Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction

Global Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Fecal incontinence (FI) can considerably impair quality of life. Through a systematic review and meta-analysis, we sought to determine the global prevalence and geographic distribution of FI and to characterize its relationship with sex and age.

METHODS

We searched PubMed, Web of Science, and Cochrane Library databases to identify population-based surveys of the prevalence of FI.

RESULTS

Of the 5175 articles identified, the final analysis included 80 studies; the median response rate was 66% (interquartile range [IQR], 54%-74%). Among 548,316 individuals, the pooled global prevalence of FI was 8.0% (95% confidence interval [CI], 6.8%-9.2%); by Rome criteria, it was 5.4% (95% CI, 3.1%-7.7%). FI prevalence was greater for persons aged 60 years and older (9.3%; 95% CI, 6.6%-12.0%) compared with younger persons (4.9%; 95% CI, 2.9%-6.9%) (odds ratio [OR], 1.75; 95% CI, 1.39-2.20), and it was more prevalent among women (9.1%; 95% CI, 7.6%-10.6%) than men (7.4%; 95% CI, 6.0%-8.8%]) (OR, 1.17; 95% CI, 1.06-1.28). The prevalence was highest in Australia and Oceania, followed by North America, Asia, and Europe, but prevalence could not be estimated in Africa and the Middle East. The risk of bias was low, moderate, and high for 19 (24%), 46 (57%), and 15 (19%) studies, respectively. Exclusion of studies with high risk of bias did not affect the prevalence of FI or heterogeneity. In the meta-regression, the high study heterogeneity (I2 = 99.61%) was partly explained by age.

CONCLUSIONS

Approximately 1 in 12 adults worldwide have FI. The prevalence is greater among women and older people.

International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs

INTRODUCTION AND HYPOTHESIS

This narrative review describes the existing epidemiologic literature and identifies gaps regarding pelvic organ prolapse (POP) prevalence, incidence, natural history, and current and future service needs.

MATERIALS AND METHODS

A PubMed search identified relevant citations published in 2000 or later. Pre-specified criteria were used to screen titles, abstracts, and manuscripts, including reference sections. Study findings were summarized to define what is known, identify gaps in current knowledge, and suggest priority areas for future research.

RESULTS

The reported prevalence of POP varies widely (1-65%) based on whether its presence is ascertained by symptoms (1-31%), pelvic examination (10-50%), or both (20-65%). Most existing population-based surveys do not include physical examination data. White women from higher income countries are overrepresented in the existing literature. Incidence and natural history data are limited and consist mainly of cohorts that follow women after pregnancy or menopause. Given global increases in aging populations in well-resourced countries, the need for POP treatment is anticipated to increase in the coming decades. In lower and middle income countries (LMICs) where demographic trends are different, there is a dearth of information about anticipated POP service needs.

CONCLUSION

Future POP incidence, prevalence, and natural history studies should include non-white women from LMICs and should combine pelvic examination data with validated patient-reported outcome measures when feasible. Anticipated future service needs differ globally, with a greater demand for POP treatment services in well-resourced settings where aging populations are prevalent.

Defecatory Dysfunction

Normal defecation is a complex and coordinated physiologic process that involves the rectum, anus, anal sphincter complex, and pelvic floor muscles. Any alteration of this process can be considered defecatory dysfunction, a term that covers a broad range of disorders, including slow-transit constipation, functional constipation, and functional or anatomic outlet obstruction. Evaluation should include history, physical, and consideration of additional testing such as colonoscopy, colonic transit studies, defecography, and/or anorectal manometry. Depending on the etiology, management options can include conservative measures such as dietary or lifestyle modifications, medications, pelvic floor physical therapy, or surgical repair.

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic

OBJECTIVE

This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability.

METHODS

This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits.

RESULTS

The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed.

CONCLUSIONS

A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.

European society of neurogastroenterology and motility guidelines on functional constipation in adults

INTRODUCTION

Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation.

DESIGN

After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation.

KEY RESULTS

Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation.

CONCLUSIONS AND INFERENCES

European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.

The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery

BACKGROUND

Defecation symptoms are common among women with pelvic organ prolapse. However, the relationship between posterior vaginal wall prolapse and defecation symptoms remains debatable. Even though there is a plausible biomechanical rationale for posterior wall prolapse to cause obstructed defecation, previous studies have drawn contradictory conclusions regarding the association.

