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11 Rectal Prolapse : Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
179
Rates of recurrence after prolapse repair have been
reported between 10 and 20 %, regardless of the type of
operation performed; rates as high as 30 % have been
reported in some studies [ 1 , 10 ]. It is unclear why recurrence
rates are higher for perineal operations. Hypotheses include
the ability to perform a complete rectal mobilization and
fi xation under direct visualization during abdominal operations and making more accurate decisions regarding resection and/or rectopexy [
10 ]. Recurrences are considered either
early (1–2 years), likely due to technical error, or late (>2
years), which may be due to patient-related factors. In a
study of 78 patients with recurrent rectal prolapse, Steele
et al. reported that 29 % of patients recurred in the fi rst 7
months after the initial operation [ 10 ]. Overall re-recurrence
occurred in 29 % of patients, signifi cantly more after perineal repair for the recurrence versus an abdominal approach
10 ]. If a repair fails, evaluation including imaging for slow-
[
transit constipation or puborectalis dysfunction, endoanal
ultrasound, manometry, defecography, and colonoscopy
should be performed depending on the associated features
(constipation or incontinence). Comorbidities should also be
investigated with cardiac and pulmonary testing when indicated because, if possible, repair of recurrent rectal prolapse
should be attempted transabdominally. The reason for this is
that secondary recurrence appears to be lower when compared to the perineal approach for recurrent prolapse [
5 , 10 ].
Fengler et al. examined the management of recurrent rectal prolapse. They identifi ed 14 patients who underwent surgery for recurrence over a 10-year period. Most of these
patients initially underwent perineal proctosigmoidectomy;
however, surgeries for the recurrence included transabdominal and perineal approaches [ 16 ]. Although this study was
small, no full-thickness prolapses were noted during the follow- up period (9–115 months) [ 16 ]. Pikarsky et al. evaluated
the outcomes of 27 patients with repair of recurrent rectal
repair of rectal prolapse during the same time period. Perineal
proctosigmoidectomy was the most commonly performed
operation for recurrent prolapse, whereas perineal and transabdominal approaches were almost equivalently performed in
the initial prolapse group [ 17 ]. Recurrence rates were not dif-
ferent between the recurrent and initial prolapse groups: 14.8
and 13.1 %, respectively [ 17 ]. The authors also found no dif-
ferences in anorectal physiology testing, ultrasound, defecography, or concomitant anorectal pathology; thus, they could
not identify other factors contributing to recurrence after prolapse surgery besides presumed technical errors [ 17 ].
If evaluation after recurrence reveals persistent or worsening constipation or a redundant sigmoid colon on imaging,
resection is indicated regardless of the fi rst operation. If constipation is persistent after non-resectional rectopexy, conservative measures including bowel retraining should be undertaken
for a minimum of 6–12 months prior to consideration of a
colectomy. Outside of the United States, sacral nerve
stimulation might well be potentially indicated in this population but is currently unavailable for this indication in the United
States. One must be very cautious when performing a sigmoid
colectomy or subtotal colectomy after an initial non-resectional
rectopexy, in particular if mesh has been used to stabilize the
rectum either anteriorly or posteriorly. The risk of an infection
is certainly of concern, and in addition, the amount of pelvic
scarring may potentially increase the risk of pelvic bleeding
and anastomotic diffi culties. Moreover, if the initial anastomosis was performed at the 15-cm level, a more distal level of
anastomosis might be required. One must be cautious about
such an anastomosis especially if the patient has decreased
sphincter tone and/or if a subtotal rather than a sigmoid colectomy is being considered, as postoperative diarrhea (or incontinence) may be extremely debilitating.
If a second resection is planned, removal of the previous
anastomosis is important to prevent ischemia with resultant
mucosal sloughing, anastomotic dehiscence, or stricture may
occur [ 1 , 16 ]. Fengler et al. noted mucosa sloughing after
perineal proctosigmoidectomy was performed for recurrent
prolapse after the initial operation was an anterior resection.
They indicated that unless resection of the previous anastomosis is conducted, resection for the recurrence should be
avoided [ 16 ]. The authors also noted that if the initial sur-
gery was an Altemeier procedure, the anastomosis will likely
prolapse; thus, repeat perineal proctosigmoidectomy should
incorporate resection of the previous anastomosis, decreasing the likelihood of ischemia or anastomotic complications
after the recurrent prolapse repair [ 16 ]. An attempt to pre-
serve the superior hemorrhoidal artery during a resectionrectopexy should be made if a perineal proctosigmoidectomy
was performed for the initial prolapse [ 1 ]. In the study by
Steele et al., only two patients developed a stricture postoperatively. The authors partly attributed this low incidence to
the preservation of the superior hemorrhoidal vascular supply when resection-rectopexy was performed after perineal
proctosigmoidectomy [ 10 ].
