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29 Pelvic Floor Conditions: Rectal Prolapse/Recurrence
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Pelvic Floor Conditions: Rectal Intussusception
EarlV.Thompson IV andNicoleM.Saur
30
Refer to Algorithm inFig. 30.1
A. Internal intussusception: Patients present in
two ways: either with symptoms later determined to be associated with internal intussusception, or after undergoing defecography
for an unrelated reason and incidentally
found to have what is thought of as an
asymptomatic anatomic abnormality.
Symptoms vary widely among patients and
can range from minor annoyance to physically or socially incapacitating. These can
include drainage of mucus or blood, tenesmus, pelvic pressure, chronic constipation,
anismus, and fecal incontinence. All of these
symptoms could also be associated with
other serious anorectal or gastrointestinal
conditions and should therefore be carefully
investigated. All patients should undergo a
complete history and physical examination
focusing not only on their specic complaint, but also by evaluating for other possible conditions (Table30.1). Also, selective
E. V. Thompson IV
Division ofColon andRectal Surgery, University
ofCincinnati College ofMedicine,
Cincinnati, OH, USA
N. M. Saur (*)
Division ofColon andRectal Surgery, Department
ofSurgery, University ofPennsylvania,
Philadelphia, PA, USA
e-mail: nicole.saur@uphs.upenn.edu
use of diagnostic studies can both inform
management of internal intussusception and
evaluate for other underlying conditions
(Table 30.2).
B. Symptomatic: Each of the symptoms listed
previously may vary in severity, and the clinician will often need to ask the patient specic questions to fully elucidate the
functional impact of his or her symptoms.
Evaluation of pelvic dysfunction in a female
patient should include questions directed at
symptoms not only of the posterior (anorectal) compartment but also urogenital compartments. The relationship between fecal
incontinence and internal intussusception is
somewhat more clearly dened than with
other symptoms. It has been shown that fecal
incontinence scores worsen as the degree of
internal intussusception demonstrated by
defecography worsens. In another study,
only 17% of patients whose fecal incontinence could not be explained after normal
anorectal physiology testing and endoanal
ultrasound had normal defecography. The
remaining 83% had some degree of internal
intussusception. In a study of sacral neuromodulation for fecal incontinence, only 16%
of patients with high-grade internal intussusception on defecography completed trial
neuromodulation and went on to have
symptomatic improvement after device
implantation. The physician should also be
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_30
229
230
E. V. Thompson IV and N. M. Saur
Fig. 30.1 Algorithm for the evaluation and management
of internal rectal intussusception ∗Multidisciplinary management ∗∗Surgery only for symptoms directly attributed
to internal intussusception or multi-organ prolapse
Table 30.1 Key features of a complete history and physical examination for a patient with internal intussusception
History Physical examination
History of
malignancy
Recent colonoscopy Full-thickness or mucosal
Constipation Vaginal prolapse, rectocele
Fecal or urinary
incontinence
Urinary symptoms –
Obstetric history –
Prior anorectal
procedures
Table 30.2 Diagnostic studies available for evaluation of
internal intussusception
Defecography
Barium enema
Colonoscopy
Endorectal ultrasound
Anorectal physiology
Colonic transit studies
Urodynamics
Sphincter tone, scarring,
ssures, hemorrhoids
prolapse
Proctoscopy:
• Malignancy/polyps
• Solitary rectal ulcer
• Proctitis
–
aware that even in patients with proven internal intussusception, the symptoms may not
correlate with the severity of the anatomic
abnormality alone. For example, it has been
shown that there is no correlation between
constipation severity scores and the degree
of internal intussusception demonstrated on
defecography.
SRUS is often discussed along with internal intussusception and rectal prolapse as it
is thought to be caused by these conditions
or other pelvic oor abnormalities. SRUS is
characterized by single or multiple lesions
on the anterior surface of the rectum. These
lesions can range from typical-appearing
cratered ulcers with brinous material at the
base to polypoid lesions. Diagnosis is conrmed histologically with the nding of
bromuscular obliteration of the lamina propria. As with internal intussusception, SRUS
can be associated with blood or mucous discharge, pelvic pain, or difculty with defecation. The etiology has not been fully
described but these lesions are believed to be
the result of chronic inammation, trauma,
or ischemia, possibly caused by internal or
external rectal prolapse.
