Anorectal function in the solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome

PURPOSE OF REVIEW

Solitary rectal ulcer syndrome (SRUS) is a rare disease which can puzzle the gastroenterologist. A review of the syndrome and new treatment options are discussed.

RECENT FINDINGS

Its association with dyssynergia in general supports an important role for pelvic floor biofeedback, which can be successful in patients with SRUS. No other novel.

SUMMARY

Awareness of this benign syndrome is important; endoscopic diagnosis and histological confirmation opens the way to a guided lifestyle therapy with regulation of defecation and pelvic floor biofeedback. A reluctance to proceed to surgery seems warranted. VIDEO ABSTRACT.

Cloacogenic polyps in an adolescent: a rare cause of rectal bleeding

Cloacogenic polyps are rare inflammatory lesions occurring around the anal transitional zone and in the lower rectum which can mimic neoplasia. They should be given diagnostic consideration in patients presenting with symptoms of rectal bleeding, tenesmus, and altered bowel habits.

Medical and surgical management of pelvic floor disorders affecting defecation

Pelvic floor disorders that affect stool evacuation include structural (for example, rectocele) and functional disorders (for example, dyssynergic defecation (DD)). Meticulous history, digital rectal examination (DRE), and physiological tests such as anorectal manometry, colonic transit study, balloon expulsion, and imaging studies such as anal ultrasound, defecography, and static and dynamic magnetic resonance imaging (MRI) can facilitate an objective diagnosis and optimal treatment. Management consists of education and counseling regarding bowel function, diet, laxatives, most importantly behavioral and biofeedback therapies, and finally surgery. Randomized clinical trials have established that biofeedback therapy is effective in treating DD. Because DD may coexist with conditions such as solitary rectal ulcer syndrome (SRUS) and rectocele, before considering surgery, biofeedback therapy should be tried and an accurate assessment of the entire pelvis and its function should be performed. Several surgical approaches have been advocated for the treatment of pelvic floor disorders including open, laparoscopic, and transabdominal approach, stapled transanal rectal resection, and robotic colon and rectal resections. However, there is lack of well-controlled randomized studies and the efficacy of these surgical procedures remains to be established.

Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded

The interpretation of colonic biopsies related to inflammatory conditions can be challenging because the colorectal mucosa has a limited repertoire of morphologic responses to various injurious agents. Only few processes have specific diagnostic features, and many of the various histological patterns reflect severity and duration of the disease. Importantly the correlation with endoscopic and clinical information is often cardinal to arrive at a specific diagnosis in many cases.

Solitary Rectal Ulcer Syndrome: Exploring Possible Management Options

Solitary rectal ulcer syndrome (SRUS) is a rare condition with various causes that results in ischemic injury. The aim of this study was to assess the clinical findings, diagnosis, and outcomes of treatment in patients with SRUS. Between 1992 and 2006, a retrospective review was undertaken for all patients diagnosed with SRUS. Fifty-eight patients were diagnosed with SRUS. Among patients with paradoxic rectal spasm (PRS), lesions disappeared in 1 of 3 given applied biofeedback treatment, and in 2 of 4 injected with Botulinum toxin (BotoxTM). Twenty-three patients underwent appropriate surgical treatment. Overall, postoperative improvement was seen in 18 patients (78.2%). In conclusion, every patient with SRUS must be assessed for causative disease. Treatment should include conservative approaches such as Botox injection; in patients with pelvic floor disorders, surgical treatment should be considered.

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.

[The solitary rectal ulcer syndrome]

The solitary rectal ulcer syndrome is a rare debilitating disorder of the rectum characterized by perianal chronic pain with passage of blood and mucus. The pathogenesis remains uncertain, rectal prolapse and trauma from straining are the main hypothesis. The diagnosis includes clinical symptoms associated with endoscopic lesion (erythema, ulcer or polypoïd lesion) and histological features. Mano-metric studies and defecography are helpful to determinate an underlying defecation disorder or rectal prolapse. The treatment is controversial including a conservative option (medications and behavioural therapy) with poor long term results, and the surgical option (treatment of a rectal prolapse with or without resection of the lesion), more aggressive with uncertain results in a long follow-up period.