Outcomes after repair of recurrent prolapse have been
examined in only a few small studies. Recurrence rates have
been shown to be equivalent to those after the initial surgery,
regardless of the approach. There is also not much evidence
evaluating incontinence or constipation after repair of recurrent prolapse. In a small study of 14 patients who underwent
surgery for recurrent prolapse over a 10-year period, three
patients were incontinent initially, and they remained incontinent even after successful repair of the recurrent prolapse
[ 16 ]. It is the preference of the senior author to preserve the
inferior mesenteric and superior rectal vessels during all
abdominal resection-rectopexy procedures.
The discussion of laparoscopy and recurrent rectal prolapse is extremely limited. Tsugawa et al. published a case
report in 2002. They used laparoscopic rectopexy safely in
two patients, without complications or recurrence noted in a
2-year follow-up [ 18 ].
180
D.M. Hayden and S.D. Wexner
Our Treatment Preferences for Rectal Prolapse
Initial Rectal Prolapse
Key Concept: We prefer a laparoscopic abdominal approach,
when feasible. Based on symptoms and subsequent work-up for
signifi cant constipation, this may involve a resection- rectopexy
(when absent) or subtotal colectomy (when present).
If the patient is unfi t for a transabdominal operation, then
we would discuss with the patient the alternative transperineal options. If a transabdominal operation is planned and
the patient has constipation, a colonic transit study should be
undertaken to insure that a subtotal colectomy with ileorectal
or ileosigmoid anastomosis is not potentially advisable. In
addition, cinedefecography and/or water-soluble contrast
enema testing may reveal a signifi cantly redundant sigmoid
colon that usually mitigates for concomitant sigmoid colectomy. Our preference is generally for a resection-rectopexy
unless the patient has profound incontinence and limited sigmoid redundancy. The reason for a resection-rectopexy is to
avoid the problems with constipation after non-resectional
rectopexy that are likely to occur in this setting.
The procedure will preferentially be performed in a laparoscopic manner with a camera in an infraumbilical port and
the two working ports in the right upper quadrant and right
lower quadrant, respectively. We routinely employ ureteric
catheters in patients in whom signifi cant adhesions and/or
fi brosis is expected. This operation is the only one in which
we deliberately do not mobilize the splenic fl exure as we wish
to have a tension-free anastomosis without redundancy. Due
to the inevitable redundancy of the left colon, splenic fl exure
mobilization is generally unnecessary. It is useful to try to
avoid redundancy, and in fact, the sigmoid colectomy is performed to avoid redundancy. Therefore, routine splenic fl exure mobilization in this scenario seems counterproductive.
In addition, we deliberately do not divide either the inferior
mesenteric artery/vein or the superior rectal artery/vein. After
full left colonic mobilization, the presacral space is entered,
and a dissection as for a total mesorectal excision is undertaken
to the level of the levator muscles. The mobilization proceeds
with visual, digital, and fl exible sigmoidoscopic assessment if
necessary. Lateral dissection defi nitely decreases recurrence
rates, although it very well may induce constipation. However,
the concomitant performance of a sigmoid colectomy with the
rectopexy should balance this potential problem. Therefore,
the combination of resection and rectopexy with division of the
lateral stalks would seem to offer the best combination of good
outcomes – including simultaneously minimizing both recurrence rates and postoperative constipation.
After full mobilization, irrigation, and verifi cation of meticulous hemostasis, a short suprapubic or short Pfannenstiel incision is made. The rectopexy is then generally undertaken
utilizing two 0-Prolene sutures through each lateral stalk
including the periosteum in a horizontal U-stitch. The three to
four rectopexy sutures are tagged but not tied. The points of
resection of the descending-sigmoid junction and the rectosigmoid junction are then divided. It is important that the superiormost rectopexy sutures are not in immediate proximity to the
anastomosis to hopefully avoid any acute angulation of that
anastomosis. The left colonic and sigmoidal vessels are divided
with an energy source along the bowel wall in order to carefully
preserve the superior rectal and inferior mesenteric vessels to
insure optimal collateral blood supply. Division of these vessels has unfortunately been associated with rectal necrosis.
A standard circular end-to-end anastomosis is performed
between the descending colon and the rectum. The standard air
insuffl ation test is undertaken using fl exible endoscopic guidance, after which the rectopexy sutures are carefully secured. It
is important to insure that the posterior aspects of the lateral
stalks are tied fl ush against the periosteum and that there are no
gaps through which small bowel might slip and become injured
by the rectopexy sutures. After the sutures are secured, the air
testing is again repeated with fl exible sigmoidoscopy to also
insure that the rectal lumen has not been compromised or narrowed. Ultimately a 19-mm suction drain is placed through a
stab wound and left in the presacral space, and the abdomen is
closed. An incision of greater than 7 cm is seldom necessary,
except in obese patients.
