Clinical Practice Guidelines for the Treatment of Rectal Prolapse

Laparoscopic Sutureless Rectopexy Using a Fixation Device for Complete Rectal Prolapse

BACKGROUND

Complete rectal prolapse (CRP) commonly affects the daily life of older people and has no established operative treatment approach. We describe our simple method of laparoscopic, sutureless rectopexy, involving rectal mobilization (along with its peritoneum bilaterally) and fixation to the sacral promontory using a fixation device. We also present an analysis of short-term outcomes in patients treated using this procedure.

MATERIALS AND METHODS

We retrospectively evaluated 62 patients with CRP, who underwent a laparoscopic rectopexy via tack fixation, between 2004 and 2017. The peritoneum was widely attached near the site of peritoneal reflection, as in rectal cancer surgery. The hypogastric nerve was carefully detached from the front of the sacrum. Keeping the nerve intact, we lifted and mobilized the dissected rectum cranially towards the promontory, and the rectal peritoneum was affixed to the sacrum by applying 2 to 3 fixed tacks bilaterally, using a fixation device.

RESULTS

The median age of the study group was 80 (10 to 91) years. All procedures were successful without serious intraoperative complications; only 1 patient required conversion to open surgery. Median values for operative duration, intraoperative blood loss, and postoperative period of hospitalization were 177 (125 to 441) minutes, 5 (0 to 275) mL, and 7 (3 to 17) days, respectively. Only 6 (9.7%) patients experienced recurrence during the follow-up period.

CONCLUSION

Laparoscopic tacking rectopexy performed using a fixation device for repairing CRP is a simple, safe, and sutureless procedure with no severe complications or mortality.

Does the Length of the Prolapsed Rectum Impact Outcome of Surgical Repair?

BACKGROUND

There are many surgical options for the treatment of rectal prolapse with varying recurrence rates reported. The association between rectal prolapse length and recurrence risk has not been explored previously.

OBJECTIVE

The purpose of this study was to determine whether length of prolapse predicts a risk of recurrence.

DESIGN

Consecutive patients from a prospectively collected institutional review board-approved data registry were evaluated.

SETTINGS

The study was conducted at the Cleveland Clinic Department of Colorectal Surgery.

PATIENTS

All patients from 2010 to 2018 who underwent surgical intervention for rectal prolapse were included.

INTERVENTION

Perineal repair with Delorme procedure and Altemeier, as well as abdominal repair with ventral rectopexy, resection rectopexy, and posterior rectopexy, was included.

MAIN OUTCOME MEASURES

Prolapse length, recurrence, type of surgery, and primary or secondary procedure were measured.

RESULTS

In total, 280 patients had prolapse surgery over 8 years, mean age was 59 years (SD = 18 y), and 92.4% were female. Seventy percent had a prolapse length documented as <5 cm, and 30% had prolapse length documented as >5 cm. The mean prolapse length was 4.8 cm (SD = 2.9 cm). The overall rate of recurrent prolapse was 18%. There were 51 patients who had a recurrent prolapse after their first prolapse surgery. Factors significant for recurrence on univariate analysis were a perineal approach (p = 0.03), previous Delorme procedure (p < 0.001), and prolapse length >5 cm (p = 0.04). On multivariate analysis there was significantly increased recurrence with length of prolapse >5 cm (OR = 2.2 (95% CI, 1.1-4.4); p = 0.02) and having a previous Delorme procedure (OR = 4.0 (95% CI, 1.6-10.1); p = 0.004). For each 1-cm increase in prolapse, the odds of recurrence increased by a factor of 2.2.

LIMITATIONS

This was a retrospective study of a heterogenous patient cohort.

