Farm and animal levels risk factors associated with rectal prolapse in bovine and buffalo calves in Egypt with special reference to the optimal treatment strategy

Background:

Rectal prolapse (RP) is a serious illness of the rectum and small intestine causing serious health problems in domestic animals. However, there is paucity in the estimation of the risk factors associated with this problem in calves.

Aim:

In the present study, we investigated the prevalence and risk factors associated with the rectal prolapse in both bovine and buffalo calves in Egypt, highlighting the most appropriate treatment strategy.

Methods:

Forty-two calves (23 bovine and 19 buffalo) suffering from varying degrees of rectal prolapse were used. From the owners’ anamnesis, the farm- and animal-level risk factors associated with each animal were collected. Fisher’s exact tests were used to determine the distribution of frequencies in the different rectal prolapse grades. Descriptive statistics were calculated in the form of mean ± standard deviation (SD) using one-way analysis of variance. Crosstabs were used to determine Spearman’s correlation between variables. According to the disease severity, the appropriate treatment strategy was accomplished either by medicinal or surgical interferences.

Results:

The final logistic regression form demonstrated that the statistical test, Hosmer and Lemeshow’s goodness of fit, indicates a significant result (χ² = 8.91). Body score was the potential risk factor for the occurrence of RP in calves. Medicinal management along with dietary modification was sufficient to treat 70% of grade I in a successful manner, while 33.3% (grade I and grade II) were effectively treated surgically with reduction and application of purse-string sutures.

Conclusion:

The current study advocates the valid role of resection of rectal mucosa combined with manual reduction and retention in treating calves suffering from grade II rectal prolapse. The final multivariate logistic regression model indicates that the calf’s body score is a potential risk factor for the occurrence of RP.

What is the recommended procedure for recurrent rectal prolapse? A retrospective cohort study in a single Japanese institution

Purpose

The choice of surgical procedure for rectal prolapse (RP) is challenging because of the high recurrence and morbidity rates. We aimed to clarify whether laparoscopic suture rectopexy (lap-rectopexy) is suitable for Japanese patients with recurrent RP.

Methods

We retrospectively evaluated 77 recurrent RP patients who had been treated on average 1.5 times between June 2008 and April 2016. Forty-one patients underwent lap-rectopexy and 36 underwent perineal procedures. We compared surgical outcomes and recurrence rate following surgery between the two groups. The multivariable logistic regression analysis was performed to determine risk factors of recurrent RP.

Results

In patients’ characteristics, significant differences were observed in the type of anesthesia (p < 0.01) and length of recurrent RP (p = 0.030). The mean operative time was significantly longer in the lap-rectopexy group (p < 0.001). Blood loss, length of hospitalization, and postoperative complications were similar. The recurrence rate was significantly lower in the lap-rectopexy group (17.1% vs. 38.9%, p = 0.032). Multivariate analysis showed that only the laparoscopic approach was significantly associated with a low recurrence following surgery (odds ratio 0.273, 95% CI − 2.568 to − 0.032).

Conclusion

Lap-rectopexy is recommended for recurrent RP because its low recurrence rate and safety profile are similar to those of perineal procedures.

Recurrence after Delorme's procedure in a single and multi-surgeon setting

BACKGROUND

Delorme's procedure (DP) is a perineal repair reserved for full-thickness rectal prolapse (FTRP) in elderly/comorbid patients due to its low perioperative morbidity. Reported recurrence rates are higher than for abdominal approaches. This study reports the long-term clinical outcomes of recurrence and postoperative bowel function after DP.

METHODS

A retrospective cohort study including all patients who underwent a DP for FTRP between February 2001 and March 2014 at two primary study sites: Groote Schuur Hospital (multi-surgeon) and Kingsbury Hospital (singlesurgeon). Primary outcome was the absence of recurrence of FTRP after DP. Secondary outcomes were 30-day mortality and morbidity, postoperative bowel function and length of hospital stay.

RESULTS

70 patients underwent DP: 37 were operated on by the single surgeon and 33 by multiple surgeons. The median age was 76 years (IQR 20 years). Median length of follow-up was 46 months (IQR 55 months). 16 recurrences occurred: 7 in the single-surgeon cohort and 9 in the multi-surgeon cohort (p = 0.4). Median time to recurrence was 23 months (IQR 36 months): 48 months in the single-surgeon cohort and 15 months in the multi-surgeon cohort (p = 0.6). Six patients each had minor and major complications. Three patients died postoperatively. 8 patients required reoperation. Median postoperative hospital stay was three days (IQR 2 days). There were no significant differences between the multi-surgeon and single-surgeon cohorts.

CONCLUSION

Long-term follow-up demonstrates a recurrence rate of 23% after DP, with no difference between an experienced colorectal specialist and supervised trainee surgeons.

Recurrence of Rectal Prolapse After Surgical Repair in Women With Pelvic Organ Prolapse

BACKGROUND

Pelvic organ prolapse is prevalent among women with rectal prolapse.

OBJECTIVE

This study aimed to determine whether clinically significant pelvic organ prolapse impacts rectal prolapse recurrence after surgical repair.

DESIGN

A retrospective cohort.

SETTING

This study was performed at a single managed-care institution.

PATIENTS

Consecutive women undergoing rectal prolapse repair between 2008 and 2016 were included.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

Full-thickness rectal prolapse recurrence was compared between 4 groups: abdominal repair without pelvic organ prolapse (AR-POP); abdominal repair with pelvic organ prolapse (AR+POP); perineal repair without pelvic organ prolapse PR-POP; and perineal repair with pelvic organ prolapse (PR+POP). Recurrence-free period and hazard of recurrence were compared using Kaplan-Meier and Cox proportional hazards methods. To identify potential confounding risk factors for rectal prolapse recurrence, the characteristics of subjects with/without recurrence were compared with univariable and multivariable analyses.

