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

Anal sphincter function in rectal intussusception and high and low "take-off" external rectal prolapse-A prospective observational study

AIM

Rectal intussusception (RI) and external rectal prolapse (ERP) are associated with anal sphincter dysfunction. The aim of this study was to examine sphincter function with anal acoustic reflectometry (AAR) in RI and two distinct phenotypes of ERP termed high and low "take-off".

METHODS

A prospective study of patients with RI and ERP attending a tertiary pelvic floor unit. Clinical data, AAR, and conventional anal manometry were analysed according to the Oxford prolapse grade.

RESULTS

A total of 108 (102 [94%] female, median age 62 years [range: 26-95]) patients were recruited into three groups according to prolapse grade: Oxford grades I and II (intrarectal RI, n = 34), Oxford grades III and IV (intra-anal RI, n = 35) and Oxford grade V (ERP, n = 39). As the grade of prolapse increased, resting AAR measurements of opening pressure, opening elastance, closing pressure, and closing elastance decreased (p < 0.001). Maximum resting pressure with manometry was reduced in ERP and intra-anal RI compared to intrarectal RI (p < 0.001). However, incremental squeeze function was not different between the three groups with either AAR or manometry (p > 0.05). There were no differences in AAR or manometry variables between grade IV RI (n = 18) and high take-off ERP (n = 20) (p > 0.05). By contrast, opening pressure (p = 0.010), closing pressure (p = 0.019) and elastance (p = 0.022) were reduced in low take-off ERP (n = 19).

CONCLUSION

Increasing rectal prolapse grade is associated with reduced anal sphincter function at rest indicating internal anal sphincter dysfunction. Physiological differences exist between high and low take-off ERP with sphincter function in the former similar to that seen in grade IV RI.

Increased Grades of Rectal Intussusception: Role of Decline in Pelvic Floor Integrity and Association With Dyssynergic Defecation

INTRODUCTION

The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades.

METHODS

Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression.

RESULTS

Analysis included a total of 238 women: 90 had no RI, 43 Oxford 1-2, 49 Oxford 3, and 56 Oxford 4-5. Age ( P = 0.017), vaginal delivery ( P = 0.008), and prior pelvic surgery ( P = 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion ( P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining, was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades.

DISCUSSION

Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation.

The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders

AIM

Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process.

METHOD

Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up.

RESULTS

After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy.

CONCLUSION

The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Co-occurrence of fecal incontinence with constipation or irritable bowel syndrome indicates the need for personalized treatment

BACKGROUND

This study aimed to compare the prevalence and symptoms of fecal incontinence (FI) in relation to irritable bowel syndrome (IBS-associated FI), constipation (constipation-associated FI), and isolation (isolated FI).

METHODS

Data were analyzed from 3145 respondents without organic comorbidities known to influence defecation function from the general Chinese population who filled in the online Groningen Defecation and Fecal Continence questionnaire. FI, IBS, and constipation were evaluated with the Rome IV criteria.

KEY RESULTS

The prevalence of FI was 10.5% (n = 329) in the non-comorbidity group. After multivariable logistic regression analysis, IBS (odds ratio [OR]: 12.55, 95% confidence interval [CI]: 9.06-17.36) and constipation (OR: 4.38, 95% CI: 3.27-5.85) were the most significant factors contributing to FI. Based on this finding, 106/329 (32.2%) had IBS-associated FI, 119/329 (36.2%) had constipation-associated FI, and 104/329 (31.6%) had isolated FI. Among the 329 FI respondents, there was a high prevalence of IBS and constipation-related symptoms, including abdominal pain (81.5%) and abdominal bloating (77.8%) for IBS and straining during defecation (75.4%), incomplete defecation (72.3%), defecation blockage (63.2%), anal pain during defecation (59.3%), and hard stools (24%) for constipation. The patients with IBS-associated FI asked for specialists' help less frequently than those with isolated FI. Interestingly, among the patients with constipation-associated FI, 56.3% used anti-diarrhea medicine.

CONCLUSIONS AND INFERENCES

The prevalence of IBS-associated FI, constipation-associated FI, and isolated FI is comparably high. It is important to diagnose and target the cause of FI to provide personalized and cause-targeting care instead of treating only the FI symptoms.

Pelvic floor training improves faecal incontinence and obstructed defaecation despite the presence of rectal intussusception

BACKGROUND

Rectal intussusception is often observed in patients with faecal incontinence and obstructed defaecation. The aim of this study is to assess if pelvic floor training improves faecal incontinence and obstructed defaecation in patients with rectal intussusception.

METHODS

Case notes of all patients referred to Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018 for the management of faecal incontinence and obstructed defaecation and rectal intussusception were retrospectively reviewed using a prospectively maintained database. St Mark's faecal incontinence and Cleveland clinic constipation scores were obtained from patients before and after they underwent pelvic floor training.

RESULTS

One hundred and thirty-one patients underwent pelvic floor training at Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018. Sixty-one patients had rectal intussusception (22 low-grade and 39 high-grade). Median St Marks score improved following pelvic floor training from 8 to 1 (P < 0.001). Median Cleveland Clinic constipation score improved from 8 to 5 (P < 0.001). In patients with low grade rectal intussusception, pelvic floor training improved median St Mark's score from 3 to 0 (P = 0.003), whereas Cleveland Clinic constipation score improved from 9 to 7 (P < 0.001). In patients with high-grade rectal intussusception, pelvic floor training improved median St Mark's score from 9 to 2 (P < 0.001), whereas median Cleveland Clinic constipation score improved from 8 to 4 (P < 0.001).

CONCLUSION

Pelvic floor training without biofeedback therapy improves faecal incontinence and obstructed defaecation. Improvement in symptoms is unrelated to rectal intussusception observed on proctography or at examination under anaesthesia in these patients.