No clear consensus exists on management of SRUS.One review offered a treatment algorithm that divided patients into
those with SRUS alone, SRUS with fullthickness rectal prolapse, and SRUS with
mucosal prolapse or intussusception. Any
appropriate prolapse repair procedure is
advocated for patients with SRUS and fullthickness rectal prolapse while biofeedback
should be rst attempted for other patients.
If the solitary rectal ulcer does not improve
with conservative measures, biopsy should
be performed to exclude the possibility of
malignancy before further treatment is
undertaken. If biofeedback is unsuccessful,
patients with SRUS and mucosal prolapse or
intussusception can be offered Delorme procedure or rectopexy as discussed later in this
section. Patients with isolated symptomatic
SRUS unrelieved by biofeedback can be
offered local excision or proctectomy with
or without coloanal anastomosis. One recent
single-institution review of patients with
SRUS treated surgically after conservative
measure failed to alleviate symptoms
provided support for laparoscopic ventral
rectopexy in patients with SRUS and full-
30 Pelvic Floor Conditions: Rectal Intussusception
231
thickness prolapse or internal intussusception. Twenty- nine of 30 patients underwent
ventral rectopexy, one underwent STARR
procedure, and 24 of 30 had satisfactory outcomes at 36 months. The remaining six
patients underwent posterior STARR procedure for persistent symptoms with a nal
rate of ulcer healing of 90% (27/30).
C. Asymptomatic: Up to 50% of healthy volun-
teers undergoing defecography have been
shown to have some degree of internal intussusception. Each of the volunteers was
screened with an exhaustive survey of bowel
habits and none reported any of the symptoms associated with internal intussusception. While it is uncommon for entirely
asymptomatic individuals to undergo defecography outside of a study population, this
report does illustrate the importance of
choosing management options that are
designed to improve symptoms and not correct aberrant anatomy that may simply be a
variant of normal.
D. Multi-organ prolapse: Anorectal (posterior
compartment) pelvic oor dysfunction is
rarely found in isolation. Female patients
will often have associated symptomatic
bladder or vaginal vault abnormalities. In
one series of patients referred for dynamic
cystoproctography for anorectal defects,
71% had cystoceles and 35% had vaginal
prolapse greater than 50%. After evaluating
100 patients with pelvic oor dysfunction,
these authors were able to conclude that 95%
have defects in all three compartments.
Patients should be fully evaluated for such
conditions as management options will often
be impacted by their presence and any
patient with multi-organ prolapse should be
managed in collaboration with a multidisciplinary team specialized in all facets of pelvic organ prolapse.
E. Non surgical measures: Unlike full-thick-
ness rectal prolapse, whose management is
typically surgical, the initial treatment of
symptomatic internal intussusception should
start with non-surgical management in
nearly every patient. Treatment options are
determined by the specic symptoms and are
described in other chapters of this text. As an
example, a patient with chronic constipation
should be counselled on dietary modication, adequate uid intake, ber supplementation, and proper toilet habits. Other patients
with symptoms of obstructive defecation
may benet from biofeedback. A retrospective review of dietary modication, biofeedback, and surgery for internal intussusception
in 36 patients showed that biofeedback was
more likely to improve constipation and
incontinence than the other modalities. In a
similar retrospective review of 34 patients
who underwent EMG-based biofeedback for
isolated internal intussusception, there was
overall signicant improvement in constipation and incomplete evacuation. Thirty-three
percent of patients had complete resolution
of their symptoms while 48% had no
improvement.