OBJECTIVE

We aimed to examine the association between posterior vaginal wall prolapse and defecation symptoms by assessing the following: (1) does prevalence of defecation symptoms increase along with posterior wall prolapse severity, (2) is postoperative symptom improvement greater in women who underwent posterior compartment procedures in comparison with those who did not, and (3) is symptom improvement related to the symptom's correlation with the degree of prolapse?

STUDY DESIGN

We used data from a nationwide longitudinal cohort study with 3515 women undergoing pelvic organ prolapse surgery. We measured the prevalence of 9 defecation symptoms at baseline and at 6 and 24 months after surgery using the short form of the Pelvic Floor Distress Inventory. Baseline degree of prolapse was categorized in stages as defined by the Pelvic Organ Prolapse Quantification System. The relationship between the degree of posterior wall prolapse and prevalence of bothersome defecation symptoms was studied with logistic regression and adjusted for patient characteristics and severity of anterior wall and apical prolapse. Generalized estimating equations were used to assess the longitudinal change in symptom prevalence in groups of participants with and without repair for posterior vaginal compartment. Correlations between symptom improvement and symptom dependency on the degree of prolapse was assessed by calculating Pearson's correlation coefficient.

RESULTS

The stage of posterior wall prolapse (stage 2 vs stage 0) correlated with splinting, straining, incomplete evacuation, fecal incontinence of liquid stool, pain during defecation, fecal urgency, and anorectal prolapse (adjusted odds ratios, 2.7, 2.1, 2.0, 1.5, 2.1, 1.4, and 2.2, respectively; P ≤ .007 for all). Flatal incontinence and fecal incontinence of solid stool were not associated with the severity of posterior vaginal wall prolapse. Obstructed defecation symptoms (splinting, straining, and incomplete evacuation) improved more in women undergoing posterior compartment surgery compared with women undergoing repair for other compartments. The greatest improvement at follow-up was observed for those symptoms that showed strongest association with the degree of prolapse at baseline.

CONCLUSION

Obstructed defecation symptoms are dependent on the posterior wall anatomy. Women presenting with posterior wall prolapse, and these symptoms can expect to improve after surgery. Other defecation symptoms also improve after pelvic organ prolapse surgery, but they are not as specific to posterior wall anatomy as obstructed defecation symptoms.

American Urogynecologic Society Best-Practice Statement on Evaluation of Obstructed Defecation

The symptoms of constipation and obstructed defecation are common in women with pelvic floor disorders. Female pelvic medicine and reconstructive surgery specialists evaluate and treat women with these symptoms, with the initial consultation often occurring when a woman has the symptom or sign of posterior compartment pelvic organ prolapse (including rectocele or enterocele) or if a rectocele or enterocele is identified in pelvic imaging. This best-practice statement will review techniques used to evaluate constipation and obstructed defecation, with a special focus on the relationship between obstructed defecation, constipation, and pelvic organ prolapse.

Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation

BACKGROUND

Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined.

AIM

To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers.

METHODS

Electronic searches of major databases were performed without date restrictions.

RESULTS

From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4 cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P = 0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study).

CONCLUSIONS

Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.

Rectocele plication: description of a novel surgical technique and review of clinical results

INTRODUCTION AND HYPOTHESIS

A rectocele is the bulging of the anterior rectal wall into the posterior vaginal compartment. The route of surgical repair can be transvaginal, transrectal or abdominal. The aim of this retrospective study is to describe a novel transvaginal surgical procedure and investigate the associated subjective and objective clinical outcomes.

METHODS

Database records were retrieved for all women who underwent a rectocele plication for the period from January 2010 until December 2015 in a referral urogynecology unit with a minimum follow-up period of 12 months. This transvaginal technique entails a plication of the anterior rectal wall by suturing of the rectal muscularis layer. Clinical findings and quality of life (QOL) metrics were evaluated and reported on.

RESULTS

One hundred thirty-nine women met the initial inclusion criteria with full data available for 123. The presenting symptoms included a vaginal bulge in 73 (52.5%), overactive bladder (OAB) in 73 (52.5%), obstructed defecation (OD) in 49 (35.3%) and anal incontinence (AI) in 35 (25.2%). The majority of women (n = 72, 51.8%) had stage 3-4 posterior prolapse. The mean follow-up period was 27 ± 15 months. The postoperative symptoms were significantly improved for all, except AI (p = 0.43). There was a significant improvement in posterior prolapse (p < 0.001) with the majority of women noted to have a stage 0 or 1 (n = 109; 88.6%) posterior prolapse at follow-up.