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.

Predictive factors for functional failure of ventral mesh rectopexy in the treatment of rectal prolapse and obstructed defecation

Background

Ventral mesh rectopexy (VMR) is widely accepted for the treatment of rectal prolapse or obstructed defecation. However, despite good anatomical results, the improvement of functional symptoms (constipation or incontinence) cannot always be obtained and in some cases these symptoms may even worsen. The aim of the present study was to identify possible predictors of functional failure after VMR.

Methods

Data of all consecutive patients who had VMR for the treatment of rectal prolapse and/or obstructed defecation between January 2017 and December 2020 in three different pelvic floor surgical centres in Italy were analysed to identify possible predictors of functional failure, intended as persistence, worsening or new onset of constipation or faecal incontinence. Symptom severity was assessed pre- and postoperatively with the Wexner Constipation score and Obstructed Defecation Syndrome score. Quality of life was assessed, also before and after treatment, with the Patients Assessment of Constipation Quality of Life questionnaire, the Pelvic Floor Disability Index and the Pelvic Floor Impact Questionnaire. Faecal incontinence was evaluated with the Cleveland Clinic Incontinence Score. The functional outcomes before and after surgery were compared.

Results

Sixty-one patients were included (M:F ratio 3:60, median age 64 years [range 33–88 years]). Forty-two patients (68.9%) had obstructed defecation syndrome, 12(19.7%) had faecal incontinence and 7 patients (11.5%) had both. A statistically significant reduction between pre- and postoperative Obstructed Defecation Syndrome and Wexner scores was reported (p < 0.0001 in both cases). However, the postoperative presence of constipation occurred in 22 patients (36.1%) (this included 3 cases of new-onset constipation). The presence of redundant colon and the pre-existent constipation were associated with an increased risk of persistence of constipation postoperatively or new-onset constipation (p = 0.004 and p < 0.0001, respectively). The use of postoperative pelvic floor rehabilitation (p = 0.034) may reduce the risk of postoperative constipation.

Conclusions

VMR is a safe and effective intervention for correcting the anatomical defect of rectal prolapse. The degree of prolapse, the presence of dolichocolon and pre-existing constipation are risk factors for the persistence or new onset of postoperative constipation. Postoperative rehabilitation treatment may reduce this risk.

MRI biomarker of muscle composition is associated with severity of pelvic organ prolapse

BACKGROUND

The pathophysiology of pelvic organ prolapse is largely unknown. We hypothesized that reduced muscle mass on magnetic resonance defecography (MRD) is associated with increased pelvic floor laxity. The aim of this study was to compare the psoas and puborectalis muscle mass composition and cross-sectional area among patients with or without pelvic laxity.

METHODS

An observational retrospective study was conducted on women > age 18 years old who had undergone MRD for pelvic floor complaints from January 2020 to December 2020 at Stanford Pelvic Health Center. Pelvic floor laxity, pelvic organ descent, and rectal prolapse were characterized by standard measurements on MRD and compared to the psoas (L4 level) and puborectalis muscle index (cross-sectional area adjusted by height) and relative fat fraction, quantified by utilizing a 2-point Dixon technique. Regression analysis was used to quantify the association between muscle characteristics and pelvic organ measurements.

RESULTS

The psoas fat fraction was significantly elevated in patients with abnormally increased resting and strain H and M lines (p < 0.05) and increased with rising grades of Oxford rectal prolapse (p = 0.0001), uterovaginal descent (p = 0.001) and bladder descent (p = 0.0005). In multivariate regression analysis, adjusted for age and body mass index, the psoas fat fraction (not muscle index) was an independent risk factor for abnormal strain H and M line; odds ratio (95% confidence interval) of 17.8 (2-155.4) and 18.5 (1.3-258.3) respectively, and rising Oxford grade of rectal prolapse 153.9 (4.4-5383) and bladder descent 12.4 (1.5-106). Puborectalis fat fraction was increased by rising grades of Oxford rectal prolapse (p = 0.0002).

CONCLUSIONS

Severity of pelvic organ prolapse appears to be associated with increasing psoas muscle fat fraction, a biomarker for reduced skeletal muscle mass. Future prospective research is needed to determine if sarcopenia may predict postsurgical outcomes after pelvic organ prolapse repair.

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation

Background

The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods

The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results

Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions

With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration

ISRCTN Registry (ISRCTN11747152).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02633-w.

Value of Defecography in the Diagnostic and Therapeutic Management of the Modified Wells Procedure for Rectal Prolapse

The main aim of this study was to explore the role of defecography in the preoperative diagnosis and postoperative evaluation of rectal prolapse surgery (modified Wells procedure). We collected and summarized the X-ray performance and then analyzed the results of 107 patients with defecatory dysfunction who underwent defecography from January 2020 to March 2021. Furthermore, the preoperative and 6-month postoperative defecography results and clinical symptoms of 25 patients who underwent rectal prolapse surgery (modified Wells procedure) were compared. Results showed that among the 107 patients with defecation dysfunction, women had worse defecography results than men (P < 0.01). A total of 25 patients successfully completed the surgery without complications such as infection and intestinal fistula and there was no recurrence at 12 months of follow-up. Compared with the preoperative results, anorectal angle during defecation, the depth of rectocele, and perineal descent were significantly improved after the surgery (P < 0.01). Moreover, the patient's feeling of obstructed defecation and incomplete defecation was significantly relieved compared to that before the procedure (P < 0.01). In conclusion, defecography can be used to diagnose rectal prolapse preoperatively and evaluate the surgical effect combined with clinical symptoms postoperatively, which provides a clinical reference.