F. Surgical Intervention: It should be stressed
again that surgical interventions should not
be undertaken without rst exhausting conservative measures. In addition, the specic
symptoms and anatomic abnormality being
treated should be correlated and treatment
goals clear before embarking on any surgical technique. Specically, patients must be
aware that despite correction of the anatomic problem, the functional symptoms
will persist and may worsen. As with repair
of full-thickness rectal prolapse, surgical
repair of symptomatic internal intussusception can be divided in to transanal and transabdominal approaches. There have been
reports of successful treatment of obstructed
defecation associated with internal intussusception with the Delorme procedure. While
this report has not been widely reproduced,
it does provide background for the introduction of the stapled transanal rectal resection
(STARR) procedure. As described in the
rst prospective trial of the technique, the
STARR procedure uses two rings of a circular stapler to resect redundant rectal wall
in a patient with internal intussusception
and rectocele. In this rst trial of 90 patients
232
E. V. Thompson IV and N. M. Saur
with obstructive defecation symptoms and a
combination of internal intussusception and
rectocele, there was signicant improvement in all measured symptoms after
STARR procedure. Later, randomized trials
of STARR versus biofeedback for obstructive defecation have shown 81.5% successful treatment with STARR compared to
33.3% with biofeedback. Adverse events in
each of these studies have been infrequent
with low single-digit percent risks of bleeding or urinary retention as the most serious
risks. As is often the case with internal
intussusception, correction of the anatomic
intussusception does not always correlate
with symptom relief. MR defecography
before and after STARR shows a high rate
of correction of internal intussusception but
symptom relief did not correlate with anatomic repair. In spite of these impressive
results, the STARR procedure has remained
reserved for highly selected patients in specialized centers.
One common criticism of STARR has
been the inability of the circular stapler to
resect larger amounts of tissue. Modication
of the STARR technique to make use of a
rechargeable transverse stapler has been
offered as a solution to this problem. The
authors of the initial description of this technique promote a proprietary transverse contour stapler, the CCS-30 Contour Transtar
(Ethicon Endosurgery), as able to resect
more tissue and offer the surgeon better visualization of the entire surgical eld. These
same authors later performed a randomized
trial of surgical management of obstructed
defecation syndrome in patients with rectocele or rectal intussusception using either the
circular or transverse stapler. In 61 patients
analyzed after randomization, it was found
that both techniques led to signicant
improvement in symptom scores at
12 months, but that this improvement was
only maintained at 24 months in the transverse stapler group. The authors suggest that
the contour staplers allow resection of a
larger specimen and therefore offer more
reliable symptom relief in patients with
larger amounts of intussusception.
Another transanal procedure described is
transanal repair of rectocele and rectal mucosectomy with one circular stapler
(TRREMS). In the initial report of this technique, the redundant, prolapsing fullthickness anterior rectal wall is excised
including the muscular layer while the vaginal wall is protected using retraction from a
Babcock clamp. A pursestring suture is then
placed incorporating the proximal fullthickness rectal wall on the anterior surface
along with mucosal and submucosal layers
of the posterior surface. Drawing the suture
tight around the stapler’s center rod and ring the stapler closes the excision wound.
The authors stress the importance of protecting the posterior vaginal wall by keeping is
separate from the staple line using a Babcock
clamp. A trial of this technique applied to 75
patients with obstructed defecation who
failed to respond to non-operative measures
showed a mean improvement of Wexner
constipation score from 16 to 4 at a mean of
21 months follow up. Complications
included persistent rectal pain in 3 (4.0%)
and strictures in 7 (9.3%) of patients. The
authors advocate this technique as a lowercost management option for anorectocele
with mucosal prolapse as it requires only one
circular stapler.
Described by the same group as
TRREMS, the apex stapling technique for
patients with rectal intussusception and
mucosal prolapse is conceptually very similar to stapled hemorrhoidopexy techniques
such as procedure for prolapse and hemorrhoids (PPH). For the apex technique, a
pursestring suture is placed through mucosa
and submucosa at the apex, or most distal
point, of the prolapse. After the anvil is
inserted into the proximal rectum, the suture
is secured to the anchor hole in the center rod
of an EEA-33 Hemorrhoid and Prolapse
Stapler Set (Covidien, New Haven, CT). A
second, slightly more distal, pursestring
suture is placed and the stapler is red. In
30 Pelvic Floor Conditions: Rectal Intussusception
233
this rst description of 45 patients, mean
Wexner constipation scores decreased from
13 to 5 at a median of 120days follow up.
Median operative time was 17min and mean
width of resected rectal wall was 5.9 cm.