CONCLUSIONS

The rectocele plication is a novel surgical technique with good subjective and objective clinical outcomes in the medium term.

Stepped-wedge randomised trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation: study protocol for a randomized controlled trial

Background

Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence.

Methods

An individual level, stepped-wedge randomised trial has been designed to allow observer-blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) pre-operative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates.

Discussion

An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks).

Trial registration

ISRCTN registry, ISRCTN11747152. Registered on 30 September 2015. The trial was prospectively registered (first patient enrolled on 21 March 2016).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2456-3) contains supplementary material, which is available to authorized users.

Comparative Study Between Trans-perineal Repair With or Without Limited Internal Sphincterotomy in the Treatment of Type I Anterior Rectocele: a Randomized Controlled Trial

BACKGROUND AND AIM

Two types of rectocele exist; type I is characterized by relatively high resting anal pressures, whereas type II has lower resting anal pressures with associated pelvic organ prolapse. We compared trans-perineal repair (TPR) of rectocele with or without limited internal sphincterotomy (LIS) in the treatment of type I anterior rectocele.

PATIENTS AND INTERVENTIONS

Consecutive patients with anterior rectocele were evaluated for inclusion. Sixty-two female patients with type I anterior rectocele were randomized and equally allocated to receive TPR alone (group I) or TPR with LIS (group II). The primary outcome was the clinical improvement of constipation. Secondary outcomes were recurrence of rectocele, operative time, and postoperative complications including fecal incontinence (FI).

RESULTS

Clinical improvement of constipation and patients' satisfaction were significantly higher in group II at 1 year of follow-up (93.3 versus 70 %). Constipation scores significantly decreased in both groups postoperatively with more reduction being observed in group II (11.1 ± 2.1 in group I versus 8 ± 1.97 in group II). Significant reduction in the resting anal pressure was noticed in group II. Recurrence was recorded in three (10 %) patients of group I and one patient of group II. No significant differences between the two groups regarding the operative time and hospital stay were noted.

CONCLUSION

Adding LIS to TPR of type I rectocele achieved better clinical improvement than TPR alone. The only drawback of LIS was the development of a minor degree of FI, which was temporary in duration.

Obstructive defecation syndrome: 19 years of experience with laparoscopic resection rectopexy

BACKGROUND

In obstructive defecation syndrome (ODS) combinations of morphologic alterations of the pelvic floor and the colorectum are nearly always evident. Laparoscopic resection rectopexy (LRR) aims at restoring physiological function. We present the results of 19 years of experience with this procedure in patients with ODS.

METHODS

Between 1993 and 2012, 264 patients underwent LRR for ODS at our department. Perioperative and follow-up data were analyzed.

RESULTS

The female/male ratio was 25.4:1, mean age was 61.3 years (±14.3 years), and mean body mass index (BMI) was 25.2 kg/m(2) (±4.2 kg/m(2)). The pathological conditions most frequently found in combination were a sigmoidocele plus a rectocele (n = 79) and a sigmoidocele plus a rectal prolapse or intussusception (n = 69). The conversion rate was 2.3 % (n = 6). The mortality rate was 0.75 % (n = 2), the rate of complications requiring surgical re-intervention was 4.3 % (n = 11), and the rate of minor complications was 19.8 % (n = 51). Follow-up data were available for 161 patients with a mean follow-up of 58.2 months (±47.1 months). Long-term results showed that 79.5 % of patients (n = 128) reported at least an improvement of symptoms. In cases of a sigmoidocele (n = 63 available for follow-up) or a rectal prolapse II°/III° (n = 72 available for follow-up), the improvement rates were 79.4 % (n = 50) and 81.9 % (n = 59), respectively.

CONCLUSIONS

LRR is a safe and effective procedure. Our perioperative results and long-term functional outcome strengthen the evidence regarding benefits of LRR in patients with an outlet obstruction. However, careful patient selection is essential.

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.

Abdominal resection rectopexy with an absorbable polyglactin mesh: prospective evaluation of morphological and functional changes with consecutive improvement of patient's symptoms

BACKGROUND

The pathophysiology of rectal prolapse and intussusception has not yet been clarified. This is reflected in the multiplicity of surgical procedures. The aim of this prospective study was to measure morphological and functional changes of the pelvic floor and the rectum before and after resection rectopexy.