Clinical presentation and surgical outcome in patients with solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome is a poorly understood clinical condition, and the schema of treatment has not yet been defined. This study reviewed the clinical spectra and outcome of various surgical treatments in patients with solitary rectal ulcer syndrome. The medical records of all patients with solitary rectal ulcer syndrome between 1992 and 1998 were retrospectively reviewed. Patients in the study population with symptoms and histopathologic findings suggestive of solitary rectal ulcer syndrome were placed in the primary solitary rectal ulcer syndrome group, and patients who underwent surgery for other diseases in whom histopathology confirmed concomitant solitary rectal ulcer syndrome were in the incidental group. Clinical features and outcomes of surgical treatment were documented. Improvement was considered as resolution of presenting symptoms, and non-improvement was considered if presenting symptoms persisted or worsened. The study cohort comprised 49 patients: 20 in the primary group and 29 in the incidental group. Ulcerative morphology was seen predominantly in the primary group (70%); erythematous (45%) and polypoid lesions (34%) were predominant in the incidental group (P = .0025). Clinical improvement after surgery was seen in 74% of patients with primary and 79% with incidental solitary rectal ulcer syndrome (P = NS). Manifestations such as tenesmus and digitation correlated with poorer outcome after surgery in both groups. Solitary rectal ulcer syndrome is a clinical condition associated with functional anorectal evacuatory disorders. The results of this study show the positive role of surgical treatment for underlying functional disorders in the improvement of incidental solitary rectal ulcer syndrome.

Evaluation of the paradoxical sphincter contraction by a strain/squeeze index in constipated patients

PURPOSE

One finding in patients with constipation is the paradoxical puborectalis contraction, i.e. , activation of the sphincter muscles during straining instead of relaxation. The aims of this study were to evaluate the importance of needle placement in sphincter-electromyography and to evaluate a strain/squeeze index in constipated patients and control subjects.

METHODS

We investigated consecutively 194 constipated patients and 16 control subjects with integrated electromyography during straining and squeezing and calculated a strain/squeeze index. The examination was performed in the puborectalis and in the external anal sphincter muscle through hook-electrodes.

RESULTS

There was a strong correlation between indices in the puborectalis muscle and in the external anal sphincter muscle (r = 0.70-0.80, P < 0.001). Forty-seven patients (24 percent) had a mean index of greater than 50 compared with none in the control group (P = 0.01). Mean overall index in patients was 24 (range, 0-306) vs. 18 (range, 0-45) in controls (P = 0.12). Patients with an index greater than 50 had impaired rectal evacuation (P < 0.001), increased threshold for urge (P < 0.05), and tended to have fewer stools (P = 0.06).

CONCLUSION

Quantification of paradoxical contraction in the puborectalis and external anal sphincter with a strain/squeeze index differentiates patients in whom paradoxical activity may be a cause of constipation. An index above 50 may be of pathologic significance. Correlations between activity in the puborectalis and external anal sphincter muscle were strong which suggests that investigation in one of them is sufficient.

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.

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.

Solitary rectal ulcer syndrome

BACKGROUND

Solitary rectal ulcer syndrome is a rare disorder characterized by erythema or ulceration of the rectal wall, associated with typical histological features, and disturbed defaecatory behaviour with the passage of blood and mucus.

METHODS

This is a review based on a literature search using a computer database (Medline) and manual cross-referencing.

RESULTS

The pathogenesis is likely to vary in different patients; it includes trauma from straining, direct digital trauma and possibly primary neuromuscular pathology. The histological findings of extension of the muscularis mucosa between crypts and muscularis propria disorganization on full-thickness specimens are characteristic. Biofeedback defaecation retraining, including habit training, can lead to symptom improvement and return to work in a majority of patients. Abdominal rectopexy offers long-term symptom improvement in approximately 50 per cent of patients. Rectal ulceration may persist after any treatment, even if symptoms improve.