Laparoscopic resection rectopexy significantly affects preexisting urinary symptoms in female patients

PURPOSE

It has previously been noted that following rectopexy, some patients report changes in urinary function. So far, not much is known about the extent of such changes. This study assesses the effects of laparoscopic rectopexy on urinary symptoms.

METHODS

Prospective observational study with 100 consecutive female patients indicated for laparoscopic resection rectopexy. Stated urinary symptoms, pre- and postoperative "International Consultation on Incontinence Questionnaire" (ICIQ), supplemented by a "quality of life " (QoL) visual analogue scale, and residual urine measurements (RUM) were compared and correlated.

RESULTS

Postoperative QoL was significantly improved, irrespective of preexisting urinary symptoms. Twenty-four (24%) patients noticed improved urinary function. This corresponded with 42% of 45 patients who had positive preoperative ICIQ scores indicating preexisting urinary symptoms. Conversely, 14 (14%) patients noticed a postoperative increase of urinary complaints. The stated symptom change was only in part reflected by changes of the ICIQ scoring. Comparing ICIQ, 19 (19%) patients scored "better" postoperatively against 8% scoring worse; 5 of the 8 patients experienced "de novo" symptoms. The improved postoperative ICIQ scoring was highly significant. RUM did not sufficiently correlate to symptoms/ICIQ for any meaningful conclusion.

CONCLUSIONS

Laparoscopic resection rectopexy had predominantly beneficial and to a lesser extent detrimental effects on urinary symptoms. Effects were highly significant; they were mainly noted in patients with preexisting urinary complaints. So far, it is not possible to predict such effects on an individual basis. It appears likely that similar effects may be found for most of the alternative operative procedures for the treatment of rectal prolapse. Without more factual knowledge and awareness about the extent of potential "collateral" effects of pelvic floor repair procedures, expert guidance of patients appears limited.

Perineal Rectosigmoidal Resection for Complete Rectal Prolapse

BACKGROUND: Rectal prolapse (RP) (rectal Providencia) is a disorder manifest by full-thickness intussusceptions of the rectal wall that protrudes externally through the anus. AIM: A retrospective study was done to evaluate the outcome of rectosigmoidal resection for complete rectal prolapse (CRP) in our hospital from 2008 to 2020. METHODS: This study analyzes the data of post-operative outcomes for 25 patients with CRP treated by perineal rectosigmoidal resection; eight patients were male and 17 were female. RESULTS: A total of 25 patients enrolled with the median age of 50 years. There was an improvement in the general condition of patients regarding constipation, bleeding per rectum, incontinence, and perineal discomfort. There were no mortality, no major complication, and a low recurrence rate. CONCLUSION: Altemier’s procedure for CRP improves patients’ general condition regarding constipation and incontinence, no mortality, low complication rate, and negligible rate of recurrence.

Modified Gant procedure for treatment of internal rectal prolapse in elderly women

BACKGROUND

Although rectal prolapse is not a life-threatening condition, it can cause defecation disorders, anal incontinence, sensory abnormalities, and other problems that can seriously affect quality of life.

AIM

To study the efficacy of the modified Gant procedure for elderly women with internal rectal prolapse.

METHODS

Sixty-three elderly female patients with internal rectal prolapse underwent the modified Gant procedure. The preoperative and postoperative anal symptoms, Patient Assessment of Constipation Quality of Life (PAC-QOL), Wexner incontinence score, incontinence quality of life score, and complications (massive hemorrhage, infection, anorectal stenosis, and anorectal fistula) were compared.

RESULTS

The improvement rates of postoperative symptoms were defecation disorders (84.5%), anal distention (69.6%), defecation sensation (81.4%), frequent defecation (88.7%), and anal incontinence (42.9%) (P < 0.05). All dimensions and total scores of the PAC-QOL after the procedure were lower than those before the operation (P < 0.05). The postoperative anal incontinence score and Wexner score were significantly lower than those before the procedure (P < 0.05). The quality of life and total scores of postoperative anal incontinence were significantly higher than those before the procedure (P < 0.05). There were no serious complications and no deaths.

CONCLUSION

The modified Gant procedure has significant advantages in the treatment of elderly women with internal rectal prolapse.

Long-term annual functional outcome after laparoscopic ventral rectopexy for rectoanal intussusception and/or rectocele: evaluation of sustained improvement

BACKGROUND

The aim of this study was to assess the long-term annual functional results and quality of life (QOL) after laparoscopic ventral rectopexy (LVR) for rectoanal intussusception (RAI) and/or rectocele.

METHODS

This study was a retrospective analysis of prospectively collected data. The study was conducted on patients who underwent LVR for RAI and/or rectocele at our institution between February 2012 and July 2015. The Fecal Incontinence Severity Index (FISI), Constipation Scoring System (CSS), and QOL instruments (i.e., 36-item Short-form Health Survey [SF-36], Patient Assessment of Constipation-QOL [PAC-QOL] scale, and Fecal Incontinence-QOL [FIQL]) were administered before and annually after surgery. The sustainability of substantial symptom improvement (reduction of at least 50% in CSS or FISI scores) postoperatively was evaluated.

RESULTS

Fifty-one patients (median age 76 [range 60-93] years, 48 women [94%]) were analyzed. No mortality or major morbidity occurred. After a median follow-up of 60 months (range 12-84 months), no mesh-related complications occurred. The median CSS and FISI scores were significantly reduced at 1 year and remained significantly reduced for 7 years. In patients who reported symptom scores ≥ 3 times postoperatively, sustained improvement of constipation and fecal incontinence was found in about 50% (18/38) and 75% (26/35) of relevant patients, respectively. All PAC-QOL and FIQL scales significantly improved over time for 5 years. Of the SF-36 scales, four showed significant improvement at 1 year but none was significantly improved after 3 years, except for the social functioning scale.