RESULTS

Overall, pelvic organ prolapse was present in 33% of 112 women and was more prevalent among subjects with rectal prolapse recurrence (52.4% vs 28.6%, p = 0.04). Median follow-up was 42.5 months; rectal prolapse recurrence occurred in 18.8% at a median of 9 months. The rate of recurrence and the recurrence-free period differed significantly between groups: AR-POP 3.8%, 95.7 months; AR+POP 13.0%, 86.9 months; PR-POP 34.8%, 42.1 months; PR+POP 57.1%, 23.7 months (p < 0.001). Compared with AR-POP the HR (95% CI) of rectal prolapse recurrence was 3.1 (0.5-18.5) for AR+POP; 14.7 (3.0-72.9) for PR-POP and 31.1 (6.2-154.5) for PR+POP. Compared with AR+POP, PR+POP had a shorter recurrence-free period (p < 0.001) and a higher hazard of recurrence (HR, 10.2; 95% CI, 2.1-49.3).

LIMITATIONS

The retrospective design was a limitation of this study.

CONCLUSIONS

Pelvic organ prolapse was associated with a higher rectal prolapse recurrence rate and earlier recurrence in women undergoing perineal, but not abdominal, repairs. Multidisciplinary evaluation can facilitate individualized management of women with rectal prolapse. Abdominal repair should be considered in women with concomitant rectal and pelvic organ prolapse. See Video Abstract at http://links.lww.com/DCR/A513.

Stapled anopexy versus transanal hemorrhoidal dearterialization for hemorrhoidal disease: a three-year follow-up from a randomized study

BACKGROUND

This randomized study compared the medium-term results of stapled anopexy (SA) and transanal hemorrhoidal dearterialization with anopexy (THD) in 4 homogeneous groups of patients, 2 with third- and 2 with fourth-degree hemorrhoids.

METHODS

Forty patients with third-degree and 30 with fourth-degree hemorrhoids were randomly submitted to SA (N.=20+15) and THD (N.=20+15), respectively. Clinical controls were done every 6 months from 1 to 42 months after the operation, with incidence of recurrent hemorrhoids as primary outcome measure. Operative time, complications, pain, time to return to normal activity, costs, Short Form-36, and overall patient satisfaction were also evaluated.

RESULTS

Frequencies of preoperative obstructed defecation symptoms and prolapse recurrence were higher in patients with fourth-degree hemorrhoids, and SA was more effective than THD in reducing the risk of recurrence at 36±6 months follow-up (P=0.049). Operative time, complications, pain, and time of return to normal activity were similar in the 4 groups. Costs were significantly higher for SA in patients with fourth-degree hemorrhoids (P>0.01). A significant improvement of quality of life was observed in all groups, and no significant difference was found in overall patient satisfaction.

CONCLUSIONS

Both techniques are safe and effective in the mid-term period. SA is more effective in reducing prolapse and obstructed defecation symptoms in fourth-degree hemorrhoids, with the disadvantage of higher costs. Prolapse size and presence of obstructed defecation symptoms could be predictive criteria for choice of the best surgical technique.

Transanal anopexy with HemorPex System (HPS) is effective in treating grade II and III hemorrhoids: medium-term follow-up

BACKGROUND

Hemorrhoidal disease is a common proctologic disorder. The HemorPex System(®) (HPS) (Angiologica, S. Martino Siccomario PV, Italy) is an innovative surgical technique based on muco-hemorrhoidopexy without Doppler guidance. The aim of this study was to evaluate the efficacy of HPS in on the treatment of grade II and III hemorrhoids.

METHODS

One hundred patients with grade II and III hemorrhoidal disease were included in the study and operated on using HPS without Doppler guidance. The procedure consists of a mucopexy carried out by means of a dedicated rotating anoscope in the 6 relatively constant positions of the terminal branches of the superior hemorrhoidal artery. A direct follow-up was carried out on 100 patients for up to 3 months. A late analysis (>12 months postoperatively) was conducted by telephone interview. At follow-up the following parameters were considered: pain, bleeding, prolapse, difficulties with hygiene and patient satisfaction with treatment.

RESULTS

Operative time was 16 ± 5 min. Three-month follow-up showed significant improvement of symptoms: pain was present in 10 (10 %) patients versus 45 (45 %) preoperatively; bleeding in 13 (13 %) of patients versus 57 (57 %) preoperatively; prolapse in 13 (13 %) of patients versus 45 (45 %) preoperatively and difficulties with hygiene in 1 (1 %) versus 24 (24 %) preoperatively (all p < 0.05). At longer follow-up which was available in 67 patients, 5 patients (7.5 %) had recurrence and were reoperated on at 8, 10, 24, 26 and 36 months, respectively after the first procedure. As regards patient satisfaction, complete satisfaction was reported by 95/100 patients (95 %) at 3 months, 62/67 (92.5 %) at 12 months and 8/56 (85.7 %) at 24 months; partial satisfaction was reported by 3/100 patients (3 %) with intermittent bleeding at 3 months, 3/67 (4.4 %) patients at 12 months and 6/56 (10.7 %) patients at 24 months, all with either intermittent bleeding or prolapse. Dissatisfaction with the procedure was reported by in 1/100 (1 %) patient at 3 months, 2/67 (2.9 %) at 12 months and 2/56 (3.6 %) at 24 months including patients who underwent reintervention.

CONCLUSIONS

HPS can be used in the treatment of grade II and III hemorrhoidal disease. Our results show that this simple technique may be an effective but due to the important limitations of this study (loss to follow-up, non-comparative study) further studies are required.

Prevalence of Giardia intestinalis and Hymenolepis nana in Afghan refugee population of Mianwali district, Pakistan

BACKGROUND

Present study aimed to investigate prevalence of Giardia intestinalis and Hymenolepis nana in Afghan refugees visiting Central Health Unit (CHU), Kot Chandana (Mianwali, Northern Punjab) during two years period (February 2007 to December 2009).