CONCLUSIONS

The greater the length of prolapsed rectum, the greater the risk of recurrence. The length of prolapse should be considered when planning the most appropriate surgical repair to modify the recurrence risk. See Video Abstract at http://links.lww.com/DCR/B463. EL TAMAÑO DEL RECTO PROLAPSADO AFECTA EL RESULTADO DE LA REPARACIÓN QUIRÚRGICA?: Existen muchas opciones quirúrgicas para el tratamiento del prolapso de recto con diferentes tasas de recurrencia publicadas. La asociación entre el tamaño del prolapso rectal y el riesgo de recurrencia no se han explorado previamente.Determinar si el largo en el tamaño del prolapso predice un riesgo de recidiva.Se evaluaron pacientes consecutivos de un registro de datos aprobado por el IRB recopilado prospectivamente.Departamento de cirugía colorrectal de la Clínica Cleveland, en Ohio.Todos aquellos pacientes que entre 2010 y 2018 se sometieron a una intervención quirúrgica por prolapso completo de recto.La reparación perineal incluyó los procedimientos de Altemeier y Delorme. Las reparaciones abdominales incluidas fueron la rectopexia ventral, la rectopexia con resección y la rectopexia posterior.Tamaño del prolapso, recurrencia, tipo de intervención quirúrgica y tipo de procedimiento (primario o secundario).En total, 280 pacientes se sometieron a cirugía de prolapso rectal durante 8 años, la edad media fue de 59 años (DE 18) donde el 92,4% eran mujeres. El 70% tenían un tamaño de prolapso documentado como < 5 cm y 30% tenían un tamaño de prolapso documentada como > 5 cm. La longitud media del prolapso fue de 4,8 cm (DE 2,9).La tasa general de recidiva del prolapso fue de 18%. Hubo 51 pacientes que presentaron recidiva del prolapso después de una primera cirugía. Los factores significativos para la recidiva en el análisis univariado fueron el abordaje perineal (p = 0.03), un procedimiento de Delorme previo (p <0.001) y el tamaño del prolapso > 5 cm (p = 0.04). En el análisis multivariado, hubo un aumento significativo de la recidiva en aquellos prolapsos de > 5 cm (OR 2,2; IC del 95%: 1,09-4,4; p = 0,02) con un procedimiento de Delorme previo (OR 4; IC del 95%: 1,6 a 10,1; p = 0,004). Por cada centímetro de tamaño del prolapso, las probabilidades de recidiva aumentaron en un factor de 2,2.Estudio retrospectivo de una cohorte de pacientes heterogénea.Cuanto mayor es el tamaño del recto prolapsado, mayor es el riesgo de recidiva. Se debe evaluar muy cuidadosamente el tamaño de los prolapsos para escoger la corrección quirúrgica más apropiada y así disminuir el riesgo de recidivas.Consulte Video Resumen en http://links.lww.com/DCR/B463. (Traducción-Dr Xavier Delgadillo).

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse

AIM

Despite the financial and value-based implications associated with higher levels of care at discharge, few studies have evaluated modifiable treatment factors that may optimize postacute care. The aim of this work was to assess the association between operative approach and disposition to a higher level of care and other outcomes following surgery for rectal prolapse.

METHOD

Using a retrospective cohort study design, the database of the National Surgical Quality Improvement Program was used to identify patients with rectal prolapse who underwent perineal repair or open or laparoscopic rectopexy with or without resection between 2012 and 2017. Discharge destination and 30-day postoperative outcomes were compared using propensity score mathcing and weighting. Nomograms generated using multivariable regression calculated the risk of requiring higher levels of care upon discharge and morbidity.

RESULTS

Propensity-score analysis included 3000 patients [1500 in the perineal group, 580 in the open abdominal group and 920 in the minimally invasive (MIS) group]. Patients who received open abdominal surgery were more likely to require elevation of care at destination compared with those who received perineal surgery (OR 1.65, 95% CI 1.22-1.24) and MIS abdominal surgery (OR 1.80, 95% CI 1.18-2.76). Similar effects were seen for overall morbidity. Increased age, higher American Society of Anesthesiologists class, congestive heart failure, dependent functional status and open surgery were independent predictors of discharge to higher level of care (c-statistic = 0.79).

CONCLUSION

Open surgery compared with MIS and perineal surgery was associated with higher levels of discharge disposition following rectal prolapse surgery. Future research should continue to identify modifiable treatment factors that reduce poor postoperative outcomes among patients with rectal prolapse.

Enterococcus faecalis infective endocarditis arising from chronic rectal prolapse in the setting of spinal cord injury

A 45-year-old man had recurrent presentations with pleuritic chest pain and shortness of breath. Four months prior, he had developed cauda equina syndrome from a spinal epidural abscess in the setting of intravenous drug use, complicated by lasting neurological deficits and a rectal prolapse. On his final presentation, blood cultures taken in the absence of antibiotics grew Enterococcus faecalis from multiple sets. A transoesophageal echocardiogram confirmed tricuspid valve endocarditis. He recovered well post-targeted long-term antibiotics. Endoscopy confirmed a chronic rectal prolapse with multiple ulcers and was hypothesised as the source of bacteraemia. He subsequently underwent perineal rectosigmoidectomy. This uncommon sequela of rectal prolapse highlights several issues, including the management of neurogenic bowel dysfunction following spinal cord injury and the importance of early prolapse recognition and management. Finally, appropriate collection of blood cultures and correct use of echocardiography are critical steps in investigating infective endocarditis.