CONCLUSIONS

LVR for RAI and/or rectocele was associated with low morbidity and long-term improvement in symptom-specific QOL. The sustainability of postoperative improvement in fecal incontinence was satisfactory, and that in constipation was fair.

Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome

BACKGROUND

Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required.

OBJECTIVES

To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome.

SEARCH METHODS

We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author.

SELECTION CRITERIA

Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information.

DATA COLLECTION AND ANALYSIS

Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE.

MAIN RESULTS

Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE.

AUTHORS' CONCLUSIONS

In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.

Solitary rectal ulcer syndrome (SRUS): observational case series findings on MR defecography

OBJECTIVE

Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS.

MATERIALS AND METHODS

MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years' experience in pelvic floor imaging made the anatomical and functional measurements.

RESULTS

Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia.

CONCLUSION

MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications.

KEY POINTS

MRD can identify and grade both rectal intussusception and dyssynergia in patients with SRUS. MRD is an acceptable substitute to evacuation proctography in assessing anorectal dysfunctions when attempting to avoid ionizing radiation. SRUS influences the pelvic floor globally. MRD depicts associated anterior and/or middle compartment prolapse.

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.

MR defecography review

Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Is there any association between symptoms and findings on imaging in pelvic floor defaecatory dysfunction? A prospective study

AIM

To compare features on imaging (integrated total pelvic floor ultrasound (transperineal, transvaginal) and defaecation proctography) with bowel, bladder and vaginal symptoms in pelvic floor defaecatory dysfunction.

METHOD

A prospective observational case series of 216 symptomatic women who underwent symptom severity scoring (bowel, bladder and vaginal), integrated total pelvic floor ultrasound and defaecation proctography. Anatomical (rectocele, intussusception, enterocele, cystocele) and functional (co-ordination, evacuation) features were examined.

RESULTS

Irrespective of imaging modality, patients with a rectocele had higher International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) scores than patients without. On integrated total pelvic floor ultrasound, ICIQ-VS quality of life scores were higher in those with a rectocele. There was a higher International Consultation on Incontinence Modular Questionnaire - Bowel Symptoms (ICIQ-BS) bowel pattern score in those with a rectocele, and a lower ICIQ-BS bowel pattern and sexual impact score in those with intussusception. Poor co-ordination was associated with increased ICIQ-BS bowel control scores and obstructed defaecation symptom scores. On defaecation proctography, ICIQ-VS symptom scores were lower in patients with poor co-ordination.

CONCLUSION

Patients with a rectocele on either imaging modality may have qualitative vaginal symptoms on assessment. In patients with bowel symptoms but no vaginal symptoms, it is not possible to predict which anatomical abnormalities will be present on imaging.

Diagnostic clues, pitfalls, and imaging characteristics of '-celes' that arise in abdominal and pelvic structures

'-Celes' is an ancient Greek language suffix that means 'tumor,' 'hernia,' 'swelling,' or 'cavity.' There are many '-celes' in the abdomen and pelvis that may be encountered during routine imaging interpretation, including santorinicele, choledochocele, ureterocele, lymphocele, mucocele, rectocele, cystocele, peritoneocele, varicocele, spermatocele, hydrocele, hematocele, pyocele and syringocele. Most '-celes' are detected incidentally at imaging for other clinical indications, but some deserve more attention due to a range of clinical symptoms or functional disorder that can adversely affect patient quality of life. The objective of this article was to address all of the '-celes' that a general radiologist and abdominal radiologist should know and be able to recognize. Imaging characteristics, diagnostic clues, and pitfalls have been provided to improve diagnostic accuracy and patient outcomes.

The relationships between the results of contemporary tests of anorectal structure and sensorimotor function and the severity of fecal incontinence

BACKGROUND

Diagnostic investigations for fecal incontinence (FI) assess the structure and sensorimotor function of the anorectum. Investigations include anorectal manometry, anorectal sensory testing, pudendal nerve terminal motor latencies (PNTML), and endoanal sonography. The severity of FI and results of investigations are often discordant and the rate of symptom resolution following treatment remains <40%. High-resolution anorectal manometry (HRAM) and three-dimensional endoanal ultrasound (3D-US) have been introduced during the last decade. This study aims to assess the strength of relationships between contemporary investigation results and FI severity.

METHODS

Adults presenting for investigation of FI were assessed using the St Mark's FI severity score (SMIS), HRAM, anorectal sensory testing, PNTML, and 3D-US.

KEY RESULTS

246 patients were included. There were significant relationships between the SMIS and HRAM (resting pressure r_s = -0.23, 95% CI = (-0.34, -0.11), P < .001; squeeze pressure (r_s  = -0.26, 95% CI = (-0.37, -0.14), P < .001) and 3D-US (anterior EAS length r_s = -0.22, 95% CI = (-0.34, -0.09), P = .001). The relationships between SMIS and HRAM had a greater effect size in those with urge-predominant symptoms (resting pressure: r_s = -0.40, 95% CI = (-0.57, -0.20), P < .001, squeeze pressure: r_s = -0.34, 95% CI = (-0.52, -0.12), P = .003). Overall, the variance in SMIS accounted for by anorectal investigations was 8.6% (R² = 0.098, adjusted R² = 0.086, P < .001).

CONCLUSIONS AND INFERENCES

Anorectal investigations are not strong predictors of FI severity. These findings may reflect the multifactorial, heterogeneous pathophysiology of FI, the limitations of the SMIS and anorectal investigations, and contributing factors extrinsic to the anorectum.

Spontaneous Internal Anal Sphincter Relaxation During High-resolution Anorectal Manometry Is Associated With Peripheral Neuropathy and Higher Charlson Comorbidity Scores in Patients With Defecatory Disorders

Background/Aims

We aimed to evaluate associations between comorbidities, peripheral neuropathy, and spontaneous internal anal sphincter relaxation (SAR) in patients with defecatory disorders.