METHODS

A total of 687 stool samples were collected from different age groups of both genders. Samples were processed under sterile conditions after gross examination. Microscopic examination was done on same day along with eggs (H. nana), cyst and trophozoites (G. intestinalis) detection after staining.

RESULTS

The prevalence of G. intestinalis was significantly higher (x2=59.54, p<0.001) than that of H. nana. Females were found more likely to be infected as compared to males (OR: 1.40, 95% CI=1.03-1.92). Prevalence of both parasites decreased with age and highest prevalence was observed in young individuals belonging to 1-15 years of age group (41.8% and 48.7% respectively for H. nana and G. intestinalis, p<0.001). Abdominal distress (OR: 1.13, 95%CI=0.83-1.53), vomiting (OR: 1.13, 95%CI=1.13-1.81) and rectal prolapse (OR: 4.26, 95%CI=1.38-13.16) were the gastro-intestinal clinical symptoms observed in G. intestinalis. Whereas, bloody diarrhea (OR: 1.56, 95%CI=1.00-2.43) and rectal prolapse (OR: 5.79, 95%CI=1.87-17.91) were associated with H. nana infections.

CONCLUSIONS

Intestinal parasitic infections are common among Afghan refugees and serious preventive measures should be implemented to promote the safety and healthy lifestyle of these people.

Anorectal conditions: rectal prolapse

Rectal prolapse, the protrusion of the layers of the rectal wall through the anal canal, may be partial (mucosal) or complete (full thickness). Although prolapse is most common among older women, it affects individuals of all ages, including children. Associated fecal incontinence and constipation are typical. Urinary incontinence and uterovaginal/bladder prolapse also may coexist. Some patients may have rectal ulcers. Diagnosis is predominantly clinical; visualization of the prolapse may require the patient to strain while sitting or squatting. Imaging studies, including fluoroscopic or dynamic magnetic resonance defecography, can confirm the prolapse if the diagnosis is uncertain, and endoscopy can aid in detecting other colonic/extracolonic pathology. Nonsurgical management (eg, increased fiber intake, fiber supplements, biofeedback) often is therapeutic in minor (first- or second-degree) mucosal prolapse and can help alleviate constipation and incontinence before and after surgery for patients with full-thickness prolapse. However, for full-thickness prolapse, transabdominal procedures are the most effective management and are favored for healthy patients, irrespective of age. Perineal procedures (eg, rubber band ligation, mucosal excision) can be used for patients with full-thickness prolapse who are not candidates for transabdominal surgery and for those with second- and third-degree mucosal prolapse.

Doppler-guided hemorrhoidal artery ligation: experience with 2 years follow-up

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal disease, consisting of the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis. The aim of the study was to assess the efficacy and safety of DGHAL, define its indications, and identify its possible advantages and limitations for the treatment of second- and third-degree hemorrhoids. The procedure was performed using a specially designed proctoscope. The Doppler probe was used to locate all the terminal branches of hemorrhoidal arteries, which were then sutured. Patients were followed up for 2 years. From November 2006 to May 2009, 50 patients (29 female, mean age 38.2 years) underwent this procedure. The procedure was performed under local anesthesia. An average of five ligatures was placed. Average length of hospital stay was 2 hours and return to work was 2.5 days. The mean postoperative pain score was 1.72. There were no intra- or immediate postoperative major complications. In 44 patients (88%), surgery resolved the symptoms completely in a 2-year follow-up period. DGHAL is a safe and effective procedure. DGHAL can be the choice for second- and third-degree hemorrhoids with minimal postoperative pain and quick recovery.

Neonatal genital prolapse

Neonatal genital prolapse is a rare condition, usually associated with congenital spinal defects and is often resistant to simple reduction. A case of complete uterine prolapse which was noted shortly after birth in a female baby with a meningocele at the lumbar region with rectal prolapse is reported. The vagina and uterus was restored to their normal position but came out immediately after reduction.

De novo rectal prolapse after obliterative and reconstructive vaginal surgery for urogenital prolapse

OBJECTIVE

The purpose of this study was to compare the incidence of de novo rectal prolapse after obliterative vaginal surgery with the incidence that was seen after reconstructive vaginal surgery for urogenital prolapse.

STUDY DESIGN

A chart review was performed on subjects who underwent vaginal surgery for urogenital prolapse from Jan. 1, 2001, through Dec. 31, 2004, at the Cleveland Clinic. Diagnosis of postoperative rectal prolapse was identified with ICD-9 code 569.1.

RESULTS

Nine hundred sixteen women underwent vaginal surgery for urogenital prolapse. Ninety-two percent of the women (n = 840) underwent reconstructive surgery, and 8% of the women (n = 76) underwent obliterative surgery. The incidence of postoperative full-thickness rectal prolapse in women who were > or = 65 years old who underwent obliterative surgery was 3 of 74 (4.1%; 95% CI, 1.4-11), with an estimated odds ratio of 22 (95% CI, 2.3-196; P < .002) compared with women who were > or = 65 years old who underwent reconstructive surgery.

CONCLUSION

Obliterative surgery is associated with a substantially greater risk of de novo rectal prolapse than reconstructive vaginal surgery for urogenital prolapse.

How accurate are published recurrence rates after rectal prolapse surgery? A meta-analysis of individual patient data

BACKGROUND

The literature shows wide variations of recurrence rates (RRs) after abdominal surgery for rectal prolapse. The aim of this meta-analysis was to evaluate the accuracy of published RRs.

METHODS

An electronic search was performed with no restrictions. Inclusion criterion was abdominal surgery in at least 10 adults with follow-up evaluation of any length of time. Two reviewers screened 1669 references. A total of 190 investigators were asked to provide individual patient data that should be the same used at the time their reports were written. The RR was estimated by actuarial analysis. Investigators were asked for comments on results.