We do not like to use mesh because of the risk of infection. Moreover, having operated on many patients in whom
prolapse has recurred after mesh placement, it is only with
great trepidation that we would perform anastomosis in the
vicinity of the mesh. Moreover, excision of the mesh is often
impossible without rectal resection, which then brings about
the scenario of a low pelvic anastomosis. Sutures through the
lateral stalks incorporating the anterior periosteum and presacral fascia should be suffi cient to stabilize the rectum without need for introducing mesh.
Perineal Proctosigmoidectomy
Key Concept: Perineal approaches are used only for a select
group of patients. Balancing adequate removal of redundant
bowel with avoiding tension at the anastomosis is key to successful outcomes.
Once again, we prefer this operation for frail elderly
patients and for patients with signifi cant comorbidity, as well
as for patients who have had prior failed perineal rectosigmoidectomy. In instances of circumferential mucosal prolapse or minimal circumferential full-thickness prolapse
after failed perineal rectosigmoidectomy, a Delorme procedure could be considered. It is important as part of the
Delorme procedure to ensure imbrications of the muscle
prior to creating an anastomosis.
We perform this perineal operation with the patient in
prone position, under general anesthesia or with an epidural
11 Rectal Prolapse : Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
181
or local with sedation. We use a handheld energy device for
division of the mesorectum and mesentery. We slowly extract
the rectum and sigmoid until there is resistance, carefully
making sure that there is hemostasis and that no bleeding
vessels retract into the anal canal. Once resistance is felt, the
colon is manipulated to be sure that there is no more redundant sigmoid left. Although the entire redundancy should be
extracted, there should be no tension on the coloanal anastomosis. The few tricks to try to decrease the rate of anastomotic leak include leaving enough laxity under the mesocolon
to comfortably lift it from the recto-peritoneum, placing the
anastomosis far enough cephalad to the rectopexy sutures to
prevent acute angulation with obstruction, and preservation
of the inferior mesenteric and superior rectal vessels. We
also prefer to create a 6 × 6 to 8 × 8 cm colonic J pouch whenever possible.
Before the anastomosis is created, the levatorplasty is usually performed. With simple sutures, if possible the anterior
and posterior levator muscles are plicated, ensuring that their
outlet is narrowed without placing too much tension on the
proximal colon that is about to be anastomosed to the anoderm.
In general, it is much easier to plicate the anterior levator muscles although this approach is the converse of the Parks’ posterior anal repair. Approximately 1–2 fi ngerbreadths left between
the levatorplasty and the colon should be adequate. The levatorplasty may help decrease incontinence as well as provide
more support to prevent recurrence. We hand sew our anastomoses with interrupted 3-0 Vicryl sutures; however, a transanal
stapler can be used to create the anastomosis. A circular stapled
anastomosis is performed in a manner akin to a PPH
TM
(Ethicon
Endo-Surgery, Cincinnati, OH) procedure in that two circumferential purse strings can be used – one in the descending
colon or colonic J-pouch and the other in the anoderm. In
instances in which a stapled anastomosis is to be undertaken,
suffi cient redundancy must exist and in addition minimal size
discrepancy. Furthermore, the initial incision should be at least
2 cm above the dentate line so that the anastomosis is not at or
potentially even below the dentate line.
Incarcerated Rectal Prolapse
Perineal proctosigmoidectomy is the treatment of choice for
incarcerated rectal prolapse, regardless of the patient’s
health. The operation is performed in standard fashion, making sure that the entire ischemic portion of the rectum and
sigmoid is resected.
Concomitant Pelvic Prolapse
Key Concept: A complete evaluation for other pelvic fl oor
disorders should be performed, as a multidisciplinary
approach may be required to repair all defects.
It is the responsibility of the colorectal surgeon to ask
about associated gynecological and urological symptoms
when patients present with prolapse. During the physical
examination, perineal descent or uterine, vaginal, or bladder
prolapse may be noted. These patients are best managed with
a multidisciplinary approach with consultation with urogynecology, and they should have a thorough evaluation including defecography, transvaginal and transrectal ultrasound, or
urodynamic testing depending on the patient’s presentation.
Defecography is undertaken in cases of internal prolapse. I
have not found any additional information to be gained from
defecography in patients with visible circumferential fullthickness rectal prolapse.
Combined procedures are reasonable and usually preferred by the patient, although the surgical approach must be
discussed initially in order to avoid placing mesh in the pelvis if a sigmoid resection is planned.
Recurrent Rectal Prolapse
Key Concept: In the setting of recurrent prolapse, a thorough
history and physical examination will guide the need for
adjuvant studies. When possible, a transabdominal repair
should be your initial choice.