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome: An alternative option for selected patients

BACKGROUND

Abdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique for ODS are very limited.

AIM

To evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS.

METHODS

Consecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department. Patient demographics, perioperative surgical results, and postoperative follow-up outcomes were collected and analyzed. Long-term follow-up was evaluated with standardized questionnaires. The severity of symptoms was assessed by the objective Wexner Constipation Score (WCS) and ODS Score. The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score. Functional outcome was compared pre- and post-operatively for each patient. The primary outcomes were determined by the improvement in symptoms and quality of life. Secondary outcome measures were operating time, postoperative length of stay, morbidity and mortality, improvement of pelvic floor structure, and patient satisfaction.

RESULTS

Four patients underwent robotic-assisted surgery, and two patients underwent a laparoscopic-assisted procedure. The mean operating time for the robotic approach was 243 min (range 160–300 min), and the mean operating time for the laparoscopic approach was 230 min (range 220-240 min). The mean postoperative length of stay was 8.2 d (range 6-12 d). There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection and anastomosis leakage occurred. Six patients were followed up for 36 mo. The WCS, ODS, and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively (P < 0.05). The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication.

CONCLUSION

Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS. However, comprehensive preoperative evaluation and careful patient selection are essential.

Perineal stapled prolapse resection for external rectal prolapse: a systematic review and meta-analysis

AIM

Rectal prolapse is an uncommon but debilitating pelvic floor disorder that significantly decreases the quality of life of affected patients. Perineal stapled prolapse resection is a relatively new perineal approach that offers an promising alternative technique in the surgical management of rectal prolapse. It appears to be a simple, reproducible and efficient method. However, long-term outcomes are limited. The aims of this review are to assess the safety and effectiveness of perineal stapled prolapse resection in the management of rectal prolapse.

METHOD

A systematic review of all articles describing this approach was searched using MEDLINE, Embase, PubMed, Cochrane, Scopus, Web of Science and China National Knowledge Infrastructure. Included in this review were all randomized and nonrandomized prospective and retrospective studies reporting patients (aged 16 years and older) with complete rectal prolapse who underwent perineal stapled prolapse resection for the surgical treatment of the rectal prolapse.

RESULTS

A total of 408 patients across 20 articles were included. There were 58 cases of recurrence out of 368 patients over a median length of follow-up of 18 months (interquartile range 12-34 months). The total weighted overall recurrence was 12%. There were 51 cases of postoperative complications in 350 cases, bleeding being the most common complication.

CONCLUSION

The recurrence rate is comparable to those of the well-established Altemeier and Delorme procedures. However, given the heterogeneity of studies and variations in lengths of follow-up, further randomized prospective studies are needed to adequately compare this technique against other procedures for complete rectal prolapse.

Epidemiological trends in surgery for rectal prolapse in England 2001-2012: an adult hospital population-based study

AIM

To analyse trends in admission and surgery for rectal prolapse in adults in England between 2001 and 2012 as well as prolapse reoperation rates.

METHOD

Analysis of data derived from a comparative longitudinal population-based cohort study using Hospital Episode Statistics (HES).

RESULTS

During the study period, a total of 25 238 adults, of median age 73 [interquartile range (IQR: 58-83] years, underwent a total of 29 379 operations for rectal prolapse (mean: 2662 per annum). The female to male ratio of this group of patients was 7:1. Median length of hospital stay was 3 (IQR: 1-7) days with an overall in-hospital mortality rate of 0.9%. Total number of admissions (4950 in 2001/2002 vs 8927 in 2011/2012) and of patients undergoing prolapse surgery (2230 in 2001/2002 vs 2808 in 2011/2012) significantly increased over the study period (P < 0.001 for trends). The overall increase in prolapse surgery (of 33% overall and of 44% for elective procedures) was dwarfed by an increase in popularity of laparoscopic surgery (of 15-fold). Overall prolapse reoperation rate was 12.7%. The lowest recurrence rate was observed for elective open resection (9.1%) but this had the highest mortality (1.9%). Laparoscopic and perineal fixations were also associated with low reoperation rates (< 11%) and the lowest mortality rates, of 0.3%, when these procedures were elective. These data refute a trend towards subspecialization (by surgeon or hospital) during the study period.