RESULTS

Individual patient data from 6 reports published with 273 patients (186 women, 87 men) with a median age of 54 years (range, 18-88 y) were available. Abdominal surgery included mobilization with pexy (88%), with additional resection (7%), or mobilization only (5%). There were 16 recurrences at a median follow-up period of 3.94 years (range, .05-15.11 y). The effect of age (hazard ratio [HR], 2.010; P = .3443), sex (HR, 2.070; P = .4260), surgical technique (HR, .743; P = .7669), and publication (HR, 1.014; P = .8747) on RR was not significant. Two publications reported a RR of 0. In another report, the published and estimated RRs of 15% did not differ. Published RRs differed from estimated RRs in 3 reports (2.5% vs 4%; 7% vs 54%; and 9.6% vs 36%). The pooled odds ratios of 6 reports revealed a borderline significant difference between the published and estimated RRs (P = .066).

CONCLUSIONS

Published RRs differed by as much as 47% from the RRs estimated by actuarial analysis depending on event definition and how the data were censored.

Epidemiologic aspects of complete rectal prolapse

BACKGROUND AND AIMS

This study was undertaken to find out the incidence of rectal prolapse.

MATERIAL AND METHODS

Ninety-nine patients operated on for rectal prolapse at Jyväskylä Central Hospital were studied. Patients operated between 1988 and 1998 were studied retrospectively from hospital records using chart review and thirty-five patients operated on between 1999 and 2002 were studied prospectively using our proctologic database.

RESULTS

The annual incidence of diagnosed complete rectal prolapse in the district of Central Finland was mean 2.5 (range, 0.79-6.08) per 100 000 population. There were ten men (10 percent) and 89 women (90 percent). Median age of the patients was 69 (range, 21-91) years. Forty-eight percent of the patients had concomitant cardiovascular disease and 15 percent psychiatric illness. Anal incontinence affecting quality of life was seen in 64 percent and constipation in 72 percent of patients. Constipation tended to be more attributed to difficult evacuation (72 percent) than to impaired bowel action (18 percent).

CONCLUSION

The annual incidence of rectal prolapse is 2.5 per 100 000 population. Rectal prolapse is associated with anal incontinence and constipation in majority of patients.

Hemorrhoids and rectal internal mucosal prolapse: one or two conditions? A national survey

The surgical modalities for the treatment of hemorrhoids are quite numerous due to the rapid diffusion of new surgical techniques and to the different approaches to the pathophysiology of the disease by the proctologists. Stapled hemorrhoidopexy, one of the most recent surgical options proposed, emphasizes the role of rectal internal mucosal prolapse (RIMP) as the main cause of the disease. We performed a national survey among the most important proctologists on this particular clinical condition, in order to better define the indications for the surgical treatment of hemorrhoids. A questionnaire concerning the main clinical features of RIMP was mailed to 84 coloproctology centers. Two-thirds of the 41 proctologists who responded found RIMP in a minority of patients with hemorrhoids, whereas only one-third found RIMP in more than half of their patients. A circumferential RIMP was identified by only 10% of the surgeons, whereas a coincidence between pre- and postoperative diagnoses of this condition was possible in half of proctologists' patients. RIMP is not frequently associated with hemorrhoids. Therefore, it is unlikely to be a cause of hemorrhoidal disease, and many surgeons still recognize it as a difficult clinical condition to define.

Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects

OBJECTIVE

The purpose of this study was to describe the distribution of pelvic organ support in a gynecologic clinic population to define the clinical disease state of pelvic organ prolapse and to analyze its epidemiologic condition.

STUDY DESIGN

This was a multicenter observational study. Subjects who were seen at outpatient gynecology clinics who required an annual gynecologic examination underwent a pelvic organ prolapse quantification examination and completed a prolapse symptom questionnaire. Receiver operator characteristic curves were used to define pelvic organ prolapse with the use of symptoms and pelvic organ prolapse quantification examination measures. Standard age-adjusted univariate and multivariate logistic regression analysis were used to evaluate various relationships.

RESULTS

The population consisted of 1004 women who were aged 18 to 83 years. The prevalence of pelvic organ prolapse quantification stages was 24% (stage 0), 38% (stage 1), 35% (stage 2), and 2% (stage 3). The definition of pelvic organ prolapse that was determined by the receiver operator characteristic curve was the leading edge of their vaginal wall that was -0.5 cm above the hymenal remnants. Multivariate analysis revealed age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus as risk factors for pelvic organ prolapse, as defined in this population.

CONCLUSION

The results from this population suggest that there is a bell-shaped distribution of pelvic organ support in a gynecologic clinic population. Advancing age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus have the strongest correlations with prolapse.

Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations

PURPOSE

Rectal prolapse is a known postoperative problem in children with anorectal malformations. The aims of this study were to determine the incidence of significant rectal prolapse (>5 mm), to objectively quantify its predisposing factors, and to offer recommendations as to its prevention and surgical treatment.

METHODS

The authors reviewed their series of 1619 patients with anorectal malformations; 1169 underwent primary posterior sagittal anorectoplasty (PSARP) at their institution between 1980 and 2002, and complete records were available for 833. The series was analyzed for incidence of prolapse, type of anorectal malformation, status of the sacrum, muscle quality, associated vertebral and spinal anomalies, and postoperative constipation. A specific technique for prolapse repair was used.

RESULTS

Of 833 patients, 45 developed significant rectal prolapse (3.8%). The mean age at the time of PSARP was 0.73 years (range, 0.19-5 years). The average time to recognition of prolapse following PSARP was 13.1 months. Of these 45 patients, 32 required surgical repair and of those, 3 required a second surgical repair. The incidence of prolapse varied by complexity of anorectal defect: cloaca (6.2%), rectobladder neck fistula (6.8%), rectourethral fistula (5.4%), rectovestibular fistula (1.2%), rectal atresia (0%), and rectoperineal fistula (0%). There was a significantly increased incidence of prolapse in patients with a low muscle quality score and in patients with vertebral anomalies (20% vs 3.2%). The presence of a tethered cord and an abnormal sacral ratio did not correlate with an increased incidence of prolapse. Twenty-two patients developed prolapse following colostomy closure, and of these, 12 (55%) suffered from constipation.