If a patient has recurrent full-thickness rectal prolapse,
evaluation is guided by the patient’s symptoms. If the patient
has constipation that continued or worsened after the initial
operation, a colonic transit study and defecography should be
conducted to evaluate for potential colonic inertia or obstructed
defecation syndrome. If the patient is incontinent, endoanal
ultrasound, manometry, and physiologic testing should be performed. The positive fi ndings may have contributed to failure
of the initial repair and may change our next steps in management. It is reasonable to recommend biofeedback fi rst if pelvic
fl oor dysfunction is present before repairing the recurrent prolapse or postoperatively once the patient recovers. This method
may help manage the patient’s expectations after surgery.
Regardless of the initial repair, we recommend a transabdominal repair if the patient is medically fi t. The selection of
the operation is determined based on the previous repair and
the patient’s current symptoms. If the patient has no constipation and no evidence of sigmoid redundancy, we perform
a suture rectopexy, regardless of whether the patient had a
previous perineal repair or abdominal approach with or without resection. If constipation is also present, we add a resection, including the previous anastomosis if resection was
performed initially. We again attempt to preserve the superior hemorrhoidal artery if resection is planned. Suture rectopexy without resection should not result in ischemia
regardless of the previous repair.
If the patient had a previous perineal proctosigmoidectomy
and is at excessive risk for a transabdominal operation, we perform a repeat perineal operation. If the previous anastomosis
182
Fig. 11.8 Treatment algorithm
for recurrent rectal prolapse
D.M. Hayden and S.D. Wexner
Recurrent prolapse detected
Mucosal Full
Symptoms? Symptoms?
•
•
Office banding
•
Delorme
Repair
Constipation
•
Incontinence
•
Anterior compartment prolapse?
Evaluation
•
Ultrasound
•
Colonoscopy
•
Defecography (dynamic MR, fluoro)
•
Colonic transit
•
Manometry
•
Anorectal physiology
•
Consultation with urogyne
Medically unfit
Initial operation?
•
•
Perinal rectosigmoidectomy
•
Delorme
cannot be transanally resected or if the blood supply appears
questionable, we would perform a Delorme procedure.
If the patient had a previous laparoscopic rectopexy with
or without resection, we would consider a laparoscopic
approach to repair the recurrence. We always perform laparoscopy using the open Hasson technique; however, in the
case of a previous operation, an open technique is mandatory.
If the patient had multiple abdominal operations or evidence
of signifi cant scar tissue at previous incisions on abdominal
exam, we would likely perform an open procedure. Due to the
Medically fit
•
Initial operation?
Symptoms?
•
•
Workup?
Abdominal rectopexy/resection
Mesh if previously used and slipped,
•
remove mesh if erosion/infection
•
Suture or tracks
Resection if constipation or redundant
•
colon, including previous
anastomosis if previous resection
•
Laparoscopic ok
Biofeedback before or after recurrent
•
surgery if pelvic floor dysfunction
reoperative nature of the surgery for recurrence, we would
likely use ureteral stents for a transabdominal approach.
Summary Pearls
Patients’ expectations should be managed from the initial
encounter. An honest discussion regarding the risk of recurrence after the initial and second repair (not higher than after
the initial operation according to the literature) is essential,
11 Rectal Prolapse : Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
183
using information provided in the individual patient’s evaluation. Nonoperative management of recurrence is generally
recommended only if the patient is unfi t for even a perineal
repair or if the symptoms are minimal and not too bothersome to the patient. Limited mucosal prolapse after initial
prolapse repair is not considered true recurrence in the literature; in-offi ce banding procedures can be performed, or if
more signifi cant, a Delorme procedure can be attempted if
the patient is willing to undergo another operation.
They should also understand that the ultimate functional
outcome of the procedure cannot be expected in less than
1–2 years after surgery. It is best to include not only the
patient but, if the patient consents, also the family in these
discussions. The postoperative function can sometimes be
optimized by a combination of anti-motility agents, fi ber,
and pelvic fl oor retraining for the immediate postoperative
period and potentially for the fi rst 1–2 years. Regardless of
the technique used, understanding the pearls and pitfalls for
each procedure and sharing realistic expectations with the
patient regarding both function and recurrence will prove
extremely benefi cial in managing rectal prolapsed (Fig.
11.8 ).
References
1. O’Brien D. Rectal prolapse. Clin Colon Rectal Surg. 2007;20(2):
125–32.
2. Altomare D, Binda G, Ganio E, De Nardi P, Giamundo P, Pescatori
M. Long-term outcome of Altemeier’s procedure for rectal prolapse. Dis Colon Rectum. 2009;52(4):698–703.
3. Purkayastha S, Tekkis P, Athanasiou T, et al. A comparison of open
vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum. 2005;48(10):1930–40.