Methods

A patient was considered to exhibit SAR during high-resolution anorectal manometry (HR-ARM) when the nadir pressure is < 15 mmHg and the time from onset to relaxation was ≥ 15 seconds in the resting pressure frame. A case-control study was performed using HR-ARM data collected from 880 patients from January 2010 to May 2015. We identified 23 cases with SAR (median age 75 years; 15 females; 12 fecal incontinence and 11 constipation). We compared HR-ARM values, Charlson index comorbidity scores, neuropathy, and the prevalence of diseases that potentially cause neuropathy between controls and SAR patients. Each SAR case was compared to 3 controls. Controls were selected to match the age, gender, and examination year of each SAR case.

Results

Compared to controls (26.1%), SAR patients (52.2%) exhibited a significantly higher frequency of fecal incontinence. SAR patients also had higher Charlson index scores (5 vs 4, P = 0.028). Nine of 23 SAR patients (39.1%) exhibited peripheral neuropathy— this frequency was higher than that for the control group (11.6%; P = 0.003). Diseases that potentially cause neuropathy were observed in 17 of 23 SAR cases and 32 of 69 controls (P = 0.022).

Conclusions

SAR develops in patients with constipation and fecal incontinence but is more common in patients with fecal incontinence. Our controlled observational study implies that SAR is associated with peripheral neuropathy and more severe comorbidities.

A 10-year retrospective cohort study to assess objective and subjective outcomes of combined stapled transanal rectal resection and urogynecological surgery for pelvic floor dysfunction

PURPOSE

To assess the subjective and objective outcomes of combined stapled transanal rectal resection (STARR) and urogynecological surgery to treat pelvic organ prolapse, with a 10-year follow-up.

METHODS

This was a retrospective cohort study analyzing prospectively collected data from 53 consecutive patients who underwent combined stapled transanal rectal resection and urogynecological surgery, from 1 January 2005 to 31 December 2007 at a tertiary referral Pelvic Floor Unit of an Italian hospital.

RESULTS

Fifty-three patients with a median age of 60 years (interquartile range (IQR) 67-52t), underwent STARR and concomitant urogynecological surgery. No serious postoperative complications were recorded, and 37/53 women (70%) were evaluated at the 10-year follow-up visit. The cure rate was optimal in 34 women (64.1%). Regarding persistent and/or recurrent symptoms, five sexually-active patients (9%) reported dyspareunia only; obstructed defecation symptoms recurred in ten women (19%); urinary incontinence occurred in eight patients (15%); four patients (11%) reported persistent perineal pain; and two patients (5%) experienced both the urge to defecate and voiding dysfunction. At the 10-year follow-up, 14/27 patients (52%) stated that they would undergo the same operation again, if necessary. Furthermore, the survey found that patients would recommend the combined surgery.

CONCLUSION

The 10-year results of this study proved that combined rectal and urogynecological surgery is well tolerated, associated with low morbidity, and more effectively treats a distressing and debilitating condition vs separate surgeries for rectal and pelvic organ prolapse. We recommend complementing the relatively small scale of this study with randomized trials involving a sufficient number of patients, to provide more conclusive evidence on the cumulative long-term effects of combined surgery vs 2- or 3-stage surgery.

Midterm functional outcome after laparoscopic ventral rectopexy for external rectal prolapse

INTRODUCTION

Although long-term crude outcomes of laparoscopic ventral rectopexy for external rectal prolapse (ERP) have been documented, repetitive functional and quality of life (QOL) assessments are scarce. This study assessed midterm annual functional results and QOL after laparoscopic ventral rectopexy for ERP.

METHODS

This study consisted of 58 patients and was a retrospective analysis of prospectively collected data. The Fecal Incontinence Severity Index, the Constipation Scoring System, and QOL instruments (ie 36-item Short-Form Health Survey and Fecal Incontinence Quality of Life scale) were administered before and after operation.

RESULTS

There was no mortality or major morbidity. After a median follow-up of 49 months (6-92 months), recurrence of ERP was noted in one patient (2%). There were no mesh-related complications. The median Fecal Incontinence Severity Index score was significantly reduced at 3 months (34 [10-61] vs 12 [0-50], P < 0.0001) and remained significantly reduced for 5 years. The median Constipation Scoring System score was significantly reduced at 3 months (14 [9-20] vs 7 [0-16], P < 0.0001) and remained significantly reduced for 4 years. No patients developed new-onset constipation. All of the Fecal Incontinence Quality of Life scales significantly improved overtime for 4 years. All of the 36-item Short-Form Health Survey scales were significantly improved at 3 and 6 months, but none of the scales significantly improved after 2 years.

CONCLUSION

Laparoscopic ventral rectopexy for ERP was associated with low morbidity, low recurrence, and a midterm improvement in function and fecal incontinence-specific QOL.

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.

Clinical and physiological risk factors for fecal incontinence in chronically constipated women

BACKGROUND

Fecal incontinence (FI) and chronic constipation (CC) are disabling symptoms that cause a significant public health problem. The pathophysiology of combined constipation and FI is not fully understood. Our aim was to delineate the clinical, physiological and anatomical factors that may contribute to the association of FI and CC.

METHODS

A retrospective study was performed in a pelvic floor unit in a tertiary medical center. Consecutive female patients diagnosed with CC were included, and further divided into two groups according to the co-occurrence of FI. Demographic characteristics, anorectal physiology (obtained by manometry) and pelvic anatomical pathology (as assessed by dynamic pelvic ultrasound) were recorded and subsequently compared.