CONCLUSIONS

The overall incidence of significant rectal prolapse following PSARP is low. Prevention of prolapse with the PSARP technique may be because of key technical steps. Patients with higher anorectal malformations, poorer muscle quality, and vertebral anomalies had a greater risk of developing postoperative rectal prolapse. The presence of tethered cord and quality of the sacrum were not predictive of postoperative prolapse. Constipation seems to be a factor in the development of prolapse.

Der Rektumprolaps des Erwachsenen

The etiology of rectal prolapse is unclear. Diagnosis is easy by local inspection. The ideal surgery would repair the prolapse, correct any functional problems such as incontinence or constipation, be minimally invasive and cost-effective, and result in minimal morbidity and recurrence. The best surgical repair remains controversial-whether by the transanal/perineal or abdominal approach-with or without resection and rectopexy. There are no prospective-randomized studies that convincingly answer the numerous questions. The best possible option today seems to be the abdominal/laparoscopic method with a resection rectopexy according to Frykman and Goldberg.

Pelvic organ descent in young nulligravid women

OBJECTIVE

There is little information available on what constitutes "normal" pelvic organ mobility. This study presents normal values for urethral, bladder, cervical, and rectal descent on Valsalva.

STUDY DESIGN

One hundred eighteen nulligravid white women aged 18 to 24 years were recruited for a prospective observational study. Translabial ultrasound was undertaken supine and after voiding, with the most effective of at least 3 Valsalva maneuvers used for evaluation.

RESULTS

Urethral rotation on Valsalva varied from 0 to +90 degrees (mean 32 degrees), bladder neck descent from 1.2 to 40.2 mm (mean 17.4 mm). The cervix descended to between 59 and 0 mm above the symphysis pubis (mean 30.8 mm); the rectal ampulla descended to between 54 mm above and 22 mm below the symphyseal margin (mean 7.8 mm). In a test-retest series, intraclass correlations were between 0.64 and 0.89, implying good-to-excellent repeatability of the ultrasound assessment.

CONCLUSION

A wide range of values was obtained for all parameters. A significant congenital contribution to the phenotype of female pelvic organ prolapse appears likely.

Rectal prolapse in autistic children

Rectal prolapse in children is not uncommon, but surgery is rarely indicated. In mentally challenged adults and children, rectal prolapse occurs more frequently than in the general population and often requires surgical intervention in the second to third decade of life. The authors describe 3 children with autism and mental retardation who presented with rectal prolapse at an earlier age than would be anticipated with mental retardation alone. All 3 children required surgical intervention.

Length of docked tail and the incidence of rectal prolapse in lambs

A multistate cooperative study was conducted to study the current issue of tail length in docked lambs and its relationship to incidence of rectal prolapse. A total of 1,227 lambs at six locations were randomly allocated to two or three tail dock treatments: 1) short--tail was removed as close to the body as possible, 2) medium--tail was removed at a location midway between the attachment of the tail to the body and the attachment of the caudal folds to the tail, and 3) long--tail was removed at the attachment of the caudal folds to the tail. Short-docked lambs had a greater (P < 0.05) incidence of rectal prolapse (7.8%) than lambs with a medium (4.0%) or a long (1.8%) dock. Female lambs had a higher (P < 0.05) incidence of rectal prolapse than male lambs. At two stations, lambs were finished either in a feedlot on a high-concentrate diet or on pasture with no grain supplementation. At one station, with a very low incidence of rectal prolapse, there was no difference in incidence between lambs finished in the feedlot or on pasture; however, at the station with a relatively high incidence of rectal prolapse, lambs in the feedlot had a higher (P < 0.05) incidence than lambs on pasture. The half-sib estimate of heritability for the incidence of rectal prolapse was low (0.14). The results of this study strongly implicate short dock length as a cause of rectal prolapse in lambs finished on high-concentrate diets. Furthermore, the results of this study and the only other study known conducted on this issue strongly suggest that docking lambs at the site of the attachment of the caudal folds to the tail will result in a negligible incidence of rectal prolapse.

Helicoidal suture: alternative treatment for complete rectal prolapse in high-risk patients

BACKGROUND AND AIMS

Optimal treatment for rectal prolapse is controversial. We describe a novel alternative treatment for high-risk patients with complete rectal prolapse.

PATIENTS AND METHODS

Sixteen high-risk patients over 60 years old with complete rectal prolapse were examined. All patients had significant past medical history and were classified as grade III (ASA) surgical risk. The helicoidal suture technique is described. Postoperative parameters evaluated were morbidity, mortality, postoperative symptoms, recurrence and anal incontinence score. Median follow-up was 60 months.

RESULTS

There were no operative complications or mortality in the series; one patient experienced recurrence. Median postoperative anal incontinence score was 6.06 (range 1-30; preoperative 23.6).

CONCLUSION

This technique provides adequate functional outcomes and could be an effective therapeutic strategy against rectal prolapse in high-risk patients.

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

OBJECTIVE

The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction.

STUDY DESIGN

Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis).

RESULTS

All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding.

CONCLUSION

The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence.

Pelvic organ prolapse

The separate disease entities that are included in the general term of pelvic organ prolapse have been discussed in detail in this chapter. The focus of discussion centered on the pathophysiology and clinical presentation of these conditions. At this point, the emergency physician should be able to properly recognize, assess, initiate treatment, and obtain appropriate referral in cases of pelvic organ prolapse. Postoperative complications commonly seen after these entities are repaired have also been reviewed to help the emergency medicine physician recognize and mange common postoperative complications.

Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers Danlos syndrome

OBJECTIVE

This study was undertaken to determine the prevalence of urinary incontinence and pelvic organ prolapse in a cohort of women with either Marfan syndrome or Ehlers-Danlos syndrome.

STUDY DESIGN

Female patients with either Marfan syndrome or Ehlers-Danlos syndrome were identified through a medical records search at two urban hospitals. Each patient's medical record was reviewed, and the history of pelvic organ prolapse and urinary incontinence was obtained through telephone interview.

RESULTS

Twelve women with Marfan syndrome were identified. Among these women 5 (42%) reported a history of urinary incontinence and 4 (33%) reported a history of pelvic organ prolapse. Eight women with Ehlers-Danlos syndrome were identified. Among these women 4 (50%) reported a history of urinary incontinence and 6 (75%) reported a history of pelvic organ prolapse.

CONCLUSIONS

Women with Marfan or Ehlers-Danlos syndrome have high rates of urinary incontinence and pelvic organ prolapse. This finding supports the hypothesized etiologic role of connective tissue disorders as a factor in the pathogenesis of these conditions.

Pathophysiology of anorectal dysfunction

Anorectal disorders are the cause of significant discomfort and embarrassment in women. The onset typically follows childbirth and symptoms increase with age. Anal incontinence, rectovaginal fistula, rectal prolapse, anal fissure, and constipation are considered.

Management of colorectal-anal dysfunction

Although the majority of patients with low-grade anal incontinence and constipation should be treated medically, for some, efforts will be unsuccessful and surgical therapy will be in order. Full thickness rectal prolapse will, in all early cases, be treated surgically. This article outlines the surgical treatment options for patients with anal incontinence, rectal prolapse, and constipation. Optimal functional outcomes with surgical treatment are based on full physiologic evaluation and careful patient selection.

[Sacral rectopexy-sigmoidectomy in the treatment of rectal prolapse syndrome. Anatomical and functional results]

Various options have been suggested to improve the functional results of abdominal rectopexy for rectal prolapse and to limit the risk of post-operative constipation.

OBJECTIVES

In this prospective study, we evaluated the results of posterior abdominal rectopexy-sigmoidectomy to treat rectal prolapse syndrome in terms of morbidity, anatomic correction and bowel function. Patient benefits after surgery were assessed according to their pre-operative functional status.

PATIENTS AND METHODS

Twenty patients (14 females, mean age: 42 years) were treated for rectal prolapse with sutured abdominal rectopexy and sigmoidectomy.

RESULTS

(a) Thirteen patients had normal post-operative course. No anastomotic leak occurred. Mean hospital stay was 9.7 days. (b) Anatomical control was obtained in all cases for a mean follow-up of 31.2 months without recurrence. (c) Functional results: bowel movements per week remained unchanged pre- and post-operatively (18.6 +/- 33 vs 18.1 +/- 17). Constipation appeared or worsened in 2 patients (10%). Anal incontinence (n = 6-30%) never worsened post-operatively and improved in 3.

CONCLUSIONS

This prospective clinical study confirmed the important functional disorders occurring in rectal prolapse syndrome. Rectopexy-sigmoidectomy is a valid option with stable mid-term results. Constipation was observed in 10% with no worsening of anal incontinence.

Association of rectal prolapse with colorectal cancer

BACKGROUND

Although screening for colorectal cancer facilitates earlier detection and improves survival, cost-effective screening requires identification of patients at high risk for colorectal cancer. Rectal prolapse has not been clearly linked to colorectal carcinoma. Whether patients with rectal prolapse should be screened for colorectal cancer is therefore unclear.

METHODS

We retrospectively identified 70 consecutive patients treated for rectal prolapse at a community hospital during a period of 16 years and monitored for an average of 4.4 +/- 2.7 years and 350 patients of similar age treated for chronic unrelated conditions in the same institution during a similar period. We determined their incidence of colorectal cancer and sought demographic correlates.

RESULTS

The prevalence of rectosigmoid carcinoma among patients with prolapse was 5.7% during the study. Only 1.4% of the comparative group had colorectal cancer. Thus patients with rectal prolapse exhibited a 4.2-fold (95% confidence interval, 1.1 to 16.0) relative risk for colorectal cancer over the comparative group (p < 0.02).

CONCLUSIONS

To the extent to which these patients represent the population of patients with rectal prolapse, routine initial screening of patients with symptomatic rectal prolapse by use of flexible sigmoidoscopy may be appropriate.

Abdominal rectopexy for rectal prolapse. Influence of surgical technique on functional outcome

PURPOSE

The aim of this study was to investigate the influence of surgical technique on functional and manovolumetric results in patients treated with Marlex mesh abdominal rectopexy.

METHODS

The lateral ligaments were completely divided (the Wells procedure) in 16 patients and preserved (the Ripstein procedure) in 16 patients. Clinical and physiologic assessment were performed before and at 3, 6, and 12 months after operation.

RESULTS

Improvement of continence was similar. Bowel regulation problems which were unchanged after the Ripstein procedure increased significantly after the Wells procedure (P < 0.01). Rectal volume became reduced in the group who received the Wells procedure (225 ml vs. 115 ml, P < 0.05 at one year), but remained unchanged after receiving the Ripstein procedure. The pressure thresholds required to elicit sensation of rectal filling and defecation urge were increased after the Wells procedure (15 cm of H2O vs. 25 cm of H2O, P < 0.05 and 25 cm of H2O vs. 45 cm of H2O, P < 0.05, respectively). In the Ripstein group there was only a slight increase of the threshold for urge (P < 0.05).

CONCLUSION

The Wells procedure was followed by severe rectal dysfunction accompanied by increased constipation and evacuation problems. The Ripstein procedure, preserving the lateral ligaments, appears not to affect such symptoms adversely. On the other hand, improvement is not likely to occur.

