Surgery for occult rectal prolapse

Sacral neuromodulation for faecal incontinence - 10 years' experience at a Scottish tertiary centre

INTRODUCTION

Sacral nerve stimulation (SNS) is increasingly popular in the management of faecal incontinence. This paper reports the first 10-year experience of SNS in the management of faecal incontinence at a tertiary referral centre. Data was collected in a prospectively maintained database.

RESULTS

In total 130 patients were referred. The majority were women (94%) under 75-year-old (98%). Seven patients were found to have full-thickness rectal prolapse at the initial work-up and proceeded to rectopexy. Eighty-three patients underwent temporary SNS testing with 73.5% positive outcome, of which 52 patients had permanent implant insertion. There were four failures of SNS (7%) following implantation despite successful temporary testing, seven infection, one lead migration and three post-operative pain/numbness. One patient subsequently developed colorectal cancer requiring SNS removal. A higher frequency of episodes of incontinence was associated with positive SNS outcome (p = 0.007). There was no significant association between age, sex, type of faecal incontinence, previous anorectal/pelvic surgery, colonoscopic or USS findings and the likelihood of successful SNS. Of the 52 patients with SNS implants, 27 patients were seen only once for follow-up; the remaining 25 patients were seen more than once - five of these were part of our initial cases of routine 6- and 12-monthly follow-up, 6 patients were seen for adjustment of voltages, whereas the remaining 14 patients were seen for complications of the implants. If the initial five patients were excluded, only 38% of patients would have been seen more frequently on an as-required basis.

CONCLUSION

SNS is a safe and effective option in the management of faecal incontinence. Of the initial work-up, endoscopy and examination-under-anaesthesia (EUA) or proctogram are essential and more likely to influence the likelihood of suitability of SNS testing. A patient-led drop-in approach to follow-up is feasible to allow patients to be seen on an as-required basis.

Rectal Prolapse in Children: Significance and Management

Rectal prolapse is a herniation of the rectum through the anus. It is rare in children. When it does occur, it is usually prior to 4 years of age and due to anatomical variants. A few conditions predispose children to rectal prolapse, the most common being constipation. Cystic fibrosis used to be commonly associated with rectal prolapse, but with the advent of cystic fibrosis newborn screening, this association is no longer as frequently seen. Many recent case reports, detailed in this chapter, describe conditions previously unknown to be associated with rectal prolapse. Management is usually supportive; however, rectal prolapse requires surgical management in certain situations. This review details the presentation of rectal prolapse, newly described clinical manifestations, and associated conditions, and up-to-date medical and surgical management.

Semi-closed bilateral partial miotomy of the puborectalis for anismus: a pilot study: Partial miotomy of the puborectalis for anismus

BACKGROUND

Anismus or non relaxing puborectalis muscle (PRM) may cause obstructed defecation (OD). Reported surgical treatment is partial miotomy, followed by sepsis, bleeding, and incontinence. The aim of the present study was to investigate on the feasibility and outcome of a modified mini-invasive operation.

PATIENTS AND METHODS

Consecutive patients with anismus and OD not responding to medical therapy, excluding multiparous females, patients with anal incontinence, recto-rectal intussusception, and disordered psychological pattern. Semi-closed bilateral partial division of PRM, pulled down through 1-cm perianal incisions, was performed. Concomitant significant rectal mucosal prolapse and rectocele, when present, were treated. OD was evaluated using a validated score and anal/vaginal ultrasound (US) was performed pre -and postoperatively. A control group of seven patients with normal bowel habit was also investigated.

RESULTS

Eight patients (seven females), median age 48 years (range 29-71) were operated. Six also had significant mucosal prolapse and rectocele. All were followed up for a median of 12 months (range 2-40). None of them had postoperative sepsis or bleeding. One had just one occasional episode of mild anal incontinence. Symptoms improved in 6 or 75 % and, OD score decreased from 19.6 ± 1.0 to 9.2 ± 2.0 (mean ± s.e.m.), P = 0.007. No patient had anismus after surgery and PRM relaxation changed from 0 to 5.9 ± 0.8 mm being 6.6 ± 1.5 mm in controls.

CONCLUSION

Semi-closed bilateral partial division of PRM achieves muscle's relaxation on straining in all patients without any significant postoperative complication. Further studies are needed prior to consider it a validated procedure.