These authors advocate for this technique as
a fast, safe, and low-cost technique to treat
rectal intussusception.
As with rectal prolapse, transabdominal
procedures are often offered to patients with
symptomatic internal intussusception. The
clinician should be aware, that while incontinence or constipation may improve with
transabdominal procedures, obstructive defecation symptoms are unlikely to improve
and may worsen. Ventral mesh rectopexy
without bowel resection has been repeatedly
shown to be successful in the treatment of
fecal incontinence in patients with internal
intussusception. Similar results have been
demonstrated for constipation. However, it is
again important to note that while defecography consistently conrms correction of
intussusception, symptomatic improvement
does not always correlate with repair of the
anatomic derangement after transabdominal
procedure for these indications. Multiple trials have failed to show signicant improvement of obstructive defecation symptoms
with transabdominal posterior mesh rectopexy, and several have shown a decrease in
patient satisfaction after the procedure. It is
therefore inadvisable to attempt to treat
obstructive defecation caused by internal
intussusception with posterior rectopexy
alone. A recent systematic review of 14 studies including 1300 patients conrms the supposition that posterior rectopexy is obsolete
as this technique was not described in any of
the trials evaluated. Further, this study noted
that improvement in bowel symptoms was
noted after ventral mesh rectopexy or resection rectopexy in 73.9% of patients with
obstructed defecation and 60.2% of patients
with fecal incontinence. These authors found
that, while no meaningful conclusions could
be drawn due to publication bias and small
sample size, ventral mesh rectopexy
appeared to have higher recurrence rates but
fewer complications, better improvement in
bowel symptoms, and shorter operative time
compared to resection rectopexy. Therefore,
in properly selected patients, ventral mesh
rectopexy or resection rectopexy can offer
acceptable symptom relief in patients with
constipation or fecal incontinence due to
internal intussusception.
Despite the various surgical approaches
available for the treatment of internal intussusception, surgical intervention should be
reserved for selected patients who have
failed an adequate trial of conservative management and have symptoms attributable to
the internal intussusception. Surgical intervention should not be undertaken simply to
correct an anatomical abnormality.
F∗. Multidisciplinary approach to internal intus-
susception: Pelvic oor laxity in the female
patient can lead to multi-organ prolapse and
a constellation of related symptoms.
Addressing only one organ system may
exacerbate symptoms in the other systems
and therefore these patients should be treated
by a multidisciplinary team consisting of
colon and rectal surgeons, urogynecologists,
pelvic oor physiotherapists, and often, primary care physicians. One large review of
abdominal sacrocolpopexy, a procedure
widely utilized to treat vaginal vault prolapse, demonstrated that it was successful in
eliminating prolapse in 58–100% of patients.
However, impact on bowel function was
mixed and poorly reported. Some studies
showed improvement of pre-existing constipation, some showed 16–26% rates of new
constipation, some showed overall subjective improvement in bowel function, and
most studies reviewed made no report of
bowel function. Techniques that stabilize the
perineal body by xing it to mesh anchored
to the sacrum have shown promise in improving bowel function in patients with multiorgan prolapse. One study showed
improvement in constipation, splinting, or
incontinence in 8 of 11 women who underwent abdominal sacral colpoperineopexy,
234
E. V. Thompson IV and N. M. Saur
although it was limited by its small size and
does not describe preoperative rectal
defecography ndings. The necessity of
multidisciplinary management of the patient
with multi-organ prolapse is reinforced by
the wide variety of procedures described. In
addition, the patient’s troubling symptom(s)
and goals of surgical treatment should be
very clearly understood prior to embarking
on any surgical option.
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Pelvic Outlet Obstruction
JenniferS.Davids
31
Refer toAlgorithm in Fig.31.1
A.Although defecation uneventfully occurs in
the majority of the population, it is actually a
complex physiologic process, under both
voluntary and involuntary control. Multiple
physiological and psychological disturbances
can potentially manifest as defecatory dysfunction, including pelvic outlet obstruction.