[Videoproctography in the study of rectal intussusception. The authors' own experience]

Videoproctography has proved to be a useful diagnostic technique to investigate anorectal disorders; it can provide morphological and functional information which no other diagnostic method yields. From a series of 898 videoproctographs, the findings of 117 patients with rectal intussusception were retrospectively reviewed. The most common symptoms were an incomplete emptying feeling (93% of cases), obstructed defecation (78%), and a feeling of upright rectal weighting (71%). Of the three known types of rectal intussusception, the most common type was distal intussusception (44%), followed by the rectoanal type (38%) and finally by the proximal type (19%). The three types of intussusception were frequently (42%) associated with other disorders of rectal ampulla and especially with rectocele (15%), mucosal prolapse (8%), and descending perineum syndrome (12%); they had different clinical correlations and proctographic patterns and could be recognized in different defecation phases. In our personal experience, proctography with videorecording was a useful diagnostic tool in the dynamic assessment of this morphofunctional disorder which represents one of its major indications.

[The functional and manometric results of 2 surgical methods of posterior abdominal rectopexy]

Functional changes after posterior abdominal rectopexy for the treatment of rectal prolapse are not fully understood. We studied the effects of Wells' or Ripstein's rectopexy on functional characteristics as related to anal sphincter function, rectal volume and sensory function in 31 patients with complete or internal rectal prolapse. We have observed an improvement of continence over 70% in both groups. However, an absent or a decreased call to stool, constipation and evacuation difficulties are the aftermath of Wells' rectopexy, while these complaints appear basically unaffected by Ripstein's technique. Maximal squeeze pressure was slightly increased after Ripstein's rectopexy, whereas no significant effects were found on anal pressures. Postoperatively the rectal capacity was reduced by Well's procedure (p < 0.05), while no significant changes were observed with Ripstein's operation. After the Wells procedure patients developed at the threshold for the relaxation of the internal sphincter progressively lower rectal volumes, reaching one year after rectopexy the statistical significance. Sensory thresholds for sense of filling and urge were significantly raised after Wells' rectopexy even one year after operation, whereas after Ripstein's operation sense of filling was not significantly affected and while sense of urge was increased early postoperatively, it was not significantly changed at one hear postoperative control. In conclusion, when fecal incontinence appears associated to a rectal prolapse has good chances to improve postoperatively. Preoperative evacuation difficulties seem to be unaffected by a posterior abdominal rectopexy, Wells or Ripstein, but an extensive dissection of the rectum with the division of the lateral stalks, as it is performed in Wells' operation, seems to be a procedure that can create a further burden of problems the the patient and it seems coupled to a manovolumetric elevation of rectal sensory thresholds.

Reappraisal of Ekehorn's rectopexy in the management of rectal prolapse in children

An old and simple operative technique for the treatment of rectal prolapse in children, first described by Ekehorn in 1909, has been reviewed. The technique consists of the insertion of a mattress suture (nonabsorbable and multifilament material) in the rectal ampulla through the lowermost part of the sacrum: the strands of the mattress suture are tied firmly over a piece of dry gauze at the level of the sacrococcygeal junction. By leaving the suture in place for 10 days, the local inflammation and infection causes firm adhesions between the rectal wall and the perirectal tissue so that the anorectal wall is bound to the surroundings (sacrorectopexy). The results of this retrospective study on 22 patients proves that this form of transsacral rectopexy in the management of rectal prolapse in children is effective (100%), simple and without complications compared to other techniques. There were no recurrences and no major morbidity. The overall surgical treatment of rectal prolapse in children is briefly reviewed.

Anterior resection for the treatment of rectal prolapse: a 20-year experience

Between 1971 and 1991, 41 patients underwent anterior resection for the treatment of complete rectal prolapse. Anterior resection was performed after full rectal mobilization to the levator ani muscles with reanastomosis (39 hand-sewn and two stapled) carried out to peritonealized distal rectum. The 41 patients comprised 35 women and six men with an average age of 56 years (range, 7-88 years). Postoperative follow-up averaged 6 years (range, 6 months to 18 years). Three patients (7%) suffered recurrent prolapse in 2, 2.5, and 5.5 years, respectively. Mortality was 0 per cent; morbidity was 15 per cent including three incisional herniae, two small bowel obstructions, and one stroke. No pelvic sepsis, abscess, or anastomotic dehiscence occurred. Anal incontinence was a preoperative finding in 21 patients (51%) with rectal prolapse. Nineteen of these patients (90%) noted either improvement or no change in postoperative continence. Anterior resection is a familiar, frequently performed operation that does not require a foreign body or rectal suspension. We believe this to be the procedure of choice for patients with complete rectal prolapse. Anterior resection withstands long-term scrutiny both in terms of recurrence rate and associated complications.

[Uterine fixation to the promontory and the Orr-Loygue operation in associated genital and rectal prolapse]

The association of genital prolapse and rectal prolapse is rare. The authors report six cases of simultaneous mixed prolapse treated surgically via an abdominal approach. The latter technique enables the treatment of genital prolapse by uterine fixation to the promontory and rectal prolapse by rectopexy using the Orr-Loygue technique. Chronic constipation and obstetric trauma are constantly found among etiological factors. Four of our patients had urinary stress incontinence. There were no preoperative complications. One patient reported worsening of her constipation. Mean follow-up is only 20 months (2 months to 3 years), but no recurrences have occurred. Review of the literature and of series with more than fifteen years follow-up shows that the Orr-Loygue operation is reliable with a low complication rate and only rare recurrences.