Rectal prolapse in children: a study of 71 cases

Introduction

Prolapse of the rectum is the herniation of the rectum through the anus, which may be categorised as mucosal or complete.

Aim

To evaluate the clinical manifestation, treatment, and surgical complications of children with rectal prolapse over a 6-year period.

Material and methods

This study was carried out on children aged < 14 years who were admitted or referred for rectal prolapse that failed to respond after medical treatment in Imam Khomeini and Abouzar Children's Hospital. Duration of the study was 6 years starting in March 2002. These cases were referred after failure of medical and conservative treatment. Age, sex, clinical manifestation, and type of procedure were recorded. Analysis was done using SPSS version 11.0 (SPSS Inc, Chicago, IL, USA). The χ² test was used for comparison.

Results

Seventy-one cases were included in this study. Of these cases, 50 (70.4%) were male and 21 (29.6%) were female (p < 0.0001). Mean age of cases was 4.97 ±3.42 years (range: 2 days to 13 years). Of the male cases, 38% were in the age range of 3–6 years. In female cases, 57.1% were in the range of 1.5–3 years. Of all 71 cases, injection sclerotherapy was done for 50 (70.43%) for the first time. Twenty-one cases had history of injection sclerotherapy and 16 (22.53%) were treated by perineal surgery, and 5 (7.04%) had abdominal surgery. One case experienced recurrent rectal prolapse (1.40%) following injection sclerotherapy.

Conclusions

In girls, more than half of the cases were in the age range 1.5–3 years. Among male cases, 38% were in the age range of 1.5–3 years. The results of treatment of rectal prolapse in our hospitals was similar to that seen in developed countries.

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.

Management of obstructed defecation

The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.

[Transabdominal procedures for functional bowel diseases]

Incontinence and constipation can occur in cases of pelvic floor dysfunction. Purely morphological changes without severe clinical symptoms are not an indication for surgery. Abdominal operations can be classified into procedures with dorsal (with or without bowel resection and with or without mesh implantation) and procedures with ventral rectopexy (with mesh). With respect to constipation and incontinence suture rectopexy alone is inferior to all other procedures. Dorsal and ventral mesh rectopexy and resection rectopexy are all comparable with respect to improvement of incontinence. Ventral rectopexy without dorsal mobilization and resection rectopexy are superior to mesh rectopexy with respect to constipation. Due to poor evidential status treatment is carried out from a pragmatic viewpoint.

Treatment of obstructed defecation

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

The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra-anal rectal intussusception

AIM

Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra-anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients.

METHOD

Forty consecutive patients with incontinence and intra-anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded.

RESULTS

The mean CCI scores were 13.2 (=/-4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as 'cured' in 26 (65%), 'improved' in 13 (32.5%) and 'unchanged' in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow-up of 38 months.

CONCLUSION

Intra-anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.

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.

Complications and reinterventions after surgery for obstructed defecation

PURPOSE

Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation.

METHODS

We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed.

RESULTS

Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years.

CONCLUSIONS

Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.

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.

Long-term follow-up of simultaneous abdominoperineal repair of enterorectocele and internal mucosal prolapse

BACKGROUND

Enterorectocele with recto-rectal intussusception and internal mucosal prolapse (ER-RI-MP) may require surgery for obstructed defecation, but symptoms tend to recur if only one lesion is corrected. This prospective study was designed to investigate the results of an abdominoperineal procedure aimed at treating all these lesions in one stage.

METHODS

Thirteen women with constipation (median age, 58 years) and ER-RI-MP underwent Douglas pouch suture, mesh obliteration of the pelvic inlet with or without rectopexy, and omentoplasty plus rectocele and prolapse obliteration. Constipation was scored on a scale from 0 to 20. Proctoscopy, enterocolpodefecography, manometry, anal-vaginal-perineal ultrasound, and psychological evaluation were performed before and after surgery.

RESULTS

Bleeding requiring transfusion, pelvic hygroma, and ureteric stricture requiring adhesiolysis occurred in three patients. Constipation score significantly decreased from a mean (+/- standard error of the mean) of 16 +/- 0.6 before to 7 +/- 0.9 after surgery (P < 0.0001). Seven patients were considered cured, five improved, and one remained unchanged at a median follow-up of 42 months. Anorectal physiology and imaging returned to normal in seven patients. Four patients had successful rehabilitation and psychotherapy for anismus, rectal hyposensation, and depression.