RESULTS

A total of 267 women were included in the study. Of those, 62 patients (23%) had an associated FI (CCFI). The CCFI group had higher body mass index (BMI) levels and a trend toward younger average age as compared to the group without FI (CCNFI). The number of vaginal and instrumental deliveries was similar in both groups. Anal resting and squeeze pressures were significantly lower in the CCFI group (64 ± 21 vs 48 ± 18, p = 0.004 and 141 ± 136.2 vs. 97.5 ± 38.6, p = 0.02, respectively). Rectal sensation abnormalities were common, but did not differ between both groups. Dyssynergic defecation and rectocele were more common in the CCNFI group (68% vs. 51%, p = 0.04 and 39% vs. 24%, p = 0/045, respectively.

CONCLUSIONS

Lower anal pressures and higher BMI were found among women with coexisting FI and CC. Pelvic floor anatomical and functional abnormalities are common in women diagnosed with CC and FI, but dyssynergia and diagnosis of significant rectocele, which cause obstructed defecation, were more common in the CCNFI group.

The Contributions of Internal Intussusception, Irritable Bowel Syndrome, and Pelvic Floor Dyssynergia to Obstructed Defecation Syndrome

BACKGROUND

Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms.

OBJECTIVE

This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms.

DESIGN

Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument.

SETTINGS

This study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

PATIENTS

The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016.

MAIN OUTCOME MEASURES

The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score.

RESULTS

Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p < 0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores.

LIMITATIONS

The study was limited because it was an observational study from a single center.

CONCLUSIONS

Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.

Outcomes of treatment of faecal incontinence with sacral nerve stimulation - a Finnish multicentre study

AIM

The aim of this multicentre study is to report the results of sacral nerve stimulation (SNS) treatment for faecal incontinence (FI) in Finland and determine factors that could influence SNS treatment outcomes.

METHOD

This is a national multicentre study, involving all patients tested for SNS implantation in Finland from 1999 to 2017. Data were collected retrospectively from electronic patient archives and analysed for possible effects on treatment outcome.

RESULTS

Of the 432 patients with FI tested for SNS, 365 were women. Three hundred and thirteen (72.5%) of the tested patients advanced to permanent implantation of a stimulator. A successful final treatment outcome, with subjective alleviation of FI, was reported by 59.3% of the patients at the end of follow-up (mean 2.4 years, range 8 days to 13.3 years). Patients with obstetric sphincter injury and idiopathic FI had more permanent stimulator implantations than patients with iatrogenic injury (P = 0.012). Male patients had significantly worse test phase outcomes than female patients (P < 0.001). Age did not influence treatment outcome (P = 0.446) CONCLUSION: Subjective final success of SNS treatment for FI was achieved in 59.3% of patients at a mean of 2.4 years. Gender and the aetiology of FI influenced the test phase and final treatment outcome of SNS treatment.

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.

Laparoscopic ventral rectopexy in patients with fecal incontinence associated with rectoanal intussusception: prospective evaluation of clinical, physiological and morphological changes

BACKGROUND

Physiological changes after laparoscopic ventral rectopexy (LVR) in patients with rectoanal intussusception (RAI) remain unclear. This study was undertaken to evaluate physiological and morphological changes after LVR for RAI, and to study clinical outcomes following LVR with special reference to fecal incontinence (FI).

METHODS

The study was conducted on patients who had LVR for RAI between February 2012 and December 2016 at our institution Patients with RAI and FI were included in the study. Patients with RAI and obstructed defecation and those with RAI and neurologic FI were not included. The patients had anorectal manometry preoperatively, and 3, 6, and 12 months postoperatively. Defecography was performed before and 6 months after the procedure. FI was evaluated using the Fecal Incontinence Severity Index (FISI).

RESULTS

There were 34 patients (median age 77 years (range 60-93) years). Thirty-two patients (94%) were female and the median number of vaginal deliveries was 2 (range 0-5). Neither maximum resting pressure nor maximum squeeze pressure increased postoperatively. There was an overall increase in both defecatory desire volume (median preoperative 75 ml vs. 90 ml at 12 months; p = 0.002) and maximum tolerated volume (median preoperative 145 ml vs.175 ml at 12 months; p = 0.002). Postoperatively, RAI was eliminated in all patients but one, although 13 had residual rectorectal intussusception found at defecography. There was an overall reduction in both rectocele size (median preop 29 mm vs. postop 10 mm; p = 0.008) and pelvic floor descent (median preop 26 mm vs. postop 20 mm; p = 0.005). Twelve months after surgery, a reduction of at least 50% was observed in the FISI score for 31 incontinent patients (91%).

CONCLUSIONS

LVR for RAI produced adequate improvement of FI, and successful anatomical correction of RAI was confirmed by postoperative proctography. Postoperative increase in the rectal volume may have a positive effect on continence.

Short- and long-term clinical and patient-reported outcomes following laparoscopic ventral mesh rectopexy using biological mesh for pelvic organ prolapse: a prospective cohort study of 224 consecutive patients

AIM

Laparoscopic ventral mesh rectopexy (LVMR) is potentially a safe and effective operation to correct pelvic organ prolapse and to treat obstructive defaecation and solitary rectal ulcer syndrome. This study aimed to evaluate, in a prospective, consecutive cohort of patients, the long-term clinical outcomes following LVMR, patient-reported functional and quality of life outcomes, and urinary and sexual dysfunction.

METHOD

Data on 224 patients who underwent LVMR with Permacol™ biological mesh were collected prospectively from May 2008 to October 2016. Outcome measures were complications, recurrence, mortality, patient satisfaction, patient-reported functional and quality of life outcomes, and urinary and sexual dysfunction. Scores were compared using the two-tailed Wilcoxon signed rank test. P < 0.05 was considered statistically significant.