METHODS

A total of 21 patients (mean age 60 years; 2 men, 19 women) with manifest rectal prolapse and rectoanal intussusception underwent sigmoidectomy and rectopexy with an absorbable polyglactin mesh graft. The following analyses were performed preoperatively and, on average, 15 months (range 6-21 month) postoperatively: radiologic defecography, rectal volumetry, sphincter manometry, and evaluation of clinical symptoms.

RESULTS

Postoperatively there was no patient with rectal prolapse, and only one with an intussusception. Rectal compliance increased from 6.4 to 10.2 ml/mmHg. Rectal volumetry showed a decrease of the thresholds for the sensation of "desire to defecate" and "maximal tolerated volume" (100-75 ml, 175-150 ml). Postoperatively, there was a higher level of the pelvic floor during contraction. The anorectal angle, vector volume, radial asymmetry, sphincter length, and resting and squeezing pressures were unchanged. Surgery improved rectal evacuation (p = 0.03), continence (p = 0.01), stool consistency (p = 0.03), and warning period (p = 0.01). Patients' personal assessment showed an improved overall satisfaction.

CONCLUSIONS

Resection rectopexy is a reliable method for treating rectal prolapse and rectoanal intussusception with clear improvement of the patient's clinical symptoms. The restored anorectal function can be attributed to improved rectal compliance, a lower sensory threshold, an elevation of the pelvic floor during squeezing, and an improved rectal evacuation.

Is pelvic pain associated with defecatory symptoms in women with pelvic organ prolapse?

OBJECTIVE

To investigate the significance of pelvic pain and its association with defecatory symptoms in women with pelvic organ prolapse (POP).

STUDY DESIGN

This is a cross sectional study of 248 women with stage II POP or greater. Women were stratified into "pain" and "no-pain" groups based on their response to a question on the Pelvic Floor Distress Inventory short form. Associations between patient demographics, exam findings and responses to validated questionnaires were evaluated.

RESULTS

In women with POP, defecatory symptoms are significantly more common in women with pelvic pain including straining with bowel movement (OR 2.4, 95% CI 1.3, 4.6), sense of incomplete emptying (OR 4.4, 95% CI 2.3, 8.2), pain with bowel movement (OR 5.3, 95% CI 1.2, 23.0) and splinting with bowel movement (OR 3.8, 95% CI 2.0, 7.5).

CONCLUSION

In women with POP, the symptom of pelvic pain is associated with the presence of defecatory symptoms.

Long-term results of stapled transanal rectal resection (STARR) for obstructive defecation syndrome

BACKGROUND

Rectocele and distal rectal intussusception are organic causes of obstructive defecation syndrome and can be corrected surgically once conservative treatment remedies have been exhausted. Stapled transanal rectal resection (STARR) procedure was introduced as a new treatment approach. This study presents the first long-term results of this procedure. PATIENTS AND PROCEDURES: A STARR procedure was performed in 14 patients (two male, 12 female, age 53 ± 12 years) between January 2003 and August 2005. The indication for surgery was a severe, conservatively treated stool evacuation disorder secondary to symptomatic rectocele and/or distal intussusception.

RESULTS

The mean follow-up period was 68 ± 10 (49-83) months. The defecation score (0-20 points) decreased from a preoperative 13.4 ± 3.4 to 3.2 ± 2.0 after 3 months and increased slightly to 4.7 ± 3.4 by the time of the final examination. In 12 patients (85.7%), the obstructive defecation syndrome was significantly improved. These positive results were also maintained in the long-term. Five patients (38.5%) reported a slight worsening of continence in terms of urge incontinence. The most affected patients were those with preoperative normal continence. Procedure-related anal reoperations were required in two patients (14.3%).

CONCLUSION

Even in long-term, transanal rectal wall resection seems to be an effective therapy for obstructive defecation syndrome. However, it is associated with a substantial number of reoperations and in some patients with persistent urge incontinence.

Evaluation and treatment of anal incontinence, constipation, and defecatory dysfunction

Posterior compartment disorders include anal incontinence, constipation, and defecatory dysfunction. These disorders cause considerable morbidity, and are typically underreported by patients and undertreated by providers. The purpose of this article is outline the approach to diagnosis and treatment of anal incontinence, constipation, and defecatory dysfunction with a brief description of the nature of the problem and approaches to evaluation and diagnosis, as well as medical and surgical management.

Surgical management of constipation

This review addresses the range of operations suggested to be of contemporary value in the treatment of constipation with critical evaluation of efficacy data, complications, patient selection, controversies and areas for future research.

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.

Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*

OBJECTIVE

Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period.

METHOD

Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months).

RESULTS

Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05).

CONCLUSION

Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.

Rectocele and intussusception: is there any coherence in symptoms or additional pelvic floor disorders?

BACKGROUND

Patients with a rectocele often suffer from such symptoms as obstructed defaecation, urine or stool incontinence and pain. The aim of this study was to assess other concomitant pelvic floor disorders and their influence on pelvic function.

METHODS

Included in the study were 37 female patients with a significant rectocele and defaecation disorder. Medical history and symptoms were analysed in terms of validated functional scores. All patients underwent open magnetic resonance defaecography (MRD) in a sitting position. Imaging was analysed for the presence and size of the rectocele, intussusception and other pelvic floor disorders.

RESULTS

Patients with a higher body mass index tended to have a larger rectocele, whereas age and vaginal birth did not correlate with the size of the rectocele. In 67.5% of the patients with a previously diagnosed rectocele, an intussusception was diagnosed on MRD. This group suffered from significantly worse urine incontinence (p=0.023) and from accessory enteroceles 64%, compared with 17% (p=0.013) for those with a simple rectocele. Patients with higher grade intussusception suffered more frequently from incontinence than from constipation.

CONCLUSION

Patients with a symptomatic rectocele frequently have other pelvic floor disorders that significantly influence the pattern of symptoms. Knowledge of all the afflictions is essential for determining the optimal treatment for each individual patient.

Clinical and morphologic correlation after stapled transanal rectal resection for obstructed defecation syndrome

PURPOSE

The clinical and morphologic outcome of patients with obstructed defecation syndrome after stapled transanal rectal resection was prospectively evaluated.

METHODS

Twenty-four consecutive patients (22 women; median age, 61 (range, 36-74) years) who suffered from obstructed defecation syndrome and with rectal redundancy on magnetic resonance defecography were enrolled in the study. Constipation was assessed by using the Cleveland Constipation Score. Morphologic changes were determined by using closed-configuration magnetic resonance defecography before and after stapled transanal rectal resection.

RESULTS

After a median follow-up of 18 (range, 6-36) months, Cleveland Constipation Score significantly decreased from 11 (range, 1-23) preoperatively to 5 (range, 1-15) postoperatively (P = 0.02). In 15 of 20 patients, preexisting intussusception was no longer visible in the magnetic resonance defecography. Anterior rectoceles were significantly reduced in depth, from 30 mm to 23 mm (P = 0.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of the 24 patients; however, only two were severe (1 bleeding and 1 persisting pain requiring reintervention).

CONCLUSIONS

Clinical improvement of obstructed defecation syndrome after stapled transanal rectal resection correlates well with morphologic correction of the rectal redundancy, whereas correction of intussusception seems to be of particular importance in patients with obstructed defecation syndrome.

Stapled trans-anal rectal resection (STARR) by a new dedicated device for the surgical treatment of obstructed defaecation syndrome caused by rectal intussusception and rectocele: early results of a multicenter prospective study

BACKGROUND AND AIM

Obstructed defaecation syndrome (ODS) represents a very common clinical problem. The aim of the this prospective multicenter study was to evaluate the efficacy and safety of stapler trans-anal rectal resection (STARR) performed by a new dedicated device, CCS-30 Contour Transtar, in patients with ODS caused by rectal intussusception (RI) and/or rectocele (RE).

MATERIALS AND METHODS

All the patients who underwent STARR for ODS caused by RI and/or RE at Colorectal Surgery Units of S. Stefano Hospital, Naples, Gepos Hospital, Telese, Benevento and S. Maria della Pietà Hospital, Casoria, Naples, Italy were prospectively introduced into a database. Preoperatively, all the patients underwent anorectal manometry and cinedefecography. The grade of ODS was assessed using a dedicated obstructed defaecation syndrome score (ODS-S). All the patients with a ODS-S >or=12 and RI and/or RE were enrolled. Patients were followed up clinically at 6 months.

RESULTS

Thirty patients, 28 (93.3%) women, mean age 56.6+/-12.7 years, underwent STARR, by Transtar, between February and October 2006. Preoperatively, ODS-S was 15.8+/-2.4. RI was present in 26 (89.6%) and RE (34.4+/-15.2 mm) in 27 (93.1%) patients. No major postoperative complications occurred. The length of hospital stay was 2.5+/-0.6 days. At 6-month follow-up, ODS-S was 5.0+/-2.3 (P<0.001). Successful outcome was achieved in 25 (86.2%) patients.