CONCLUSION

Behavioural therapy and carefully considered operations offer the best treatment results. Further work on psychological factors and neuromuscular and vascular pathology is required.

Long-term clinical outcome of surgery for solitary rectal ulcer syndrome

BACKGROUND

When severe symptoms of solitary rectal ulcer syndrome persist despite medical management, surgery may be necessary.

METHODS

A retrospective review was carried out of 81 patients undergoing surgery for solitary rectal ulcer syndrome in the 10-year period from 1984 to 1993 to determine the long-term outcome at a minimum follow-up of 12 months. Of the 81 patients, 15 were excluded from further analysis (11 were followed up for less than 12 months, two died and two were lost to follow-up). Sixty-six patients were studied (median age 38 (range 15-77) years; 53 female). Of these, 49 underwent rectopexy, nine Delorme's operation, two anterior resection and four creation of a stoma as the initial operation.

RESULTS

At a median follow-up of 90 (range 12-177) months, the rectopexy had failed in 22 of 49 patients; 19 of these patients underwent further surgery, including rectal resection with coloanal anastomosis (four with three failures), colostomy (11) and other procedures (four). Ultimately, 14 required a stoma. Constipation was the indication for a stoma in nine of the 11 patients who had colostomy as the first procedure after failure of rectopexy. Nine patients had Delorme's operation as the first procedure. At median follow-up of 38 (range 19-107) months, there were four failures. Two of these ultimately required a stoma. Of the seven patients who underwent anterior resection as the initial or subsequent procedure, a stoma was finally necessary in four. Anterior resection used as a salvage procedure was not successful. The overall stoma rate was 30 per cent (20 patients). Of 11 symptoms assessed before operation only incontinence and incomplete evacuation were related to a poor outcome following surgery.

CONCLUSION

Antiprolapse operations result in a satisfactory long-term outcome in about 55-60 per cent of patients having surgery for solitary rectal ulcer syndrome. Results of anterior resection are disappointing.

Anorectal and pelvic floor function. Relevance of continence, incontinence, and constipation

Anorectal tests need to be tailored to the presentation of the individual patient. Clearly the tests are most useful when they identify anatomic or physiologic abnormalities for which there are successful treatments. For the incontinent patient, anal manometry is the most useful test. Sphincter injuries should be repaired, whereas neurogenic incontinence is best treated initially with biofeedback. Three tests are more useful for the constipated patient: colonic transit time, degree of pelvic floor descent on straining, and balloon expulsion. Colonic inertia responds to total colectomy and pelvic floor dysfunction to biofeedback. Meanwhile, patients with irritable bowel syndrome require rereferral back to their physicians.

Internal rectal intussusception--fact or fancy?

PURPOSE

There is still considerable debate whether internal intussusception represents a functional disorder. We have reviewed our results in an effort to define its symptomatology and to assess defecography.

METHODS

Rectopexy has been performed for internal intussusception in 37 patients. Eighteen had solitary rectal ulcer syndrome (SRUS), and 31 had anterior rectal wall prolapse. Defecography demonstrated anterior wall prolapse in 13, circular prolapse in 21, and no disorders in 3 patients. Pelvic floor function was normal. Follow-up varied from one to nine years.

RESULTS

Twenty-six patients became asymptomatic. Anterior wall prolapses could not be palpated anymore. All SRUS lesions healed. Patients with SRUS (P < 0.001) or circular prolapse (P < 0.001) became significantly more asymptomatic. Results in patients with anterior rectal wall prolapse were significantly worse (P < 0.001).

CONCLUSIONS

Internal intussusception is a distinct functional rectal disorder. Its symptomatology and findings during physical examination are aspecific. Characteristic defecographic features and presence of SRUS are indications for surgery, provided pelvic floor function during straining is normal.