Prior to evaluating patients with disordered
defecation, it is important to understand the normal physiology of defecation. The defecation
process is initiated when the rectum lls with
stool and becomes distended. The contents of
the low rectum and upper anal canal are “sampled” as the internal anal sphincter relaxes in
response to rectal distension by the recto-anal
inhibitory reex, and the external anal sphincter
compensates by contracting through the rectoanal excitatory reex. When the urge to defecate
is sensed and acted upon, a seated or squatting
position is assumed. The abdominal muscles
contract voluntarily to raise intra- abdominal
pressure by the Valsalva maneuver. The puborectalis muscle, as part of the levator ani, wraps
around the rectum as a “sling;” it relaxes in
response to Valsalva, broadening the anorectal
J. S. Davids (*)
Department ofSurgery, University ofMassachusetts
Memorial Medical Center, Worcester, MA, USA
e-mail: Jennifer.Davids@umassmemorial.org
angle, allowing for passage of stool (Fig.31.2).
If the urge to defecate is deferred, the external
anal sphincter muscles are voluntarily contracted, the puborectalis muscle remains contracted, and the sensation dissipates.
Pelvic outlet obstruction, also referred to as
paradoxical puborectalis contraction, obstruc-
tive defecation, anismus, or pelvic oor dyssynergia, occurs when the puborectalis muscle fails
to relax (“nonrelaxation”) or contracts further
during attempted defecation. Importantly, the
puborectalis does not function in isolation; this
disorder should be considered a consequence of
dysregulation of the pelvic oor musculature
with defecation. The rectum will distend with
stool, and despite Valsalva, stool is not
evacuated.
B. Patients with pelvic outlet obstruction will
often present simply as being “constipated.”
In particular, common symptoms include
straining with minimal passage of stools (C),
or sensation of incomplete evacuation (D).
Stool texture may range from watery/loose
(overow diarrhea) to hard or pellet-shaped.
Patients will frequently have the urge to defecate, and will sit on the toilet straining for prolonged periods of time. Failure to defecate
often results in abdominal distension and
cramping, which can then indirectly result in
poor appetite and early satiety. Some patients
will perform vaginal or perineal splinting to
facilitate passage of stools (E).
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_31
237
238
Fig. 31.1 Algorithm for pelvic outlet obstruction
J. S. Davids
F. Pelvic outlet obstruction frequently occurs in
the setting of other associated disorders of
gastrointestinal motility or pelvic oor abnormalities, making diagnosis extremely challenging in many cases. Multiple other
pathologies may synergistically contribute to
“constipation,” such as irritable bowel syndrome, slow transit constipation, rectocele,
enterocele, rectal prolapse, internal rectal
intussusception, and uterovaginal prolapse
(G). Half of patients will have abnormal sensation of the anoderm and anal canal. Two
thirds of patients with pelvic outlet obstruction also have slow transit constipation.
H. Although some patients with outlet obstruc-
tion will report having constipation since
childhood, many others will identify “triggers” or inciting events that led to worsening
constipation, such as life stressors including
new job, divorce, nancial trouble, sexual
abuse or assault, surgery (often a hysterectomy), or the onset of use of antibiotics or narcotics. Multiple studies have identied a
higher incidence of comorbid psychiatric conditions in patients with pelvic outlet obstruction, including obsessive-compulsive disorder,
phobia of stool, and eating disorders such as
anorexia nervosa and bulimia; some patients
have been victims of sexual assault or abuse.
A thorough, detailed history and physical
exam are critical to establishing the diagnosis
of pelvic outlet obstruction. The differential
diagnosis for pelvic outlet obstruction is
broad, and includes: Irritable bowel syndrome,
slow transit constipation, global dysmotility
disorder, short-segment Hirschsprung’s,
mechanical obstruction including mass, polyp,
or stricture, internal rectal intussusception,
rectocele, enterocele, or rectal or uterovaginal
pelvic organ prolapse; history-taking in these
patients is often a lengthy process and should
not be rushed. Table 31.1 lists specic elements of the initial history, which should be
included.
A detailed past medical and surgical history
is equally important. Often these patients have
had an exhaustive workup by one more gastroenterologists; all records should be obtained
and reviewed. An obstetric history should be
taken, noting any vacuum/forceps deliveries,
macrosomia, episiotomy or tear, or other complications such as abscess. Patients should be