Is rectal intussusception a cause of idiopathic incontinence?

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.

METHODS

This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.

RESULTS

Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).

CONCLUSION

In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Effect of posture on anorectal manometric measurements in female patients with fecal incontinence and rectoanal intussusception

PURPOSE

This study aimed to investigate the influence of erect position on anorectal manometry in patients with rectoanal intussusception (RAI).

METHODS

This was a single center prospective observational study. Eighty female patients with fecal incontinence (FI) who underwent defecography between 1st January 2016 and 30th April 2022 were included. The effect of posture on commonly measured parameters during manometry was assessed in the left-lateral and erect positions. The severity of FI was assessed using FI Severity Index (FISI).

RESULTS

Defecography showed that 30 patients had circumferential RAI (CRAI), and 50 had non-CRAI. There were no significant differences in age, parity, FI type, and FISI scores between the groups. However, FISI scores were significantly lower in 51 patients with passive FI than 12 patients with mixed FI type [21 (8-38) vs. 32 (8-43), P = 0.007]. Endo-anal ultrasound showed no significant difference in the incidence of sphincter defects between the groups. Maximum squeeze pressure was significantly lower in the erect position than in the left-lateral position in the CRAI patients [119 cm H₂O (59‒454 cm H₂O) vs. 145 cm H₂O (65‒604 cm H₂O), P = 0.006] however, this finding was not observed in the non-CRAI group and the subgroup of anterior RAI patients. In either group, maximum resting pressure, defecation desire volume, and maximum tolerated volume were significantly higher, while anal canal length was significantly shorter in the erect position than in the left-lateral position, respectively.

CONCLUSION

Voluntary contraction in female FI patients with CRAI was suppressed in the erect position.

Absent or impaired rectoanal inhibitory reflex as a diagnostic factor for high-grade (grade III-V) rectal prolapse: a retrospective study

Background

Clinically diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse.

Methods

In this retrospective study, we evaluated 107 patients who underwent both anorectal manometry and defecography between July 2012 and December 2019. Rectal prolapse was classified in accordance with the Oxford Rectal Prolapse Grading System. Patients in the high-grade (III–V) rectal prolapse (high-grade group, n = 30), and patients with no rectal prolapse or low-grade (I, II) rectal prolapse (low-grade group, n = 77) were analyzed. Clinical variables, including symptoms such as fecal incontinence, feeling of prolapse, and history were collected. Symptoms were assessed using yes/no surveys answered by the patients. The manometric results were also evaluated.

Results

Frequencies of fecal incontinence (p = 0.002) and feeling of prolapse (p < 0.001) were significantly higher in the high-grade group. The maximum resting (77.5 vs. 96 mmHg, p = 0.011) and squeezing (128.7 vs. 165 mmHg, p = 0.010) anal pressures were significantly lower in the high-grade group. The frequency of absent or impaired RAIR was significantly higher in the high-grade group (19 cases, 63% vs. 20 cases, 26%, p < 0.001). In a multivariate analysis, the feeling of prolapse (odds ratio [OR], 23.88; 95% confidence interval [CI], 4.43–128.78; p < 0.001) and absent or impaired RAIR (OR, 5.36; 95% CI, 1.91–15.04, p = 0.001) were independent factors of high-grade (III–V) rectal prolapse. In addition, the percentage of the absent or impaired RAIR significantly increased with grading increase of rectal prolapse (p < 0.001). The sensitivity of absent or impaired RAIR as a predictor of high-grade prolapse was 63.3% and specificity 74.0%.

Conclusions

Absent or impaired RAIR was a meaningful diagnostic factor of high-grade (III–V) rectal prolapse. Furthermore, the absent or impaired reflex had a positive linear trend according to the increase of rectal prolapse grading.

Absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with rectal intussusception and fecal incontinence

PURPOSE

Fecal incontinence (FI) is common in patients with rectal intussusception (RI), although the mechanism behind its formation is unclear. Recent data indicate that a reduction in internal sphincter tone may cause FI, which becomes notable with increasing RI levels. However, the roles of other anatomical abnormalities in anal function remain unclear. This study assessed the relationships between various pelvic floor abnormalities and anal sphincter function in patients with RI and FI.

METHODS

Data for patients with RI, collected in a prospective pelvic floor database, were assessed retrospectively. All women with FI, without anal sphincter defect, were included. Data on anorectal physiology and evacuation proctography were analyzed.