Proctographic changes after rectopexy for solitary rectal ulcer syndrome and preoperative predictive factors for a successful outcome

Rectopexy is advocated as treatment for solitary rectal ulcer syndrome despite variable outcome. Sixteen patients with this condition, who remained symptomatic after surgery, were examined before and after operation by evacuation proctography and compared with a matched group of seven patients whose symptoms had been relieved, to investigate the effect of rectopexy on rectal configuration or emptying, or both, and to identify any preoperative factor associated with a good outcome. Rectal prolapse, demonstrated in 19 of 23 patients before operation (internal in 12, external in seven), was seen in only one patient after surgery. The rectal axis became more vertical at rest (median 44 degrees before operation versus 35 degrees after surgery, P = 0.006) and on evacuation (median 38 degrees versus 31 degrees, P = 0.023). Preoperative evacuation time was increased in patients with poor outcome (median (range) 22 (8-60)s versus 10 (5-15)s, P = 0.008). Rectopexy successfully treats rectal prolapse in patients with solitary rectal ulcer syndrome and alters rectal configuration. These features, however, are unrelated to outcome. Prolonged preoperative evacuation time, suggesting a defaecatory disorder, may predict poor symptomatic outcome.

Solitary rectal ulcer syndrome: the clinical entity and anorectal physiological findings in Singapore

The clinical pattern and physiological abnormalities in solitary rectal ulcer syndrome (SRUS) occurring in Singapore, were investigated. Since April 1989, 25 patients have presented with histologically proven SRUS. There were 13 males and 12 females (20 Chinese, 4 Malay and 1 Indian) with a mean age of 47.5 (+/- 3.1) years. Ninety-six per cent presented with rectal bleeding, 92% strained at stools, 40% had mucus discharge, 40% felt incomplete defecation and 32% digitated to defecate. Four had previous haemorrhoidectomies that did not cure their symptoms. The lesions were at a mean 6.8 (+/- 0.5) cm above the anal verge, usually anteriorly (64%) but one was circumferential. Anorectal physiology performed on 14 patients was compared with 13 age and gender matched normal controls. The measured mean resting perineum level in SRUS (1.4 +/- 0.3 cm) was significantly lower than in normals (P < 0.01). The mean anal electrosensory threshold (2.5 +/- 0.52 mV) was also significantly higher than in the controls (P < 0.05). Fifteen patients were successfully treated with a high fibre diet and avoidance of straining. Three patients required surgery and the most recent seven patients have responded well to biofeedback treatment. Awareness of this uncommon anorectal condition is necessary for early diagnosis and appropriate management. The physiological findings support a pelvic straining pathophysiology resulting in perineal descent, with less sensitive rectal mucosa prolapsing into, and raising, the anal canal electrosensory threshold. Treatment strategies aimed at correcting the straining have usually been successful.

Endosonography of the anal sphincters in solitary rectal ulcer syndrome

Twenty-one patients with histologically proven solitary rectal ulcer syndrome (SRUS) were examined by anal endosonography (AES) in order to determine the frequency of any ultrasound abnormality. Comparison was made with a group of 17 age and sex matched asymptomatic subjects. Four patients with SRUS had anal sphincter defects on AES. All were of the internal anal sphincter (IAS), which appeared fragmented in two patients with complete rectal prolapse. Measurements of internal and external anal sphincter (EAS) diameter and cross-sectional area were taken, excluding the 4 patients with defects. The submucosa was inhomogeneous (P = 0.0016) and thickness increased in patients with SRUS (median 4.0 mm vs 2.0 mm; P < 0.0001). IAS diameter was increased (median 3.8 mm vs 2.0 mm; P < 0.0001), as was cross-sectional area (median 241 sq mm vs 112 sq mm; P < 0.0001). EAS diameter was also increased (median 8.5 mm vs 7.0 mm; P = 0.0173), as was cross-sectional area (median 905 sq mm vs 594 sq mm; P = 0.0052). The ratio of EAS to IAS thickness was reduced in patients with SRUS (median 2.6 vs 4.0; P = 0.0029). The mechanism of these changes is unclear but apparent muscle hypertrophy on ultrasound may diagnose those patients with SRUS in whom defecatory difficulty is a predominant symptom.