The importance of the endopelvic fascia repair during vaginal hysterectomy

During 1985 to 1989, 177 vaginal hysterectomies were performed in the Department of Gynecology, Kaplan Hospital, Rehovot, Israel, using the Porges technique with some modifications. Ninety patients had some degree of loss of the pelvic support--anterior or posterior wall relaxation, enterocele or uterine prolapse in various degrees. The patients were allocated to two groups, in which two different techniques were compared: group 1, with repair of the pubocervical and pararectal fascia and group 2 without the repair. The repair of the pubocervical and pararectal fascia after vaginal hysterectomy prevented vaginal vault prolapse (zero versus 15 percent, p < 0.01) and reduced the incidence of recurrent rectocele (23 versus 55 percent, p < 0.05) and recurrent cystocele (14 versus 45 percent, p < 0.005). Recurrent genuine stress incontinence was found in 9 percent of patients in group 1 and 18 percent of patients in group 2 (not statistically significant; p = 0.163). Optimal management of relaxation of the vaginal wall during vaginal hysterectomy requires clinical suspicion and precise preoperative diagnosis and therapeutic plan. In the present study, the need for careful repair of the pubocervical and pararectal fascia during vaginal hysterectomy to prevent vaginal vault prolapse is emphasized. This procedure does not prolong the operation significantly (92 +/- 15 versus 84 +/- 17 minutes) and has no deleterious postoperative complications.

[The functional recovery of the internal anal sphincter and the restoration of continence after rectopexy for rectal prolapse]

Eleven patients with full thickness rectal prolapse underwent ambulatory fine wire electromyography (EMG) of the internal anal sphincter (IAS), external anal sphincter and puborectalis muscle, and anorectal manometry using a computerised system. Examinations were performed preoperatively and at 3 months following rectopexy. The median preoperative IAS EMG frequency was 0.21 Hz (range = 0.05-0.30) and the median preoperative resting anal pressure (RAP) was 13 cmH2O (range = 2-84 cmH2O). A significant improvement in the IAS EMG frequency (median = 0.31 Hz; 0.23-0.47 Hz; p < 0.02) and RAP (median = 30 cmH2O; 20-84 cmH2O; p < 0.01) was noted post-rectopexy but these parameters remained significantly different from a group of normal controls (median IAS EMG frequency = 0.48 Hz; 0.25-0.61 Hz; median RAP = 76 cmH2O; 22-120 cmH2O). We suggest that repair of the prolapse allows the IAS to recover by removing the cause of persistent recto-anal inhibition.

[The functional and manometric-volumetric results following abdominal rectopexy for total rectal prolapse]

Functional changes after the posterior abdominal rectopexy for the treatment of rectal prolapse are not fully understood. We studied the effects of Wells' or Ripstein's rectopexy on functional characteristics as related to anal sphincter function, rectal volume and sensory function in 21 patients with complete rectal prolapse. We have observed an improvement of continence over 70 per cent in both groups. However, an absent or a decreased call to stool, constipation and evacuation difficulties are the aftermath of Wells' rectopexy, while these complaints appear basically unaffected by Ripstein's technique. Sensory thresholds for sense of filling and urge were significantly raised after Wells' rectopexy even one year after operation, whereas after Ripstein's operation sense of filling was not significantly affected and while sense of urge was increased early postoperatively, it was not significantly changed at one year postoperative control. In conclusion, when fecal incontinence appears associated to a complete rectal prolapse has good chances to improve postoperatively. Preoperative evacuation difficulties seems to be unaffected by a posterior abdominal rectopexy, Wells or Ripstein, but an extensive dissection of the rectum with the division of the lateral stalks, as it is performed in Wells' operation, seems to be a procedure that can create a further burden of problems to the patient and it seems coupled to a manovolumetric elevation of rectal sensory thresholds.

[Rectal prolapse and fecal incontinence. A prospective manometric study]

In the present work we have studied two consecutive series of patients who underwent a posterior abdominal rectopexy according to Wells or Ripstein. During the year of follow up no recurrences were observed. Functional results, evaluated according to a protocol, by history of the patient and manovolumetry, shoved an improvement of fecal continence in more than half of the incontinents in both series. However, constipation increased after Wells' rectopexy, while no major changes were observed after Ripstein's rectopexy. We conclude that the first surgical technique may offers worse functional results.

Internal rectal prolapse: rubber-band ligation as treatment for a neglected disease

Internal rectal prolapse was diagnosed in 21 patients with signs and symptoms consistent with this syndrome. They all underwent rubber-band ligation of the excess mucosa--2.2 procedures per patient on average. Eight patients became asymptomatic and 13 significantly improved clinically. Six patients, in spite of the clinical improvement, had rectoscopic evidence of recurrence. No side effects or complications were noted. Internal rectal prolapse has to be considered in the differential diagnosis of anorectal syndromes. Rubber-band ligation is a safe, simple procedure, leading to resolution of symptoms, and may prevent progression to total rectal prolapse.

Rates of diseases and their associated costs in two Colorado sheep feedlots (1985-1986)

Data related to rates of disease and their associated costs were collected for 12 months from 2 sheep feedlots in northern Colorado. There was an apparent seasonal occurrence of many of the diseases. Pneumonia, enterotoxemia, acidosis, and transport tetany accounted for most of the diseases seen in these feedlots and were responsible for most of the economic losses. There was a large difference in the incidence of diseases between the 2 feedlots and in the expenditures for disease prevention between the 2 feedlots.

Patterns and determinants of rectal prolapse in a herd of pigs

A prospective cohort study was designed to describe the patterns and to determine the factors associated with the risk of rectal prolapse in a commercial swine herd in California, USA. Thirty (1.0 per cent) of 2862 pigs prolapsed between 12 and 28 weeks of age with the peak incidence occurring in 14- to 16-week-old pigs. The overall prolapse rate was 9.1 cases per 100,000 days at risk. Prolapse rates were highest during the winter and autumn months. Other factors associated with an increased risk of prolapse were maleness (relative risk 2.3) birthweight less than 1000 g (relative risk 3.4) Yorkshire boar A (relative risk 2.8) and dams of litter number 1 (relative risk 14.9), 2 (relative risk 8.2) and 3 (relative risk 9.8). No evidence was found to support the hypothesis that diarrhoea and coughing are factors associated with a risk of prolapse.