4. Varma M, Rafferty J, Buie WD. Practice parameters for the man-
agement of rectal prolapse. Dis Colon Rectum. 2011;54(11):
1339–46.
5. Papaconstantinou HT. Recurrent rectal prolapse. In: Billingham RP,
Kobashi KC, Peters WA, editors. Reoperative pelvic surgery. New
York: Springer; 2009. p. 145–51.
6. Hool GR, Hull TL, Fazio VW. Surgical treatment of recurrent complete rectal prolapse: a thirty-year experience. Dis Colon Rectum.
1997;40(3):270–2.
7. Cirocco W. The Altemeier procedure for rectal prolapse: an operation for all ages. Dis Colon Rectum. 2010;53(12):1618–23.
8. Baig MK, Galliano D, Larach JA, Weiss EG, Wexner SD,
Nogueras JJ. Pouch perineal rectosigmoidectomy: a case report.
Surg Innov. 2005;12(4):373–5.
9. Raftopoulos Y, Senagore A, Di Giuro G, Bergamaschi R.
Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data.
Dis Colon Rectum. 2005;48(6):1200–6.
10. Steele S, Goetz L, Minami S, Madoff R, Mellgren A, Parker S.
Management of recurrent rectal prolapse: surgical approach infl uences outcome. Dis Colon Rectum. 2006;49(4):440–5.
11. Byrne C, Smith S, Solomon M, Young J, Eyers A, Young C. Longterm functional outcomes after laparoscopic and open rectopexy for
the treatment of rectal prolapse. Dis Colon Rectum. 2008;51(11):
1597–604.
12. Heemskerk J, de Hoog Dominique ENM, van Gemert W, Baeten
CGMI, Greve JWM, Bouvy N. Robot-assisted vs. conventional
laparoscopic rectopexy for rectal prolapse: a comparative study on
costs and time. Dis Colon Rectum. 2007;50(11):1825–30.
13. Deen KI, Grant E, Billingham C, Keighley MR. Abdominal resection-rectopexy with pelvic fl oor repair versus perineal rectosigmoidectomy and pelvic fl oor repair for full-thickness rectal
prolapse. Br J Surg. 1994;81(2):302–4.
14. Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2000;(2):CD001758.
15. Glasgow S, Birnbaum E, Kodner I, Fleshman J, Dietz D. Recurrence
and quality of life following perineal proctectomy for rectal prolapse. J Gastrointest Surg. 2008;12(8):1446–51.
16. Fengler SA, Pearl RK, Prasad ML, et al. Management of recurrent
rectal prolapse. Dis Colon Rectum. 1997;40(7):832–4.
17. Pikarsky AJ, Joo JS, Wexner SD, et al. Recurrent rectal prolapse: what
is the next good option? Dis Colon Rectum. 2000;43(9):1273–6.
18. Tsugawa K, Sue K, Koyanagi N, et al. Laparoscopic rectopexy for
recurrent rectal prolapse: a safe and simple procedure without a
mesh prosthesis. Hepatogastroenterology. 2002;49(48):1549–51.
Obstructive Defecation
Ann C. Lowry and Jennifer Lynn Irani
1 2
Key Points
• Obstructed defecation is defi ned by patient
symptoms.
• Adjunctive tests such as transit studies, anorectal
manometry, balloon expulsion, EMG, fl uoroscopic
(conventional) defecography, MR defecography,
and perineal ultrasound may be useful in identifying a potential cause for a patient’s symptoms but
ought to be interpreted cautiously.
• Treatment depends on the etiology of obstructed
defecation and is initially nonoperative. Fiber,
improved toileting habits, and biofeedback are generally the primary approach.
• Obstructive defecation symptoms improve with
rectocele repair, but optimal surgical approach
remains uncertain.
• Preliminary results for ventral rectopexy and
STARR for internal intussusception are emerging.
Evaluation
History
Key Concept : Obstructive defecation is defi ned by patient
symptoms .
The prevalence of constipation ranges from 0.7 to 79 %,
with a median of 16 % worldwide, and patients with outlet
dysfunction (i.e., obstructive defecation) make up a signifi cant portion [ 1 ]. While differentiating among the various eti-
ologies of constipation can be diffi cult, a careful history
remains the key aspect. Patients with obstructive defecation
complain of the need for prolonged straining and of a sense
of incomplete rectal evacuation. Frequently they report
spending up to 30 min in the bathroom attempting to defecate. They often use laxatives or enemas; they may use digital extraction and vaginal or perineal pressure to aid
evacuation. Some patients may complain of both an infrequent urge to defecate and diffi culty evacuating stool that
reaches the rectum. While abdominal discomfort may
accompany these symptoms, it is not the dominant complaint, as opposed to patients with slow-transit constipation
or irritable bowel syndrome. Nausea and emesis are rare.