Atypical forms of inflammatory bowel disease

Atypical forms of IBD include the microscopic colitides, collagenous and lymphocytic colitis, and two macroscopic colitides, SRUS and diversion colitis. Clinical presentations include chronic, watery diarrhea and intermittant rectal bleeding. Constitutional symptoms are typically absent; laboratory data are often nonspecific. Colonoscopic evaluation and mucosal biopsy are essential in establishing these diagnoses and excluding more classic forms of IBD (i.e., Crohn's disease or idiopathic ulcerative colitis). Prognosis and response to treatment are variable; potential therapeutic options include dietary manipulations, topical or systemic anti-inflammatory agents, and, in refractory cases, surgical intervention.

Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome

Transrectal ultrasonography is of clinical value in anorectal carcinoma and in inflammatory diseases of the anorectum. In this study a rigid linear endorectal probe was used to examine 15 patients with endoscopically and biopsy proved diagnosis of solitary rectal ulcer syndrome. In 13 of the 15 patients the rectal wall was thicker (mean (SEM) 5.7 (0.4) mm; normal values: 2.8 (0.1) mm) near the rectal ulcer. In all these cases the muscularis propria layer exceeded the maximum normal diameter of 2 mm. In nine of the 15 patients the normal rectal wall echo-structure, with five distinct layers, was disturbed and there was fading of the borders between the mucosa and the muscularis propria. Poor relaxation of the puborectalis muscle during straining was seen on ultrasound in 11 patients, as was intussusception of the rectal wall. The obvious enlargement of the muscularis propria points to a chronic mechanical load on the rectal wall. The ulcerative lesions are formed in this area of overloaded rectal wall. The direct visualisation of the puborectalis muscle during dynamic transrectal ultrasonography indicates that the fact that it does not relax is an important element in the pathogenesis of solitary rectal ulcer syndrome.

How accurate is clinical examination in diagnosing and quantifying pelvirectal disorders? A prospective study in a group of 50 patients complaining of defecatory difficulties

We prospectively evaluated 50 patients (38 females and 12 males; mean age, 44.7 +/- 15 years) who complained of defecatory difficulties to determine the accuracy of the clinical examination in diagnosing and quantifying pelvirectal abnormalities. Each parameter was then compared with the features of anorectal manometry and evacuation proctography performed by two independent observers. Global agreement between clinical diagnosis and the reference method (radiology for rectoceles, rectal intussusceptions, and abnormal perineal descent; manometry for anismus) was observed in 80 percent of cases. In rectoceles, anismus, and rectal intussusceptions especially, excellent negative predictive values were obtained (96, 96, and 80 percent, respectively). Clinical examination always diagnosed high-grade intussusceptions. Nevertheless, abnormal perineal descent was poorly evaluated in 20 patients. When compared with anal manometry, digital assessment was able to quantify resting and squeeze pressures and length of the anal canal with excellent correlation and good global agreement as well as predicting a short or hypotonic anal canal. Clinical assessment is usually sufficient and accurate in most pelvirectal disorders encountered in patients complaining of defecatory difficulties. Both anorectal manometry and evacuation proctography retain a definite but limited place in investigating pelvirectal disorders.