CONCLUSION

STARR, performed by the new dedicated device, CCS-30 Contour Transtar, seems to be an effective and safe procedure to treat ODS caused by RE and/or RI. A longer follow-up and a larger number of patients is needed to confirm these results.

Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic

OBJECTIVE

To identify symptom clusters, management strategies and survey patient satisfaction in our combined multidisciplinary pelvic floor clinic (PFC).

METHOD

Retrospective cohort study, patient satisfaction questionnaire.

SAMPLE

Secondary and tertiary referrals with complex pelvic floor disorders.

MAIN OUTCOME MEASURES

symptom clusters and treatment received; patient satisfaction.

RESULTS

A total of 113 new cases over a 3-year period. There were two main symptom clusters: (i) obstructed defaecation with rectoceles (n = 55); of these, 23 had abdominal sacrocolpopexy with rectopexy, six had transvaginal rectocele repairs; and (ii) of the 33 with double incontinence, 10 had anal sphincter repairs, five had tension-free vaginal tapes and two had colposuspensions. Patient satisfaction audit: 73% found the care to be excellent/good, 12% satisfactory and 6% unsatisfactory.

CONCLUSION

Combined PFCs led to a more pragmatic approach in treating patients' symptoms. Combined surgery was undertaken in one-fourth of patients and is associated with cost savings and a single recuperation period. Overall, patients rated this service very highly.

Anorectal three-dimensional endosonography and anal manometry in assessing anterior rectocele in women: a new pathogenesis concept and the basic surgical principle

OBJECTIVE

The anatomy of the anal canal, the anorectal junction and the lower rectum was studied with 3-D ultrasound.

METHOD

Seventeen women with normal bowel transit, without rectocele (group 1) and 17 female patients with a large anterior rectocele (group 2) were examined with a B&K Medical Rawk. Mean age was 44.5 and 51.6 years respectively. In group 1, one (5.8%) patient was nuliparous, five (29.4%) had a caesarian section, 11 (64.7%) had a vaginal delivery while in group 2, two (11.7%) patients were nuliparous, four (23.5%) had a caesarian section and 11 (64.7%) had a vaginal delivery. Images were reconstructed in midline longitudinal (ML) and transverse (T) planes. The external (EAS) and internal (IAS) anal sphincters were measured in both projections.

RESULTS

In the ML plane, the EAS length was longer in group 1 (1.94 cm vs 1.61 cm, P < 0.05), the gap length was shorter (1.54 cm vs 1.0 cm P < 0.01) and the wall thickness was shorter in group 2 (0.40 cm vs 0.50 cm P < 0.01). The IAS (0.18 cm vs 0.23 cm P < 0.01) and EAS thickness (0.68 cm vs 0.77 cm, P < 0.05) (left lateral of the posterior quadrant) was greater in group 2. In group 1, the anterior upper anal canal wall in normal females was an extension of the rectal wall and the circular muscle was thicker in the mid-anal canal to form the IAS. In group 2, however, the wall layers were not identified and the IAS was found to be more distal. The differences were not statistically significant in the anal canal resting and squeeze pressures in the two groups.

CONCLUSION

Obstetric trauma does not seem to play any role in rectocele pathogenesis because the anal sphincter muscles are anatomically and functionally normal and rectocele is also present in nuliparous and in women with caesarian sections. It seems that it is associated with the absence of EAS and thinner IAS in the anterior upper anal canal. Herniation starts at the upper anal canal extending to the lower rectum in high or large rectoceles and maybe produced by rectal intussusception because of excessive and prolonged straining during defecation. In fact, the denomination 'rectocele' should be changed to 'anorectocele'.

Functional results of laparoscopic resection rectopexy for symptomatic rectal intussusception

PURPOSE

This study was designed to assess the role of laparoscopic resection rectopexy for symptomatic rectal intussusception in patients who failed medical treatment. The functional outcomes of laparoscopic resection rectopexy were evaluated.

METHODS

Patients who underwent laparoscopic resection rectopexy for rectal intussusception between July 1998 and November 2004 were identified. All patients with obstructed defecation failing medical treatment were included. Data were prospectively collected for the perioperative period. A follow-up questionnaire was used to assess functional outcome.