Rectal pain is unusual unless the etiology is sphincter spasm
related to an anal fi ssure.
Physical Examination
A. C. Lowry , MD (*)
Division of Colorectal Surgery, Department of Surgery ,
University of Minnesota , 1055 Westgate Drive, Suite 190 ,
St. Paul, Minneapolis , MN 55114 , USA
e-mail: alowry@crsal.org
J. L. Irani , MD
Department of Surgery ,
Harvard Medical School,
Brigham and Women’s Hospital ,
75 Francis Street , Boston , MA 02115 , USA
e-mail: jirani@partners.org
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_12, © Springer Science+Business Media New York 2014
Key Concept : Obstructive defecation has a large differential
diagnosis . It is critical to exclude mechanical causes of
obstruction such as anal or rectal cancers .
The term obstructive defecation covers a set of symptoms
that may be caused by rectal prolapse, internal rectal prolapse, rectocele, enterocele, pelvic organ prolapse, solitary
rectal ulcer syndrome, descending perineum syndrome, and
pelvic fl oor muscle dysfunction. The portion of the syndrome that relates to pelvic fl oor muscle dysfunction is also
known as paradoxical puborectalis contraction, non-relaxing
185
186
A.C. Lowry and J.L. Irani
Fig. 12.1 Rectocele. Rectal prolapse can also seen at the verge that was
easily visualized with straining ( Courtesy of M . Shane McNevin , MD )
puborectalis syndrome, outlet obstruction, anismus, pelvic
fl oor dyssynergia, spastic pelvic fl oor syndrome, and dyschezia. The fi rst step in the evaluation is a careful physical
examination. The purpose of the examination of these
patients is to exclude other abnormalities and to identify the
underlying cause. Inspection of the perianal area may reveal
a patulous anus, skin irritation, or an anal fi ssure. The perianal and perineal regions should be examined at rest and
with straining for perineal descent, rectal prolapse, and vaginal bulge (Fig. 12.1 ). The digital examination may reveal
stenosis or a mass causing the symptoms. Attention should
be paid to resting tone, squeeze, and sphincter response to
Valsalva during the digital examination. The sphincter muscles and puborectalis muscle normally relax with straining.
The examiner should also be aware to check for rectal wall
descending during Valsalva (i.e., intussusception or prolapse) or a bulging from above in the rectovaginal septum
(i.e., enterocele). Pressure on the anterior rectal wall during
the examination may also identify a rectocele. Examination
on the commode after bearing down may reveal a rectal prolapse or signifi cant vaginal prolapse.
A careful urogynecologic examination is also important,
particularly in any patient with a suggestion of rectal or other
pelvic organ prolapse. If prolapse is visible at the vaginal
introitus or a bulge is noted during the Valsalva maneuver, a
systematic examination should be performed. With the
patient in a supine position and the head of the examination
table elevated to 45°, an appropriately sized vaginal speculum is placed in the vagina to view the cervix or vaginal cuff.
While the patient is performing the Valsalva maneuver, the
speculum is slowly removed. The extent to which the cervix
or the vaginal vault follows the speculum through and out of
the vagina is noted. The speculum is disassembled and the
posterior or fi xed blade is used for examination. To examine
the anterior vaginal wall, the posterior vaginal wall is
retracted with the fi xed blade and the extent of any anterior
vaginal prolapse during the Valsalva maneuver is noted. To
examine the posterior vaginal wall, the fi xed blade is
inverted, the anterior vaginal wall is retracted, and the patient
is instructed to repeat the Valsalva maneuver. Any resulting
prolapse or bulge is noted. Bimanual and rectovaginal examinations help identify any coexisting pelvic abnormalities,
including those of the perineal body. If pelvic organ prolapse
is not evident, especially in a woman feeling a bulge, the
patient should be examined in the standing position while
she performs the Valsalva maneuver [ 2 ].
Endoscopy
The next step in evaluation of these patients is anoscopy and
fl exible sigmoidoscopy or colonoscopy. Anoscopy may
identify circumferential folds in the rectal wall descending
from above indicating a possible prolapse or intussusception.
While the choice of endoscopic procedure is determined by
the patient’s age and interval since last screening examination, it is necessary to exclude polyps or neoplasm as the
cause of the obstructive symptoms. The examination may
also identify a solitary rectal ulcer, colitis cystica profunda,
or any suspicious lesion that should be biopsied to exclude a
neoplastic process and confi rm the diagnosis. If the endoscopy is negative, the next step depends upon your clinical
suspicion for another diagnosis and the patient’s response to
conservative therapy
Adjunctive Tests
Key Concept : Additional testing is useful if the patient has
mixed symptoms of infrequent urge and obstructed defecation . The testing is also performed to confi rm fi ndings on
physical examination as the source of the symptoms or to
identify the cause if there is uncertainty on the physical
examination .