Clinical and pathologic factors associated with delayed diagnosis in solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome (SRUS) often goes unrecognized or is misdiagnosed. Of 98 patients with a final clinicopathologic diagnosis of SRUS, an initially incorrect diagnosis had been made in 25 patients (26 percent). In these 25 patients with a misdiagnosis, the median age was 43 years and the female-to-male ratio was 3.2:1. The median duration of incorrect diagnosis was five years (range, three months to 30 years), and seven patients received prednisone (> 30 mg/day) for a mistaken diagnosis of inflammatory bowel disease. The main clinical symptoms were rectal bleeding (84 percent) and a disturbance of bowel function (56 percent). Rectal prolapse was present in 13 patients. Original rectal biopsy specimens from 23 patients were reviewed; inadequate specimens and failure to recognize diagnostic features of SRUS contributed to delayed diagnosis in 13 and 10 patients, respectively. The most common clinicopathologic misdiagnoses in SRUS patients with rectal ulcers or mucosal hyperemia were Crohn's disease and mucosal ulcerative colitis. In patients with "polypoid" SRUS, diagnostic confusion was usually with a neoplastic polyp. Persistent bowel symptoms and rectal lesions led to review of the presentations and repeat biopsy directed toward the edge of the rectal ulcers or from within the polypoid or hyperemic rectal lesions, finally establishing the diagnosis of SRUS. Intractable symptoms led to surgery in 15 patients (60 percent), with symptomatic improvement in over two-thirds.

Solitary rectal ulcer: an unusual cause of rectal bleeding in children

The solitary rectal ulcer syndrome (SRUS) is a disease which is commonly diagnosed in adults but only rarely described in children. Rectal prolapse and intussusception are frequently associated with this entity. A relationship between SRUS and chronic constipation due to spastic pelvic floor syndrome (SPFS) is often observed. Thus biofeedback defaecation training is an efficient treatment of both conditions. We describe two paediatric patients suffering from SRUS associated with SPFS who showed complete recovery after biofeedback defaecation training.

Defecatory disorders, anorectal and pelvic floor dysfunction: a polygamy? Radiologic and manometric studies in 41 patients

A consecutive series of 41 patients with defecatory disorders was prospectively studied by anal manometry and evacuation proctography to determine the relationship between abnormalities and symptoms. The patients (29 female, 12 male, aged 41 +/- 2.3 years) all complained of difficulty in evacuation. All had normal colonoscopy and biochemistry. There was no evidence of megacolon or megarectum, and no symptoms had been previously treated by pelvic floor surgery. All subjects completed detailed questionnaires related to gastrointestinal symptoms with special reference to excessive straining and discomfort, digital manipulations during defecation, a sense of pelvic heaviness and incomplete evacuation. Each patient underwent clinical examination, anal manometry and defecography during a single outpatient visit. Rectocele (16 patients) was significantly associated with vaginal digitation, lower stool frequency, delayed rectal emptying and decreased rectal sensation to distension. Increased anal pressure on straining (14 patients) was also related to a poor rectal emptying in 13 patients. Neither perineal descent (24 patients) nor external rectal prolapse (12 patients) was related to objective obstruction. Nevertheless there was an association with pelvic heaviness and lower anal manometric recordings. Five among 16 patients with rectocele had manometric anismus. Forty percent of patients with intussusception also had a paradoxical sphincter response during defaecation. Furthermore, associated abnormalities were extremely common (34 of 41 patients), accurate interpretation of which was necessary for planning effective therapy.

Association between rectocele and paradoxical sphincter response

Rectocele as well as paradoxical sphincter reaction may lead to rectal emptying difficulties and outlet obstruction. Forty-one patients with emptying disturbances and rectocele were investigated with defecography, anorectal manometry, colon transit time, and electromyography. Twenty-nine patients (71 percent) had concomitant paradoxical sphincter reaction, and 13 of these also had increased colon transit time. The functional results after surgical treatment of rectocele are not always satisfactory, probably because patients often have several causes for their emptying disturbances. It is emphasized that careful preoperative investigations are important before surgical treatment of rectocele in patients with emptying difficulties.