RESULTS

Of 397 patients with RI, 85, who had predominantly passive FI, met the inclusion criteria. Maximum resting pressure (MRP) was significantly lower in patients with rectoanal intussusception (RAI) than in those with rectorectal intussusception (RRI) [51.1 (17.9-145.8) vs. 70.7 (34.7-240.6) cmH₂O, P = 0.007]. Moreover, MRP was significantly lower in RI patients without rectocele than in RI patients with rectocele [50.1 (17.9-111.0) vs. 69.9 (34.7-240.6) cmH₂O, P < 0.0001]. Regression analysis showed that RAI rather than RRI and RI without rectocele rather than RI with rectocele were predictive of decreased MRP. However, no variable was significantly associated with decreased maximum squeeze pressure on multivariate analysis.

CONCLUSION

In addition to an advanced level of intussusception, the absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with RI and FI.

Rectoanal intussusception is very common in patients with fecal incontinence

Objectives: Fecal incontinence (FI) is a multifactorial disorder, the etiology of which is not fully understood. Recent data have shown the significance of rectoanal intussusception (RAI) in the evaluation of FI. The present study aimed to determine the incidence of RAI in patients with FI. Methods: Between June 2010 and February 2016, 74 patients, who were evaluated using evacuation proctography, anorectal manometry, ultrasound, and incontinence scores, were included in this study. RAI was diagnosed when the apex of the rectal intussusception (RI) impinged on the internal anal orifice or was intra-anal, based on the images taken during maximal straining defecation at evacuation proctography. The characteristics of RAI patients were further analyzed. Results: There were 59 women (80%) and 15 men, with a median age of 74 (52-93) years. Sixty patients (81%) had RI, and 56 (76%) showed RAI. The incidence of RAI among the 32 patients with FI alone and the 42 patients with FI and symptoms of obstructed defecation (OD) was 72% (23/32) and 79% (33/42), respectively. The incidence of RAI was not significantly different between the patients with normal manometry (maximum resting pressure [MRP] ≥55 cmH₂O and maximum squeeze pressure [MSP] ≥150 cmH₂O, n=26) and those with subnormal manometry (MRP <55 cmH₂O and/or MSP <150 cmH₂O, n=48). Conclusion: RAI is common in patients with FI. Evacuation proctography should be taken into account as a part of the regular study of FI patients.

Anterior intussusception descent during defecation is correlated with the severity of fecal incontinence in patients with rectoanal intussusception

BACKGROUND

Rectoanal intussusception (RAI) is a common finding on evacuation proctography in patients with defecation disorders. However, it remains unclear whether intussusception morphology affects the severity of fecal incontinence (FI). The aim of this study was to examine the effect of morphology during defecation on the severity of FI in patients with RAI.

METHODS

We included 80 patients with FI who were diagnosed as having RAI on evacuation proctography. Various morphological parameters were measured, and the level of RAI was divided by the extent of descent onto (level I) or into (level II) the anal sphincter. FI symptoms were documented using the FI Severity Index (FISI).

RESULTS

Twenty-eight patients had level I and 52 had level II RAI. The mean (range) FISI score was 24.0 (8-47). FISI scores tended to be significantly higher in level II than in level I [26.3 (10-47) vs. 21.8 (8-42); p = 0.05]. The mean anterior intussusception descent was significantly greater in level II than in level I [24.2 (9.2-39.5) vs. 17.7 (7.8-39.4) mm; p < 0.0001]. Regression analysis showed that anterior intussusception descent was predictive of increased FISI scores.

CONCLUSIONS

The severity of FI may be affected by anterior intussusception descent in patients with RAI.

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

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

MRI defaecography in patients with faecal incontinence

AIM

Faecal incontinence (FI) requires careful assessment of its aetiology to determine the most effective treatment. The aims of this study were to evaluate MRI defaecography in FI and to compare it with clinical examination combined with rigid rectoscopy in assessing the pelvic floor in patients with FI.

METHOD

Consecutive patients with FI referred over a 3-year period to our tertiary centre for MRI defaecography were retrospectively studied. MRI images of the pelvic floor were compared with clinical examination and anuscopy and rectoscopy.