CONCLUSIONS

Simultaneous abdominoperineal ER-RI-MP repair integrated with conservative treatment of associated dysfunctions achieved a satisfactory long-term outcome. The results need to be confirmed in larger series.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-year experience

AIM: To evaluate the role and our experience of injection sclerotherapy with cow milk in the treatment of rectal prolapse in children.

METHODS: In the last 30 years (1976-2006) we made 100 injections of sclerotherapy with cow milk in 86 children. In this study we included children who failed to respond to conservative treatment and we perform operative treatment.

RESULTS: In our study we included 86 children and in all of the patients we perform cow milk injection sclerotherapy. In 95.3% (82 children) of patients sclerotherapy was successful. In 4 (4.7%) patients we had recurrent rectal prolapse where we performed operative treatment. Below 4 years we had 62 children (72%) and 24 older children (28%). In children who needed operative treatment we performed Thiersch operation and without any complications.

CONCLUSION: Injection sclerotherapy with cow milk for treatment rectal prolapse in children is a simple and effective treatment for rectal prolapse with minimal complications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robot-assisted laparoscopic rectovaginopexy for rectal prolapse: a prospective cohort study on feasibility and safety

Robotic systems may be particularly supportive for procedures requiring careful pelvic dissection and suturing in the Douglas pouch, as in surgery for rectal prolapse. Studies reporting robot-assisted laparoscopic rectovaginopexy for rectal prolapse, however, are scarce. This prospective cohort study evaluated the outcome of this technique up to one year after surgery. From January 2005 to June 2006, 15 consecutive patients with a rectal prolapse, either with or without a concomitant rectocele or enterocele, underwent robot-assisted laparoscopic rectovaginopexy with support of the da Vinci robotic system. A prospective cohort study was performed on operating times, blood loss, intra-operative and post-operative complications, and outcome at a minimum of one year after surgery. Median age at time of operation was 62 years (33-72) and median body mass index 24.9 (20.9-33.9). Median robot set-up time was 10 min (3-15) and median skin-to-skin operating time was 160 min (120-180). No conversions to open surgery were necessary. No in-hospital complications occurred and there was no mortality. Median hospital stay was four days (2-9). During one year follow-up, two patients needed surgical reintervention. One patient was operated for recurrent enterocele and rectocele one week after surgery. In another patient an incisional hernia at the camera port occurred three months after surgery. At one year after surgery, 87% of patients claimed to be satisfied with their postoperative result. Robot-assisted laparoscopic rectovaginopexy proved to be an effective technique with favourable outcomes in most patients in this prospective series. The operating team experienced the support of the robotic system as beneficial, especially during the dissection of the rectovaginal plane and suturing in the Douglas pouch.

Proctalgia in a patient with staples retained in the puborectalis muscle after STARR operation

Stapled transanal rectal resection (STARR) is a novel surgical technique for the treatment of intussusception and rectocele causing obstructed defecation. In this procedure, a double full-thickness rectal resection is performed transanally using two circular staplers. We describe the case of a patient complaining of persistent pain, tenesmus and fecal urgency after STARR. The patient also had an external rectal prolapse requiring an Altemeier rectosigmoid resection; during this operation we found and removed several staples that had stuck to the puborectalis muscle during STARR. Some degree of muscle inflammation was found at histological analysis. The patient recovered fully after this reintervention. Among the complications reported after STARR, the present one had not previously been described. The retained staples might have caused proctalgia in this patient.

A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'

OBJECTIVE

Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders, in order to alert the clinician of these and minimize failures.

METHOD

One hundred consecutive constipated patients with OD symptoms, 81 women, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry and anal/vaginal ultrasound (US). Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultations. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded.

RESULTS

Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three of them: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33%, respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most cases. Surgery was carried out in 14 (14%) patients.

CONCLUSION

The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.

A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'

OBJECTIVE

Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders in order to alert the clinician of these and minimize failures.

METHOD

One hundred consecutive constipated patients with OD symptoms, 81 female patients, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry, and anal/vaginal ultrasound. Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultation. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded.

RESULTS

Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33% respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most patients. Surgery was carried out in 14 (14%) patients.

CONCLUSION

The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.

Overt rectal prolapse following repair of stage IV vaginal vault prolapse

Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.

Treatment of obstructed defecation

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