Outlet obstruction constipation (anismus) managed by biofeedback

Fifteen subjects presenting with intractable constipation due to obstructive defecation, mean (SEM) duration 8.8 (1.8) years, had the inappropriate contraction and electromyographic changes in the pelvic floor muscles and external and sphincter typical of this condition. An electromyographically derived index was used to grade its severity. A self applied biofeedback device was used to allow electromyographic recording of the abnormal external anal sphincter. The subjects were encouraged to reduce the abnormal electromyographic activity on straining after instruction and training. The procedure was intended as a relearning process in which the non-relaxing activity of the pelvic floor was gradually suppressed. Biofeedback training was maintained on a domiciliary basis for a mean time of 3.1 weeks and resulted in a significant reduction in the anismus index (mean (SEM) 69.9 (7.8)% before biofeedback, mean 14 (3.9)% after biofeedback, p less than 0.01). There was an associated reduction in the time spent straining at stool and in the difficulty of defecation and an increased frequency of defecation. Defecatory video proctograms in six subjects showed improvements in the anorectal angle during straining and evacuation. The clinical benefit to the patients persisted after a mean follow up of 6.2 months.

Assessment and treatment of obstructed defecation

Defecation may be considered as "the last taboo". The inability to defecate, or to achieve it only by digital evacuation, has never been a popular topic among patients and doctors. The extensive development of tests in laboratories studying colorectal disorders during recent years, however, has made it possible to study the different parts of the mechanism for maintaining continence. Since constipation is a disorder of this mechanism, namely a disorder of rectal evacuation, application of these tests on constipated patients is logical. Certainly surgery, either colectomy or sphincter division, is not the solution, nor is the injection of muscle weakening solutions. Biofeedback, however, seems to be a logical treatment. Development of new functional tests and strategies is needed to enable a better understanding of the problem. Collaboration between surgeon and psychologist has proved valuable and is recommended.

A combined electromyographic and cineradiologic investigation in patients with defecation disorders

Records from 20 patients on whom defecography and electromyography were performed simultaneously because of defecation disorders were analyzed. According to the electromyographic investigation, the patients could be divided into three main groups: 1) normal sphincter reaction; 2) paradoxical sphincter reaction; and 3) combined reaction. Group A was characterized by a marked reduction of muscular activity during emptying and a pronounced closing reflex after emptying. This was followed by return of normal tonic activity. Patients in group B had no relaxation of the sphincters during emptying but a pronounced increased activity in the external sphincter and the puborectalis muscle. They also had severe emptying difficulties at defecography. No closing reflex was seen. In group C the electrical activity in the sphincters increased during moderate straining and when emptying was complete a clear closing reflex was seen. In this study, a dynamic visualization of the defecation together with a registration of electromyographic activity in the striated anal sphincters was performed. It was shown that patients with paradoxical sphincter reaction were lacking a closing reflex after emptying was complete. This has not been reported previously and is important evidence for the paradoxical defecation pattern. It was also shown that the patients with rectoceles had paradoxical sphincter reaction.

Rectopexy for internal rectal intussusception

Twelve patients presented with symptomatic internal intussusception of the rectum between 1979 and 1987. All were women with a mean age of 55.5 years. Ten patients had symptoms of obstructed defaecation and only three were completely continent. Polyvinyl alcohol sponge abdominal rectopexy was performed in each patient. Over a mean follow-up period of 26.9 months there was no recurrence of internal intussusception. The functional results, however, were mixed but only one patient remained incontinent for solid stool. Rectal discomfort and defaecatory difficulties persisted; six patients continued to strain at stool and in three this was worsened by the operation. Abdominal rectopexy can be recommended for those with associated incontinence, significant rectal bleeding or solitary rectal ulcer but may not benefit those who have obstructed defaecation.

The investigation of anorectal dysfunction in the solitary rectal ulcer syndrome

To investigate anorectal function in solitary rectal ulcer syndrome 22 patients were studied by means of balloon expulsion, intestinal transit time, barium enema and evacuation proctography. Half of the patients tested had difficulty in expelling a water filled balloon. Delay in intestinal transit was noted in only three patients. Barium enema was of little benefit in diagnosing the condition. Evacuation proctography was the investigation of choice in that it showed at least one abnormality of pelvic floor function in all of the patients and can help select patients for surgery.