RESULTS

Between 1998 and 2004, a total of 56 patients (53 females (95 percent); age range, 23-83 years) underwent laparoscopic resection rectopexy for rectal intussusception. The median operative time was 123 minutes. Morbidity was 7 percent, and there was no mortality. Fifty-two patients were available for follow-up, and of these 33 (63 percent) reported an overall improvement in their function after surgery. Of 28 patients suffering constipation, 15 (53 percent) reported an improvement in bowel frequency. Sixty-seven percent of patients incontinent before surgery improved. Symptoms of incomplete evacuation resolved in 38 percent of affected patients. Thirty-six percent of patients needing to strain at stool did not have this problem after surgery. Median follow-up was 44 (range, 15-92) months.

CONCLUSIONS

The management of patients with rectal intussusception and obstructed defecation failing medical treatment is challenging. Laparoscopic resection rectopexy is an option that might offer symptomatic relief and improved function. Further studies are required to define the selection criteria to optimize the outcome in this patient group.

Multimedia article. External pelvic rectal suspension (the express procedure) for internal rectal prolapse, with or without concomitant rectocele repair: a video demonstration

PURPOSE

Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol), designed to correct internal rectal prolapse, with or without rectocele.

INCLUSION CRITERIA

severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol patch in the rectovaginal plane.

RESULTS

Short-term results for the "Express" are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography.

CONCLUSIONS

This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.

Stapled transanal rectal resection (STARR): a new option in the treatment of obstructive defecation syndrome

BACKGROUND

Rectocele and distal intussusception are organic causes of outlet obstruction. A new surgical option called the stapled transanal rectal resection (STARR) is described within a prospective study.

PATIENTS AND METHODS

Fourteen patients with symptomatic rectocele (four females), rectocele with coexistent intussusception (eight females), and intussusception (two males) underwent STARR procedure. The symptoms were measured by means of a defecation score (0-20 points).

RESULTS

Complications included local bleeding postoperatively in two cases, and temporary ischuria in four cases. The subjective sense of pain was low; from day 1 postoperatively five patients did not need any analgetics. Only one female patient had prolonged pelvic pain, without any organic reason. All patients showed improvement in rectal evacuation. The mean score of defecation (0-20 points) decreased from 13+/-3 to 4+/-3 after 1 month (p<0.05) and remained low. The overall follow-up was 19+/-9 months. Only one male patient with intussusception had defecation disorder again 6 months after surgery. Three patients had temporary urge incontinence.

CONCLUSION

STARR is an effective therapy for obstructive defecation disorder due to a symptomatic rectocele and/or a distal intussusception.

Posterior pelvic floor compartment disorders

Posterior pelvic floor compartment disorders generally refer to functional anorectal disturbances that by definition are symptom-based rather than anatomical defect-based and have a significant impact on quality of life. Symptoms attributed to the posterior compartment are often non-specific and associated with structural, neuromuscular and functional defects giving rise to symptoms of prolapse, pelvic pressure, faecal incontinence, stool trapping and constipation. They may range from mild to incapacitating and occur in varying combinations. While symptoms of constipation and incontinence may conceptually represent the opposing extremes of normal anorectal function, the dynamic interrelationships between the different pathophysiological mechanisms involved in the development of these disorders suggest a more complex explanation. Faecal continence and defecation are dependent on several neurological and anatomical factors that involve coordinated physiological processes, including intestinal transit and absorption, colonic transit, rectal compliance, anorectal sensation and continence mechanism. However, it is well recognized that pelvic floor symptoms originating from one compartment do not imply absent pathology in another compartment. Furthermore, symptoms associated with one disorder (such as constipation related to functional obstructed defecation) can be causative in the sequential development of other pelvic floor disorders, such as a urogenital prolapse syndrome, that may further exacerbate symptoms. In addition, it has been found that treatment that corrects one problem may improve, worsen or even predispose to other symptoms from another compartment. Consequently, while the concept of global pelvic floor dysfunction has emerged, the traditional single speciality referral and evaluation of pelvic floor problems continues to foster potentially segregated management strategies that can overlook the relevance of concomitant symptomatology. The evaluation and treatment of posterior pelvic compartment disorders needs to assume an individualized but multidisciplinary therapeutic approach. Given the variation in surgical approaches described to correct anatomical integrity of posterior pelvic compartment deficits, the consensus on optimal management has yet to be achieved. Therefore, it is critical that outcome measures following surgery are clearly defined. Treatment is to a great extent dictated to by functional severity and the impact that symptoms have on quality of life. Long-term follow-up should ensure that the potential for complications is minimized and satisfactory bowel, bladder and sexual function is maintained.

