Method MEDLINE, EMBASE, Scopus and other relevant databases were searched to identify studies. Randomized controlled trials or nonrandomized studies with more than 10 patients receiving ventral mesh rectopexy surgery were considered for the review.

RESULTS

Twelve nonrandomized case series studies with 728 patients in total are included in the review. Seven studies used the Orr-Loygue procedure (VR with posterior rectal mobilization to the pelvic floor) and five studies used VR without posterior rectal mobilization. Overall weighted mean percentage decrease in faecal incontinence (FI) rate was 45%. The weighted mean percentage decrease in constipation rate was 24%. Weighted mean recurrence rate was 3.4%.

CONCLUSIONS

There are limitations in published literature on VR. The available data indicate that VR has low recurrence and improves FI in patients suffering from these conditions. There is a greater reduction in postoperative constipation if VR is used without posterior rectal mobilization.

Solitary rectal ulcer syndrome: a case series

A retrospective analysis of the clinical profile, endoscopic features and management of 22 children (age 18 months-18 years) diagnosed as solitary rectal ulcer syndrome is presented. The majority (81.8%) were ≥8 years of age. Rectal bleeding was the presenting feature in all the children. Mucorrhea, constipation, tenesmus and rectal prolapse were observed in 77.3%, 63.6%, 59% and 13.6% children, respectively. Colonoscopy showed classical single rectal ulcer in 68.2% and multiple ulcers in 22.7%. Polypoidal and erosive lesions were documented in 4.5% each. The medical management comprised of bowel training and high fibre diet for all children. The other modalities included oral 5-amino salicylate (59%), sucralfate enema (4.5%) and rectal mesalamine in 9%. 64% children recovered and 13.6% had recurrence of symptoms.

Laparoscopic correction of enterocele associated to stapled transanal rectal resection for obstructed defecation syndrome

BACKGROUND AND AIMS

We report our experience of concomitant laparoscopic treatment for enterocele and stapled transanal rectal resection (STARR) for rectocele and/or rectal prolapse in patients with complex obstructed defecation syndrome (ODS).

PATIENTS AND METHODS

From June 2005 to June 2007, we submitted 20 patients with ODS due to rectal prolapse and/or rectocele, combined with stable enterocele, to STARR and laparoscopic correction of the enterocele. Preoperative assessment included symptom evaluation with standardized questionnaires, clinical examination, colonoscopy, proctoscopy, anal sphincter ultrasonography, video-defecography with synchronous opacification of the ileal loops in all patients and colpography in female patients, and anorectal manometry. Follow-up was performed in the first, third, sixth, 12th, and 24th month after surgery.

RESULTS

Eighteen (90%) patients were submitted to both procedures, simultaneously. One patient, previously submitted to STARR, underwent laparoscopic treatment of the enterocele. Postoperative complications occurred in two (10%) patients: one case of postoperative rectal bleeding and one case of retropneumoperitoneum. Median (range) preoperative and postoperative Altomare's obstructed defecation score was ten (6-14) and two (0-14), respectively (p<0.001). Median (range) preoperative and postoperative quality of life score was 79 (39-109) and 109 (50-126), respectively (p<0.001). No symptom related to ODS was detected at 6-month follow-up (19 patients) and at 24-month follow-up (19 patients).

CONCLUSION

The combination of STARR and laparoscopy provides a safe and effective method to treat ODS caused by rectal internal prolapse and/or rectocele combined with enterocele.

Function and dysfunction of the colon and anorectum in adults: working team report of the Swedish Motility Group (SMoG)

Symptoms of fecal incontinence and constipation are common in the general population. These can, however, be unreliably reported and are poorly discriminatory for underlying pathophysiology. Furthermore, both symptoms may coexist. In the elderly, fecal impaction always must be excluded. For patients with constipation, colon transit studies, anorectal manometry and defecography may help to identify patients with slow-transit constipation and/or pelvic floor dysfunction. The best documented medical treatments for constipation are the macrogols, lactulose and isphagula. Evolving drugs include lubiprostone, which enhances colonic secretion by activating chloride channels. Surgery is restricted for a highly selected group of patients with severe slow-transit constipation and for those with large rectoceles that demonstrably cause rectal evacuatory impairment. For patients with fecal incontinence that does not resolve on antidiarrheal treatment, functional and structural evaluation with anorectal manometry and endoanal ultrasound or magnetic resonance (MR) of the anal canal may help to guide management. Sacral nerve stimulation is a rapidly evolving alternative when other treatments such as biofeedback and direct sphincter repair have failed. Advances in understanding the pathophysiology as a guide to treatment of patients with constipation and fecal incontinence is a continuing important goal for translational research. The content of this article is a summary of presentations given by the authors at the Fourth Meeting of the Swedish Motility Group, held in Gothenburg in April 2007.

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.