CONCLUSION

Admissions for rectal prolapse increased in England between 2001 and 2012, together with increases in rectal prolapse surgery. Surgical decision making has changed over this period and may be reflected in outcome.

Anorectal Physiology Testing for Prolapse-What Tests are Necessary?

Rectal prolapse frequently occurs in conjunction with functional and anatomic abnormalities of the bowel and pelvic floor. Prolapse surgery should have as its goal not only to correct the prolapse, but also to improve function to the greatest extent possible. Careful history-taking and physical exam continue to be the surgeon's best tools to put rectal prolapse in its functional context. Physiologic testing augments this and informs surgical decision-making. Defecography can identify concomitant middle compartment prolapse and pelvic floor hernias, potentially targeting patients for urogynecologic consultation or combined repair. Other tests, including manometry, ultrasound, and electrophysiologic testing, may be of utility in select cases. Here, we provide an overview of available testing options and their individual utility in rectal prolapse.

Trends in the Diagnosis and Management of Combined Rectal and Vaginal Pelvic Organ Prolapse

OBJECTIVE

To examine the rates of surgical repair of comorbid rectal prolapse (RP) and pelvic organ prolapse (POP) over time in a large population-based cohort.

MATERIALS AND METHODS

We queried Optum, a national administrative claims database, from 2003 to 2017. We evaluated female patients age 18 or older with a diagnosis of POP and/or RP. Sociodemographic characteristics, comorbidities, and rates of procedures were collected.

RESULTS

We identified 481,051 women diagnosed with RP and/or POP. Only 2.0% of women in the cohort had comorbid POP and RP. While 29.9% of women with RP had dual prolapse, only 2.1% of women with POP had both diagnoses. Overall, 25.8% of women had one or more surgical repairs. Surgical repairs were done in 26.0% of women with POP, 15.0% of women with RP, and 48.2% of women with comorbid POP/RP, though only 19.8% of patients with dual diagnoses had both RP and POP repairs. Over the study period, the rate of multidisciplinary surgical repairs increased by 2.7-fold.

CONCLUSION

The prevalence of comorbid RP and POP among women in our cohort is low (2.0%). Rates of multidisciplinary surgery have increased possibly due to the increased use of imaging, laparoscopic surgery, and awareness of the shared pathophysiology of the disease.

Surgical Treatment of Rectal Prolapse: A 10-Year Experience at a Single Institution

Purpose

Methods

Results

Conclusion

Changing Trend of Rectal Prolapse Surgery in the Era of the Minimally Invasive Surgery

With the life span of the general population increased, rectal prolapse in elderly patients became a major concern in terms of the decision of the treatment modalities and quality of life of patients. Most elderly patients with rectal prolapse in the past received a perineal approach with the fear of general anesthetic complications rather than the abdominal approach. However, improvement in perioperative care in anesthesiology and minimally invasive surgery, the trend of surgical management of rectal prolapse is rapidly changing. Minimally invasive surgery including the laparoscopic and robotic surgeries showed comparable short-term outcomes even in elderly patients. Recently published guidelines also recommended a laparoscopic abdominal approach for the management of rectal prolapse.

Anal encirclement using polypropylene mesh for high grade complete full-thickness rectal prolapse: A case report

INTRODUCTION

Rectal prolapse is defined as protrusion of the rectal wall outside the anus caused by pelvic floor abnormalities. Operative repair is the only definitive treatment. Until now, there is no ideal surgical technique that can be used for all patients.

PRESENTATION OF CASE

Here we report two cases of full-thickness rectal prolapse in elderly patients with high-risk comorbidities. A seventy and seventy-eight-year-old female patients presented with complaints of anal lumps. Their past medical history was significant for arrhythmia, hypertensive heart disease, and pneumonia. The patients then underwent surgical repair with mesh cerclage. The patients were hospitalized for three days after surgery. On days 3, 7, 14, and 6 months after surgery the patients did not complain of any recurrence nor complications.

DISCUSSION

We did a modified anal encirclement surgical repair technique in managing these elderly patients with full-thickness rectal prolapse and high-risk comorbidities using mesh to prevent recurrence.

CONCLUSIONS

Anal encirclement technique using mesh can be considered as an alternative procedure for the treatment of full-thickness rectal prolapse in elderly patients with high-risk comorbidities because this procedure is simple, safe, causes fewer postoperative complications, and also can prevent recurrence.