There is no single test that is able to defi nitively diagnose obstructive defecation or the underlying etiology.
Several adjunctive studies may be performed to help arrive
at a diagnosis, including transit studies, anorectal manometry, balloon expulsion, EMG, fl uoroscopic (conventional)
defecography, MR defecography, and perineal ultrasound
[ 3 , 4 ]. If the patient complains of an infrequent urge to def-
ecate, as well as diffi cult evacuation, colonic transit time
and balloon expulsion tests may be useful to determine the
primary problem.
Colonic Transit Study
Colonic transit can be evaluated with a colonic marker
study (Fig. 12.2a, b ) [ 3 ]. This test involves asking the
patient to swallow a capsule containing radiopaque rings
12 O bst ruct ive Def ecatio n
187
a
b
Fig. 12.2 ( a , b ) Sitzmark study demonstrating large stool burden in
the rectum and left colon and retained sitzmarkers
followed by abdominal x-ray typically on day 3 and day 5
to determine the number of markers left and their locations [ 4 ]. If more than 5 of the 24 markers are present on
day 5, the study suggests slow-transit constipation. The
distribution of the markers may also suggest an etiology,
with a diffuse pattern suggesting colonic inertia, and
markers predominantly present in the distal colon and rectum suggesting that pelvic outlet obstruction is the primary problem, rather than abnormal transit through the
colon [ 5 ].
Balloon Expulsion
A balloon expulsion test involves infl ation of a rubber balloon inserted into the rectum; the patient is then asked to
expel the balloon. Normal subjects can expel the balloon in
1 min. While a positive test (i.e., inability to expel) indicates
obstructive defecation, some patients with obstructive defecation may still be able to expel the balloon. Although a
simple test, the methods for performing the balloon expulsion test are not standardized in regard to the fi lling volume
of the balloon, position of the patient, and expulsion time [ 6 ].
It also does not defi ne the mechanism of obstructed
defecation, but simply helps confi rm it is the cause of the
patient’s symptoms. Therefore, it is best used as a screening
test for a functional defecation disorder [ 7 ].
Key Concept : The primary purpose of some tests is to iden-
tify pelvic fl oor dyssynergia . One of the tests , manometry ,
also excludes Hirschsprung ’ s disease .
If the patient complains only of obstructive defecation
symptoms, the goal of additional testing is to identify the
underlying etiology. More than one contributing factor may
be seen on the testing. The following tests may be useful:
Anorectal Manometry
Anorectal manometry testing will tell you the resting anal
pressure, squeeze pressure, rectoanal inhibitory refl ex, rectal
sensations (fi rst and maximum tolerable), rectal compliance,
and rectal and anal pressure during attempted defecation
[ 6 , 7 ]. Abnormalities in these parameters may direct the clini-
cian towards potential pathophysiology causing obstructive
defecation. The main abnormality in obstructive defecation is
absent or inadequate relaxation of the anal sphincter, sometimes associated with contraction during straining [ 6 ]. An
absent rectoanal inhibitory refl ex (RAIR) is an indication of
Hirschsprung’s disease, which is usually diagnosed in childhood, rather than obstructive defecation. Elevated sensory
thresholds, increased compliance, and rectal motor dysfunction may be seen with obstructive defecation and can be
treated with biofeedback [ 6 , 8 ]. You should be aware that
manometry may overdiagnose dyssynergia. Paradoxical
sphincter contraction has been shown in 22 % of asymptomatic controls, and the rate was not statistically different in
constipated patients [ 7 , 9 ]. The fi nding may be due to the
horizontal patient position and simulated environment.
Electromyography (EMG)
EMG is a direct and specifi c test for the examination of
somatic muscular activity of the external anal sphincter,
puborectalis muscle, and pubococcygeus muscle during
attempted defecation [
10 ]. EMG may be performed with a
needle study, but more frequently EMG recruitment testing is done with a sponge for the patient’s comfort. With
either method, the patient is asked to tighten the sphincter
188
A.C. Lowry and J.L. Irani
Fig. 12.3 Defecography of rectocele
muscle and then to bear down. Myoelectrical activity at
rest, during squeeze, and push are recorded. Nonrelaxation, or even increased activity, in these muscles during attempted defecation is considered abnormal and may
Fig. 12.4 Defecography of rectal prolapse with enterocele
indicate that the patient’s symptoms are secondary to dysfunctional muscle. However, paradoxical activation of the
puborectalis and external sphincter has been observed in
disorders other than obstructive defecation and in normal
subjects [ 11 , 12 ]. Also, some patients with symptoms of
obstructive defecation demonstrate normal inhibition of
external sphincter and puborectalis activity [ 11 , 13 , 14 ],
suggesting another etiology.