RESULTS

Seventy-four female patients [mean age 60.5 (30.0-81.0) years] were recruited. MRI defaecography showed conditions which often overlapped, including internal intussusception in 19 (25.7%) and pelvic floor descent in 24 (32.4%). There was average agreement between MRI and clinical examination for a significant anterior rectocoele (κ = 0.40) and poor agreement between MRI and anuscopy/rectoscopy for intra-rectal (κ = 0.06) and intra-anal intussusception (κ = 0.11).

CONCLUSION

Other than for anterior rectocoele, there is poor correlation between MRI defaecography and clinical examination with rigid rectoscopy. MRI can detect a variety of abnormal static and dynamic pelvic disorders. This includes enterocoele, which could result in a modification of the surgical approach to intussusception and anterior rectocoele.

[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.

Medium-term results of stapled transanal rectal resection (STARR) for obstructed defecation and symptomatic rectal-anal intussusception

AIM

Stapled transanal rectal resection (STARR) is an increasingly accepted treatment for obstructed defaecation syndrome (ODS) associated with internal rectal prolapse (IRP) and rectocoele. The aim of this study is to evaluate the medium to long-term outcomes of STARR for ODS.

METHOD

The intermediate-term results of STARR used over a 9-year period were reviewed from the analysis of a prospectively maintained database. Patients were followed for a median period of 98 (95% CI 85-112, range 5-386) weeks.

RESULTS

Three hundred and forty-four (234 woman) patients of median age 54 (19-90) years underwent STARR over a 9-year period. Preoperative symptoms included pelvic pain (93%), incomplete evacuation (90%), urgency (74%), a sensation of obstruction (65%) and rectal digitation (27%). Thirteen had the solitary rectal ulcer syndrome. Of 326 patients with follow-up data, 249 (76%) were followed beyond 1 year and 149 (43%) beyond 2 years. The ODS score improved [14.6 ± 5.4 pre vs 1.6 ± 3.1 post (P < 0.0001)] as did the faecal incontinence (FI) score [3.5 ± 3.3 pre vs 0.4 ± 1.3 post (P < 0.0001)]. Fifteen (4.3%) patients reported deterioration in FI, and 11 (3.2%) experienced new onset minor incontinence. Urgency was 72% at 8 weeks, 20% at 16 weeks, 11.5% at 52 weeks and 5% at 1.5 years. None of the 29 patients followed beyond 4 years reported urgency. Urgency was unrelated to sex, age or preoperative ODS symptoms (Mantel-Cox log-rank). Recurrent symptoms of ODS occurred in 4.9%. Eighty-one per cent of patients were highly satisfied with STARR and would recommend or have it again.

CONCLUSION

STARR was successful for the treatment of selected patients with ODS and IRP. Postoperative faecal urgency rapidly decreases with time. It is not possible to predict who will develop urgency.

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.

Coexistence of constipation and incontinence in children and adults

The coexistence of constipation and fecal incontinence has long been recognised in paediatric and geriatric populations, but is grossly underappreciated in the rest of the adult population. In children, functional fecal incontinence is usually associated with constipation, stool retention and incomplete evacuation, and is frequently allied to urinary incontinence. Pathophysiology of the incontinence is incompletely understood, although both in children and adults, it is thought to be secondary to overflow, while in adults it may also be related to pelvic floor dysfunction and denervation. Incontinence has an important impact on quality of life and daily functioning, and in children may be associated with behaviour problems. The treatment of underlying constipation usually results in improvement in incontinence. This review broadly addresses the epidemiology and pathophysiology of coexistent constipation and incontinence in both children and adults, and also reviews clinical presentation and treatment response in pediatrics.

Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results

OBJECTIVE

Over the last 15 years, posterior rectopexy, which causes rectal autonomic denervation, was discredited for internal rectal prolapse because of poor results. The condition became medical, managed largely by biofeedback. We aimed to audit the short-term functional results of autonomic nerve-sparing laparoscopic ventral rectopexy (LVR) for internal rectal prolapse.

METHOD

Prospectively collected data on LVR for internal rectal prolapse were analysed. End-points were changes in bowel function (Wexner Constipation Score and Fecal Incontinence Severity Index) at 3 and 12 months. Analysis was performed using Mann-Whitney U-test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p-test). Functional outcomes were compared with those achieved previously for external rectal prolapse (ERP).