RESULTS

There was no mortalities associated with LVMR in this series; complications occurred in 10.7% of patients (4.9% early, 5.8% late). Mesh-related morbidity was 0.45% and vaginal suture-related morbidity was 1.33%. Recurrence occurred in 25 patients (11.4%), 5% at 12 months, 10.7% at 5 years. Significant improvement in patient-reported functional outcomes were seen (P < 0.001) for both constipation and faecal incontinence symptoms. Furthermore, significant improvement in quality of life outcomes for patients with constipation, faecal incontinence and prolapse persisted through follow-up (P < 0.001). Patient satisfaction was positive for > 90% of patients during follow-up. Symptoms of stress urinary incontinence, urge incontinence and dyspareunia improved significantly postoperatively (P < 0.001).

CONCLUSION

LVMR using Permacol is associated with low morbidity and mortality, recurrence and, additionally, significantly improved constipation, faecal incontinence and prolapse functional and quality of life outcomes, with associated improvement in urogynaecological symptoms.

Expert consensus document: Advances in the evaluation of anorectal function

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Trends in the treatment of rectal prolapse: a population analysis

PURPOSE

Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI).

METHODS

This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive.

RESULTS

There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p < 0.001), with no change in the mean age of patients over time (p = 0.229). The application of a laparoscopic approach increased over time (p = 0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1 ± 17.3 versus 75.2 ± 15.5 years, p < 0.001) despite having a similar Charlson Comorbidity Index (p = 0.097). The mortality rate for elective repair was 0.2%.

CONCLUSIONS

Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme's procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Radiological Changes After Resection Rectopexy in Patients with Rectal Prolapse-Influence on Clinical Symptoms and Quality of Life

BACKGROUND

Resection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients' symptoms and quality of life.

METHODS

The study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life.

RESULTS

Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p < 0.05). The clinical symptoms and quality of life improved in both, the total population (n = 40) and in patients with improved radiological prolapse grade (n = 30): all clinical scores (p < 0.05), SF-36 (vitality, social role, mental health p < 0.05), and Fecal Incontinence Quality of Life Scale (lifestyle, coping, embarrassment p < 0.05). Patients without improved radiological findings showed no change in their symptoms or quality of life.

CONCLUSION

Our study demonstrates that the radiological prolapse grade is improved by resection rectopexy. Correction of the anatomic defect was associated with improvement in symptoms and quality of life. Defecography may therefore be useful in the postoperative assessment of persistent symptoms or reduced quality of life.

Short-term outcomes of laparoscopic ventral rectopexy for obstructed defecation in patients with overt pelvic structural abnormalities-a Chinese pilot study

AIM

As laparoscopic ventral rectopexy (LVR) gained increasing popularity in the past decade, studies from non-western area remain rare. The aim of this pilot study is to evaluate the efficacy and safety of LVR for obstructed defecation (OD) in Chinese patients with overt pelvic structural abnormalities.

METHODS

A series of 19 consecutive patients is presented undergoing LVR for OD. All patients showed various forms of pelvic structural abnormalities which were verified by dynamic defecography exam. Data was prospectively recorded and the functional outcomes were evaluated using the Cleveland Clinic Constipation Score (CCCS) and Patients Assessment of Constipation Quality of Life Score (PAC-QoL).

RESULTS

Pelvic structural abnormalities of the 19 patients included external rectal prolapse (ER) in 10.5% (2/19), high grade internal rectal prolapse (IR) in 57.8% (11/19), rectocele in 52.6% (10/19), enterocele in 15.7% (3/19), cystocele/vaginal prolapse in 15.7 (3/19), descending perineum (DP) in 63.5% (12/19). 89.4% patients (17/19) showed at least two co-existed abnormalities and 15.7% (3/19) showed multicompartmental abnormalities. The mean follow-up was 9 months (range 1-18). No mesh-related complication was observed. At last available follow-up (LAFU), improvement of OD symptom was observed in 15 (78.9%) patients, the mean scores of CCCS decreased from 17 to 10 (p < 0.05), all four subsets of PAC-QoL scores improved, and three of them (physical discomfort, worries and concerns, satisfaction) showed statistical significance (p < 0.05).

CONCLUSION

Laparoscopic ventral rectopexy appears to be a safe and effective procedure for obstructed defecation in Chinese patients with overt pelvic structural abnormalities in short-term follow-up.

Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision)

AIM

To assess the outcomes of rectal excisional procedures in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty-seven studies were identified, providing data on outcomes in 8340 patients. Average length of procedures was 44 min and length of stay (LOS) was 3 days. There was inadequate evidence to determine variations in procedural duration or LOS by type of procedure. Overall morbidity rate was 16.9% (0-61%), with lower rates observed after Contour Transtar procedure (8.9%). No mortality was reported after any procedures in a total of 5896 patients. Although inconsistently reported, good or satisfactory outcome occurred in 73-80% of patients; a reduction of 53-91% in Longo scoring system for obstructive defecation syndrome (ODS) occurred in about 68-76% of patients. The most common long-term adverse outcome is faecal urgency, typically occurring in up to 10% of patients. Recurrent prolapse occurred in 4.3% of patients. Patients with at least 3 ODS symptoms together with a rectocoele with or without an intussusception, who have failed conservative management, may benefit from a rectal excisional procedure.

CONCLUSION

Rectal excisional procedures are safe with little major morbidity. It is not possible to advise which excisional technique is superior from the point of view of efficacy, peri-operative variables, or harms. Future study is required.

[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]

INTRODUCTION

The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique?

MATERIAL AND METHODS

This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]).

RESULTS

It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology.

CONCLUSION

Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. © 2016 Published by Elsevier Masson SAS.