Imaging
Key Concept : Imaging is used when rectal prolapse , rectocele , solitary rectal ulcer syndrome , or fi ndings suggestive of
pelvic organ prolapse are seen on examination . Imaging may
also confi rm or refute the presence of non - relaxation of the
puborectalis muscle .
Defecography
Defecography can identify structural abnormalities and also
assess functional parameters [ 15 ]. Defecography may allow
diagnosis of several problems that may be contributing to
the patient’s symptoms such as internal intussusception,
external rectal prolapse, rectocele, sigmoidocele, enterocele, and paradoxical contraction of the puborectalis muscle
(Figs. 12.3 , 12.4 and 12.5 ) [ 6 , 7 ]. However, other than rectal
prolapse, many of these fi ndings are present in asymptomatic controls, so the defecography fi ndings ought not to be
the sole indication for surgery [ 6 , 16 , 17 ]. Anorectal angle
measurements among observers are greatly variable, as
there is no consensus on whether the rectal axis should be
drawn through the anterior, central, or posterior wall [ 7 , 18 ].
Fig. 12.5 Defecography of deep internal intussusception
MR defecography is a newer modality that allows anatomic and dynamic pelvic fl oor evaluation in real time without radiation exposure (Figs. 12.6 and 12.7 ) [ 7 , 19 ]. Several
studies have compared conventional defecography to MR
defecography with differing results. MR defecography,
unless open, requires a horizontal positioning of the patient,
which is not a physiologic defecatory position but, however,
has shown more reproducible results, compared to conventional fl uoroscopic defecography [ 6 , 20 ]. In a small study,
seated open MR defecography compared to closed supine
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189
Fig. 12.6 MRI defecography of rectocele
defecography and supine MR with evacuation phase showed
no signifi cant differences in sphincter hypotonia, dyssynergia, rectocele, or rectal prolapse [
22 , 23 ]. In contrast, a small
study comparing dynamic pelvic MRI and videoproctography showed videoproctography to be more sensitive in
detecting anterior and posterior rectoceles, rectoanal intussusceptions, sigmoidoceles, and perineal descent [ 24 ]. A dif-
ferent small study showed dynamic cystocolpoproctography
and dynamic pelvic MR to be concordant for rectocele,
enterocele, cystocele, and perineal descent; dynamic MR
was the only modality that identifi ed levator ani hernias;
dynamic cystocolpoproctography identifi ed sigmoidoceles
and internal rectal prolapse more often than dynamic MR
[ 25 ]. Likely, your local expertise will dictate the appropriate
imaging modality at your institution.
Perineal Ultrasound
Dynamic perineal ultrasound is performed by placing a
probe on the perineum, between the anus and the introitus.
Compared to healthy controls, patients with symptoms of
obstructive defecation demonstrate signifi cantly greater
absence of relaxation of the puborectalis muscle on straining
and signifi cantly higher incidence of rectal internal mucosal
prolapse on dynamic perineal ultrasound [ 26 ]. There is good
concordance between dynamic transperineal ultrasound and
defecography for identifying rectocele, rectoanal intussusception, anorectal angle, and dyssynergic contraction of the
puborectalis [ 27 , 28 ]. Like many studies of this nature, the
performance and interpretation are reliant on the experience
and expertise of the user.
Fig. 12.7 MRI defecography of enterocele, cystocele, and rectal
invagination
MR defecography shows similar detection of most clinically
relevant fi ndings. Rectal intussusception was seen only on
seated MR [
21 ]. Studies comparing conventional
Our Recommendations
Key Concept : The choice of adjunctive tests depends upon
the patient ’ s symptoms and the fi ndings on physical
examination .
In our practice, after thorough history, physical examination, and endoscopy, we start with conservative management, including stool bulking and osmotic laxatives. If the
patient has combined symptoms, we perform transit studies
to help qualify the type of constipation the patient may be
experiencing: slow transit vs. pelvic outlet obstruction vs.
combination. Currently defecography is done for patients
with demonstrated or suspected rectal prolapse or solitary
rectal ulcer syndrome, as well as patients with symptomatic
rectocele or enterocele. The goals are better understanding of
the anatomy and exclusion of concomitant abnormalities.
Admittedly, defecography is readily available at our site;
however, when it is not, dynamic MRI is an option, but it is
important to have a radiologist with the interest and training
for appropriate interpretation. It is possible that in the future
perineal ultrasound will replace both tests for radiation exposure and cost reasons, but at the present, there is only limited