RESULTS

Seventy-five patients underwent LVR (median age 58, range 25-88 years, median follow up was 12 months). Mortality (0%), major (0%) and minor morbidity (4%) were acceptably low. Median length of stay was 2 days. Preoperative constipation (median Wexner score 12) and faecal incontinence (median FISI score 28) improved significantly at 3 months (Wexner 4, FISI 8, both P < 0.0001) and 12 months (Wexner 5, FISI 8, both P < 0.0001). No patient had worse function. Functional outcomes were similar to those for ERP.

CONCLUSION

Laparoscopic ventral rectopexy for internal rectal prolapse improves symptoms of obstructed defaecation and faecal incontinence in the short-term. This establishes proof of concept for a nerve-sparing surgical treatment for internal rectal prolapse.

Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study

BACKGROUND

The aetiology of faecal incontinence is multifactorial, yet there remains an approach to assessment and treatment that focusses on the sphincter. Rectal intussusception (RI) is underdiagnosed and manifests primarily as obstructed defecation. Yet greater than 50% of these patients admit to faecal incontinence on closer questioning. We aimed to evaluate the incidence of RI at evacuation proctography selectively undertaken in the evaluation of patients with faecal incontinence.

METHOD

Patients with faecal incontinence seen in a pelvic floor clinic were evaluated with anorectal physiology and ultrasound. Where the faecal incontinence was not fully explained by physiology and ultrasound, evacuation proctography was undertaken. Studies were classified as 'normal', 'low-grade RI' (recto-rectal), 'high-grade RI' (recto-anal) or 'anismus'.

RESULTS

Forty patients underwent evacuation proctography (33 women, 83%). Median age was 63 years (range 34-77 years). Seven patients (17%) had a normal proctogram. Three (8%) had recto-rectal RI. Twenty-five (63%) demonstrated recto-anal RI. Five patients (12%) had anismus.

CONCLUSION

Recto-anal intussusception is common in patients undergoing selective evacuation proctography for investigation of faecal incontinence. The role of recto-anal intussusception in the multifactorial aetiology of faecal incontinence has been largely overlooked. Evacuation proctography should be considered as part of routine work-up of patients with faecal incontinence.

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

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.

Functional results of laparoscopic resection rectopexy for symptomatic rectal intussusception

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of findings at defecography in patients with genital prolapse

OBJECTIVE

Defecography may be useful in pre-operative assessment of patients with genital prolapse. Defecography is an invasive and embarrassing procedure for patients and little effort has been made to optimalise selection criteria for defecography. This study investigated whether discrimination of high and low probability of abnormal defecography is possible based on the quantified findings from patient history, pelvic examination and a validated questionnaire.

DESIGN

Prospective observational study.

SETTING

Three teaching hospitals in The Netherlands.

POPULATION

Eighty-two patients undergoing surgical correction of uterine prolapse Stages 2-4.

METHODS

A history and pelvic examination were obtained from all patients. A validated questionnaire was used to assess the presence of defecation and micturition symptoms. Using multivariate logistic regression analyses with receiver operating characteristic curves, a diagnostic model to predict the presence of an abnormal defecography was systematically constructed and validated.

MAIN OUTCOME MEASURE

Presence of abnormal finding at defecography.

RESULTS

The most important predictors for abnormal defecography were prolapse of the posterior vaginal wall, history of abdominal or pelvic surgery and the presence of constipation. With these variables, a prediction rule could be constructed which predicted the prevalence of an abnormal defecography (area under curve = 0.73; 95% CI 0.61-0.83).

CONCLUSIONS

This study shows that a diagnostic model based on findings obtained from a non-invasive workup can accurately predict the presence of an abnormal defecography. Such a model provides the possibility to tailor the request for defecography to the individual patient.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Defecographic disorders in anal incontinent women: relation to symptoms and anal endosonographic patterns

OBJECTIVE

The need for a defecography in incontinent women is still debatable. We prospectively evaluated the prevalence of defecographic abnormalities in incontinent women in order to determine whether any symptom or endosonographic findings could be associated with a particular defecographic pattern.

MATERIAL AND METHODS

Fifty incontinent women (aged 30-87 years) underwent defecography and anal endosonography to look for pelvic floor descent, rectocele, intussusception, enterocele and the presence of anal sphincter defects. Other symptoms, i.e. straining at stools and pelvic pressure, were recorded.