Rectoanal intussusception: presentation of the disorder and late results of resection rectopexy

BACKGROUND

Rectoanal intussusception may cause symptoms of obstructed defecation, and functional results of prosthesis rectopexy are usually not satisfactory. The aim of this study was to assess several parameters of the disorder and to evaluate the outcome of resection rectopexy.

METHODS

During a 10-year period, 27 female patients with symptomatic large rectoanal intussusception had resection rectopexy (23 laparoscopy; 4 laparotomy). Conservative treatment, including biofeedback treatment in 22 patients, had failed in all cases. Preoperative and postoperative evaluation included clinical assessment, anorectal manometry, evacuation defecography, and colon transit studies. Follow-up ranged between one and five years.

RESULTS

Length of intussusception was 2 to 4.9 cm and was significantly related to pelvic floor descent (P = 0.003) and inversely related to resting anal pressures (P < 0.001). Eleven patients had undergone a previous hysterectomy, 9 had enterocele-sigmoidocele, 7 had incontinence of varying severity, and 8 had a solitary rectal ulcer. Colon transit was abnormal in all but five cases. Immediate functional results were bad in two-thirds of the cases; tenesmus, urge to defecate, and frequent stools were the main complaints. By the time these symptoms had subsided, and one year after surgery, all but two patients were satisfied with the outcome. Intussusception was reduced in all cases, anal sphincter tone recovered (P = 0.002), perineal descent decreased (P < 0.001), and colonic transit was accelerated (P < 0.001). Patients available at five-year follow-up had no or only minor defecatory problems.

CONCLUSION

Resection rectopexy improves symptoms of obstructed defecation attributed to large rectoanal intussusception.

EXternal Pelvic REctal SuSpension (Express procedure) for rectal intussusception, with and without rectocele repair

Background

The results of conventional treatment for rectal intussusception and rectocele are unpredictable. The aim was to develop a less invasive surgical approach and to evaluate outcome in selected patients.

Methods

Seventeen patients (13 women; median age 47 (range 20–67) years) with rectal evacuatory dysfunction and rectal intussusception, 13 of whom had a rectocele, were selected. The intussusception was corrected by external pelvic suspension of the rectum, using collagen strips attached to the rectal wall and pubis. The rectocele was repaired with a collagen patch. Patients were assessed before and 6 months after surgery by symptom and quality of life questionnaires, anorectal physiological investigation and proctography, and were followed up for a median of 12 months.

Results

Sepsis requiring exploration occurred in two patients but there was no extrusion or need to remove the collagen. Of the 15 patients assessed after surgery, total symptom scores were significantly decreased (P &lt; 0·001) and quality of life scores improved (P &lt; 0·001). Proctographically, the degree of intussusception was improved in ten patients; six patients had normal postoperative proctograms. The rectocele was reduced in size in all patients, and was not demonstrable in eight.

Conclusion

An effective procedure for rectal intussusception and rectocele has been developed in a selected group of patients with marked evacuatory symptoms.

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.

[Obstructed defecation]

Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.

Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception

OBJECTIVE

The aim of this study was to determine whether open-magnet magnetic resonance (MR) defaecography could provide more useful clinical information than evacuation proctography (EP) alone in the evaluation of a cohort of patients with full-thickness rectal intussusception and could assist in decisions concerning management.

METHODS

Ten patients (4 male; median age 43, range 30-65) with symptomatic circumferential rectal intussusception diagnosed on EP, underwent open-magnet MR defaecography. Pathologies visible with each technique were recorded and 12 parameters of anorectal configuration and morphology measured and compared.

RESULTS

There was discordance in the diagnosis of rectal intussusception in three cases. In another two patients, MR defaecography demonstrated mucosal descent only. Measurements of anorectal configuration and morphology were similar between techniques; only rectal size and lateral dimensions of the rectocoele were significantly different, being smaller on MR defaecography than EP. Two patients were shown on MR defaecography to have significant bladder descent and two female patients had significant vaginal descent.

CONCLUSION

EP remains the first line investigation for the diagnosis of rectal intussusception, but may not distinguish mucosal from full-thickness descent. MR defaecography further complements EP by giving information on movements of the whole pelvic floor, 30% of the patients studied having associated abnormal anterior and/or middle pelvic organ descent. If surgery is planned for patients with rectal intussusception, MR defaecography provides useful information regarding the presence and degree of anterior pelvic compartment descent that may need to be addressed if a good functional outcome is to be achieved.