High-grade internal rectal prolapse: Does it explain so-called “idiopathic” faecal incontinence?

Analysis of factors that indicated surgery in 400 patients submitted to a complete diagnostic workup for obstructed defecation syndrome and rectal prolapse using a supervised machine learning algorithm

BACKGROUND

Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach.

METHODS

This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested.

RESULTS

A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001).

CONCLUSIONS

Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared.

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

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.

The Minimal Important Difference of the Fecal Incontinence Quality of Life (FIQL) Questionnaire for Patients with Posterior Compartment Prolapse: A Prospective Cohort Study

Objectives:

The minimally important difference (MID) of the Fecal Incontinence Quality of Life (FIQL) scale has never been determined. Thus, in this study, we aimed to estimate the MID of the Japanese FIQL for patients with posterior compartment prolapse (PCP).

Methods:

For 3-months after surgery, we followed a prospective cohort of 136 patients with PCP combined with fecal incontinence (FI) who had undergone ventral rectopexy between 2012 and 2018. Usable data from 114 patients were analyzed. Patients have both completed the FIQL and the 36-Item Short Forum Health Survey (SF-36) before and after surgery. Distribution-based MID values were estimated at 1/2 SD and the standard error of measurement (SEM) for domain and total scores across time points. Changes in the domain scores anchored to changes in a SF-36 overall health assessment question were used to estimate anchor-based MID. To be interpreted as true change, the median, anchor-based MID values that were greater than the corresponding SEM were proposed as estimates of the MID for the FIQL.

Results:

Distribution-based MID of 1/2 SD for each domain and total score ranged between 0.3 and 0.4, whereas SEM ranges were between 0.2 and 0.3. The anchor-based approach resulted in the median MID estimates of 0.4 to 1.0. Final estimates of MID for each FIQL and total score were as follows: lifestyle (0.6-1.1), coping/behavior (0.8-1.4), depression/self-perception (0.4-0.8), embarrassment (1.0-1.6), and total score (0.7-1.1).

Conclusions:

The results provide a basis for clinically important differences in FIQL scores after surgery for patients with PCP and FI.

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.

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.

International Continence Society best practice statement for use of sacral neuromodulation

AIMS

Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel.

METHODS

Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group.

RESULTS

The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research.

CONCLUSIONS

These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.