Perineal rectosigmoidectomy for rectal prolapse-the preferred procedure for the unfit elderly patient? 10 years experience from a UK tertiary centre

BACKGROUND

Rectal prolapse is a disease presentation with a prevalence of about 1%, mainly affecting older women. It usually presents with symptoms of rectal mass, rectal bleeding, fecal incontinence or constipation, with patients frequently feeling socially isolated as a result. Perineal rectosigmoidectomy is associated with lesser morbidity and mortality than the abdominal procedure, but with a much higher recurrence rate. Therefore, this technique is mainly suitable for the frail elderly patient. Specific outcomes in an elderly population have been described in only a few studies. We evaluated the morbidity, mortality, recurrence rate and functional results after this procedure related to age.

METHODS

All patients who underwent a perineal rectosigmoidectomy over a 10-year period in two tertiary referral centers were included in the study. American Society of Anesthesiology (ASA) grade, pre- and postoperative symptoms, pathology-reported post-fixation specimen length, length of in-patient stay, 30-day morbidity/mortality, and recurrence were measured.

RESULTS

A total of 45 patients underwent a perineal rectosigmoidectomy. Forty-three (95%) were female, with a median age of 82.0 years (IQR 70.5-86.5), ASA grade III and median follow-up of 20 months (range 8.5-45.5 months). Half of the cohort was over 80 years old. Significant symptomatic relief was achieved, predominantly the resolution of rectal mass (8.9% vs. 60.0% preoperatively), fecal incontinence (15.6% vs. 46.7%) and constipation (4.4% vs. 26.7%). The median length of stay was 6 days, while morbidity occurred in 14 patients (31.1%) and recurrence occurred in 6 patients (13%). There were no deaths within 30 days of the procedure and outcomes were comparable in the < 80 and ≥ 80 age group.

CONCLUSIONS

Perineal rectosigmoidectomy is safe for older patients with greater comorbidities resulting in good functional results and is associated with low morbidity and mortality.

Surgical decision-making for rectal prolapse: one size does not fit all

BACKGROUND

Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience.

METHODS

91 consecutive patients ≥18 years old diagnosed with external and/or high-grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgment, and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared.

RESULTS

Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p < 0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with a recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach.

CONCLUSIONS

With multiple options available for the treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.

Altemeier's procedure for complete rectal prolapse; outcome and function in 43 consecutive female patients

Background

The aim of this retrospective study was to evaluate morbidity, mortality, postoperative function and recurrences in patients treated by Altemeier’s rectosigmoidectomy for complete rectal prolapse in a referral center for pelvic floor functional disorders.

Methods

Peri-operative data on 43 consecutive female patients were reviewed. At follow-up any change in pelvic floor function and recurrences were determined. Thirty four patients were assessed at a median interval of 49 (2–135) months, six being deceased for reason not related to the prolapse and three lost to follow-up.

Results

Post-operative complications at 30 days occurred in 18 patients (38%). Major complication occurred in only one patient that was pneumonia with lung failure. Major complications were not related to the ASA score, BMI or age [average age 76.4]. There was no post-operative mortality at 30 days.

At long-term follow-up functional results demonstrate a statistically significant decrease in the Obstructive Defecation Syndrome (ODS) score, but no statistically significant changes in the Vaizey score, the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) score and the urinary retention score. ODS score decreased with respect to levatorplasty and the change was statistically significant instead of Vaizey score in which were not.

At the same follow-up there were 12 (35%) cases of recurrence with an estimated risk at 48 months of 40%. There were no statistically significant differences between patients with and without recurrence regarding age (p = 0.188), BMI (p = 0.864), ASA score (p = 0.433), previously repaired prolapse (p = 0.398), previous hysterectomy (p = 0.705), length of resected bowel (p = 0.126), and levatorplasty (p = 0.304). Patient satisfaction showed a mean of 8.8 and 6.4 respectively in patients without and with recurrences (p = 0.012).

Conclusions

Altemeier’s procedure had in our series low complications rate and no mortality. It offered improved evacuation in constipated patients while didn’t improve fecal and urinary continence. Recurrence of prolapse was 40% at four years.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0463-7) contains supplementary material, which is available to authorized users.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Defecography: An Overview of Technique, Interpretation, and Impact on Patient Care

Pelvic floor and defecatory dysfunction are common in the female patient population. When combined with physical examination, barium defecography allows for accurate and expanded assessment of the underlying pathology and helps to guide future intervention. Understanding the imaging findings of barium defecography in the spectrum of pathology of the anorectum and pelvic floor allows one to appropriately triage and treat patients presenting with defecatory dysfunction.