RESULTS

Twenty-five cases of external sphincter defect (12 associated with an internal defect) and 4 cases of isolated internal defect were identified. Defecography identified 25 patients with perineal descent at rest, 28 with perineal descent at straining, 30 with rectocele, 30 with intussusception and 14 with enterocele. Three defecographies were normal. In the 29 women with sphincter defects, the prevalence of defecographic abnormalities did not differ from that observed in the 21 women without sphincter defects. In women complaining of straining at stools (n=26) or idiopathic pelvic pressure (n=32), the prevalence of defecographic abnormalities did not differ from that observed in women who did not have these symptoms.

CONCLUSIONS

The prevalence of pelvic floor disorders in incontinent women was similar whether associated symptoms or anal sphincter defects were present or not. When defecography has to be performed to investigate female anal incontinence, neither clinical nor endosonographic features can predict a higher diagnostic efficiency.

Clinical skills: nursing considerations in patients with faecal incontinence

Faecal incontinence is a distressing and socially debilitating problem. Nurses are ideally placed to support patients and assist them in improving their quality of life. In order to provide the necessary holistic care the nurse needs to understand the nature of the patient's symptoms and be aware of a variety of management interventions. In this article the author outlines the various causes of faecal incontinence and highlights the importance of a thorough nursing assessment which takes into account the physical, psychological and social aspects of the symptoms. Planned care should be based on a firm knowledge base, but should reflect the needs of the individual. A good nurse-patient interaction facilitates this process and should be valued.

Frequency of anal incontinence and results of pelvic viscerography in 291 women with pelvic organ prolapse

OBJECTIVES

To determine the prevalence of anal incontinence in a population of 291 women with pelvic organ prolapse and evaluate the results of pelvic viscerogram in this situation.

MATERIALS AND METHODS

Each patient answered a standardized questionnaire on medical, obstetric and surgical past histories and answers were logged in a database. The viscerograms were performed by a single specialized radiologist.

RESULTS

All patients but one were parous. The prevalence of anal incontinence was 26.1%. Stress urinary incontinence and urge urinary incontinence were significantly associated with anal incontinence. No obstetric or surgical risk factor for anal incontinence was demonstrated. Viscerography demonstrated rectoceles (n=86, 29.1%), enteroceles (n=77, 26.5%), cystoceles (n=174, 59.8%), and intra-anal rectal prolapse (n=106, 36.4%). A significant association was found between intra-anal rectal prolapse and anal incontinence.

CONCLUSION

Anal incontinence is frequent in patients with pelvic organ prolapse, even more so in the presence of urinary incontinence, and should be investigated by pelvic viscerography. Pelvic floor dysfunction is frequently associated with enteroceles, rectoceles and rectal prolapse. Pelvic viscerograms should be systematically performed in the diagnostic work-up in patients with pelvic organ prolapse when surgical treatment is considered.

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

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Long-term results and functional outcome after Ripstein rectopexy

PURPOSE

The aim of this study was to evaluate operative mortality, morbidity, and functional results after Ripstein rectopexy for rectal prolapse and internal rectal intussusception.

METHODS

Sixty-nine patients with rectal prolapse and 43 with internal rectal intussusception were included. All patient records were studied and complications registered. Long-term follow-up was possible in 105 patients and performed by clinical examination and standardized interview, telephone interview, or patient records. Seventy-six patients were prospectively evaluated, comparing bowel function before and after rectopexy.

RESULTS

There was no operative mortality. Operative morbidity was 33 percent, and most complications were minor. Severe early complications included one large-bowel obstruction and one transient ureteric stenosis. Median time of follow-up was seven years in patients with rectal prolapse and 5.4 years in patients with internal rectal intussusception. Late complications included two rectovaginal fistulas and one lethal sigmoid fecaloma. Five patients underwent subtotal colectomy for severe constipation. There was one recurrent prolapse (1.6 percent). Functional evaluation showed that incontinence improved (P = 0.049), whereas the number of bowel movements per week decreased (P < 0.001). Frequency of emptying difficulties did not change significantly in patients with rectal prolapse but increased in patients with internal rectal intussusception (P = 0.038).

CONCLUSION

Ripstein rectopexy can be performed with low mortality and recurrence rate, but with a high early complication rate. There were also some serious late complications. Continence was improved, although increased constipation was a problem in some patients, especially among those with internal rectal intussusception.

Imaging of anorectal disease

BACKGROUND

Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease.

METHODS

The literature on imaging techniques for anorectal diseases was reviewed over the period 1980-1999.

RESULTS

For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy.

CONCLUSION

High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.