Integrated total pelvic floor ultrasound in pelvic floor defaecatory dysfunction

AIM

Imaging for pelvic floor defaecatory dysfunction includes defaecation proctography. Integrated total pelvic floor ultrasound (transvaginal, transperineal, endoanal) may be an alternative. This study assesses ultrasound accuracy for the detection of rectocele, intussusception, enterocele and dyssynergy compared with defaecation proctography, and determines if ultrasound can predict symptoms and findings on proctography. Treatment is examined.

METHOD

Images of 323 women who underwent integrated total pelvic floor ultrasound and defaecation proctography between 2011 and 2014 were blindly reviewed. The size and grade of rectocele, enterocele, intussusception and dyssynergy were noted on both, using proctography as the gold standard. Barium trapping in a rectocele or a functionally significant enterocele was noted on proctography. Demographics and Obstructive Defaecation Symptom scores were collated.

RESULTS

The positive predictive value of ultrasound was 73% for rectocele, 79% for intussusception and 91% for enterocele. The negative predictive value for dyssynergy was 99%. Agreement was moderate for rectocele and intussusception, good for enterocele and fair for dyssynergy. The majority of rectoceles that required surgery (59/61) and caused barium trapping (85/89) were detected on ultrasound. A rectocele seen on both transvaginal and transperineal scanning was more likely to require surgery than if seen with only one mode (P = 0.0001). If there was intussusception on ultrasound the patient was more likely to have surgery (P = 0.03). An enterocele visualized on ultrasound was likely to be functionally significant on proctography (P = 0.02). There was, however, no association between findings on imaging and symptoms.

CONCLUSION

Integrated total pelvic floor ultrasound provides a useful screening tool for women with defaecatory dysfunction such that defaecatory imaging can avoided in some.

Internal rectal prolapse: Definition, assessment and management in 2016

Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.

Accuracy of integrated total pelvic floor ultrasound compared to defaecatory MRI in females with pelvic floor defaecatory dysfunction

OBJECTIVE

Defaecatory MRI allows multicompartmental assessment of defaecatory dysfunction but is often inaccessible. Integrated total pelvic floor ultrasound (transperineal, transvaginal, endoanal) may provide a cheap, portable alternative. The accuracy of total pelvic floor ultrasound for anatomical abnormalities when compared with defaecatory MRI was assessed.

METHODS

The dynamic images from 68 females who had undergone integrated total pelvic floor ultrasound and defaecatory MRI between 2009 and 2015 were blindly reviewed. The following were recorded: rectocoele, enterocoele, intussusception and cystocoele.

RESULTS

There were 26 rectocoeles on MRI (49 rectocoeles on ultrasound), 24 rectocoeles with intussusception on MRI (19 rectocoeles on ultrasound), 23 enterocoeles on MRI (24 enterocoeles on ultrasound) and 49 cystocoeles on MRI (35 cystocoeles on ultrasound). Sensitivity and specificity of total pelvic floor ultrasound were 81% and 33% for rectocoele, 60% and 91% for intussusception, 65% and 80% for enterocoele and 65% and 84% for cystocoele when compared with defaecatory MRI. This gave a negative-predictive value and positive-predictive value of 74% and 43% for rectocoele, 80% and 79% for intussusception, 82% and 63% for enterocoele and 48% and 91% for cystocoele.

CONCLUSION

Integrated total pelvic floor ultrasound may serve as a screening tool for pelvic floor defaecatory dysfunction; when normal, defaecatory MRI can be avoided, as rectocoele, intussusception and enterocoele are unlikely to be present. Advances in knowledge: This is the first study to compare integrated total pelvic floor ultrasound with defaecatory MRI. The results support the use of integrated total pelvic floor ultrasound as a screening tool for defaecatory dysfunction.

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.

Impact of Rising Grades of Internal Rectal Intussusception on Fecal Continence and Symptoms of Constipation

BACKGROUND

A theory of rectal intussusception has been advanced that intrarectal intussusception, intra-anal intussusception, and external rectal prolapse are points on a continuum and are a cause of fecal incontinence and constipation.

OBJECTIVE

This study evaluates the association among rectal intussusception, constipation, fecal incontinence, and anorectal manometry.

DESIGN

Patients undergoing defecography were studied from a prospectively maintained database and classified according to the Oxford Rectal Prolapse Grade as normal or having intra-rectal, intra-anal, or external intussusception. Patient symptoms were assessed using the Constipation Severity Index and the Fecal Incontinence Severity Index. Quality-of-life surveys were also used. Patients also underwent anorectal manometry.

SETTINGS

The study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

PATIENTS

The study included 147 consecutive patients undergoing evaluation for evacuatory dysfunction and involved defecography, symptoms questionnaires, and anorectal physiology testing from January 2011 to December 2013.

MAIN OUTCOME MEASURES

Symptom severity and quality-of-life scores were measured, as well as anal manometry results.

RESULTS

Increasing Oxford grade was associated with an increase in severity of fecal incontinence (median score: normal = 23.9, intrarectal = 21.0, intra-anal = 30.0, external prolapse = 35.3; β = 4.71; p = 0.009), which persisted in a multivariable model including age (β = 2.13; p = 0.03), and decreased sphincter pressures (median mean resting pressure: normal = 75.4, intra-rectal = 69.7, intra-anal = 64.3, external prolapse = 48.3; β = -8.57; p = 0.003), which did not persist in a multivariable model. Constipation severity did not increase with rising intussusception (mean score: normal = 37.4, intrarectal = 35.0, intra-anal = 41.4, external prolapse = 32.9; p = 0.79), and balloon expulsion improved rather than worsened (normal = 47.1%, intrarectal = 60.5%, intra-anal = 82.9%, external prolapse = 93.1%; p < 0.001).

LIMITATIONS

The study was limited because it was an observational study from a single center.

CONCLUSIONS

Increasing grades of rectal intussusception are associated with increasing fecal incontinence but not constipation.