Overt rectal prolapse and fecal incontinence

OUP accepted manuscript

Background

External rectal prolapse is a relatively rare disease, in which male patients account for a minority. The selection of abdominal repair or perineal repair for male patients has rarely been investigated.

Methods

Fifty-one male patients receiving abdominal repair (laparoscopic ventral rectopexy) or perineal repair (Delorme or Altemeier procedures) at the Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between March 2013 and September 2019 were retrospectively analysed. We compared the recurrence, complication rate, post-operative defecation disorder, length of stay, and quality of life between the abdominal and perineal groups.

Results

Of the 51 patients, 45 had a complete follow-up, with a median of 48.5 months (range, 22.8–101.8 months). A total of 35 patients were under age 40 years. The complication rate associated with abdominal repair was less than that associated with perineal repair (0% vs 20.7%, P = 0.031) and the recurrence rate was also lower (9.5% vs 41.7%, P = 0.018). Multivariate analysis showed that perineal repair (odds ratio, 9.827; 95% confidence interval, 1.296–74.50; P = 0.027) might be a risk factor for recurrence. Moreover, only perineal repair significantly improved post-operative constipation status (preoperative vs post-operative, 72.4% vs 25.0%, P = 0.001). There was no reported mortality in either of the groups. No patient's sexual function was affected by the surgery.

Conclusions

Both surgical approaches were safe in men. Compared with perineal repair, the complication rate and recurrence rate for abdominal repair were lower. However, perineal repair was better able to correct constipation.

Long-term impact of full-thickness rectal prolapse treatment on fecal incontinence

BACKGROUND

Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse.

OBJECTIVE

We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse.

DESIGN

A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010).

MAIN OUTCOME MEASURES

Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score.

RESULTS

Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017).

LIMITATIONS

Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias.

CONCLUSION

Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies.

Incontinence in full-thickness rectal prolapse: low level of improvement after laparoscopic rectopexy

AIM

The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse.

METHOD

Eighty-five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self-administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery.

RESULTS

After a mean follow-up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (-3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients' average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P < 0.0001) were significantly higher in patients suffering from postoperative incontinence.

CONCLUSION

Despite some continence improvement in two-thirds of patients who underwent surgery for rectal prolapse, the level of improvement remained low in more than half of the patients.

Underlying functional bowel disorder may explain patient dissatisfaction after haemorrhoidal surgery

AIM

The aim of this study was to assess patient dissatisfaction and functional symptoms following haemorrhoid surgery, aspects of which are seldom covered in other published series.

METHOD

A self-administered questionnaire was mailed to 359 consecutive patients (prospective database; 198 men, 161 women; median follow up, 59 [1-120] months) who underwent either Milligan-Morgan haemorrhoidectomy (n=205) or stapled haemorrhoidopexy (n=154).

RESULTS

The response rate was 72%; 2.4% of patients had no opinion, 13.6% were dissatisfied, 33.0% were satisfied, and 51.0% were very satisfied with the treatment. Dissatisfied patients were more likely to be women and more likely to have a long history of constipation and irritable bowel syndrome. The duration of surgery and the rates of pre- and postoperative complications did not differ between groups. Residual bleeding (49% vs 32%), prolapse (67% vs 31%) and pain (91% vs 55%) occurred more frequently in the dissatisfied group compared with the satisfied group (P<0.001). Incontinence (4 [0-16] vs 1 [0-15]; P=0.0003) and constipation (19 [1-34] vs 8 [0-31]; P<0.0001) scores were significantly higher in the dissatisfied group compared with satisfied patients. Anal pain was the predominant symptom associated with dissatisfaction in a logistic regression model.

CONCLUSION

Persistent pain remains the major long-term factor associated with dissatisfaction after surgery for haemorrhoids.

Joint hypermobility and rectal evacuatory dysfunction: an etiological link in abnormal connective tissue?

BACKGROUND

  Previous studies report an association between joint hypermobility (JHM), as a clinical feature of underlying connective tissue (CT) disorder, and pelvic organ prolapse. However, its association with rectal evacuatory dysfunction (RED) has not been evaluated. To investigate the prevalence of JHM in the general population and in patients with symptoms of RED referred for anorectal physiological investigation.

METHODS

Bowel symptom and Rome III questionnaires to detect irritable bowel syndrome were sent to 273 patients with RED. Patients then underwent full investigation, including evacuation proctography. A validated 5-point self-reported questionnaire was used to assess JHM in both the patient group and 100 age- and sex-matched controls [87 female, median age 55 (range 28-87)].

KEY RESULTS

Seventy-three patients were excluded from analysis (incomplete questionnaire or investigation). Of 200, 65 patients [32%: 63 female, median age 52 (range 15-80)] and 14% of controls (P = 0.0005 vs patients) had features satisfying criteria for JHM. Overall constipation score (P < 0.0001), abdominal pain (P = 0.003), need for manual assistance (P = 0.009), and use of laxatives (P = 0.03) were greater in the JHM group than the non-JHM group. On proctography, 56 of JHM patients (86%) were found to have significant morphological abnormalities (e.g. functional rectocoele), compared with 64% of the non-JHM group (P = 0.001).

CONCLUSIONS & INFERENCES

The greater prevalence of JHM in patients with symptoms of RED, and the demonstration of significantly higher frequencies of morphological abnormalities than those without JHM, raises the possibility of an important pathoaetiology residing in either an enteric or supporting pelvic floor abnormality of CT.

Practical performance of defecography for the evaluation of constipation and incontinence

By opacifying the sigmoid, rectum, and vagina with different barium consistencies and using fluoroscopy to evaluate the mechanics of defecation in a physiologic setting, a wide range of pathologies associated with constipation and incontinence can be diagnosed. This review article discusses the primary indications for fluoroscopic defecography, techniques, common diagnoses, and challenges faced in clinical practice.