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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_894_Библиотеки_им_академика_М_И_Перельмана.pdf
AB
agina
colon
7 Functional Anorectal Disorders
a
123
b
Sizer
Sigmoid
colon
Sacrum
Sacral
promontory
Bladder
L5
Ureter
Vagina
Bladder
Bladder
Ureter
V
Mesh
graft
Sigmoid
colon
Peritoneum
C
Sigmoid
Fig. 7.4 Different surgical approaches for perineal
descent syndrome. (a) Abdominal sacral colpoperineopexy—sagittal section illustrating dissection of rectovaginal space and attachment of mesh to perineal body, which
is elevated by surgeon’s hand. (b) Laparoscopic sacral
colpoperineopexy—A. Initial laparoscopic view with
sizer in vagina showing position of vaginal apex and
sacral promontory. B. Suturing graft material to anterior
aspect of vaginal cuff. C. Laparoscopic view after completion of culdoplasty showing complete excision of graft
material from peritoneal cavity. (c) Retrorectal
levatoroplasty—A. A series of placation of stitches have
been placed 1cm apart in the posterior wall of the rectum
and tied as shown in A. These are then sewn individually
to the anterior periosteum of the sacrum as shown in B.
The levator plate is restored and lengthened by bringing
the pubococcygei of each side together in the midline
between the coccyx and the rectum as shown in C. The
bellies of the pubococcygei may be shortened with a Z
stitch placed as shown in C. (d) Retro-anal levator plate
myorrhaphy: surgical steps—A. Skin incision. B. Scissors
introduced between levator plate and ano-coccygeal ligament (also called intermediate loop of the external anal
sphincter). C. The ano-coccygeal ligament ready to be cut
(two extremities marked with a thread). D. Levator plate
myorrhaphy between coccyx and ano-rectal junction until
suppression of the sagging (checked by rectal examination). E. Ano-coccygeal ligament repaired. F. Skin closure
with a Y-shaped multi-tubular drain at the posterior edge
of the incision
124
B. L. Bello et al.
c
B
Coccyx
Levator
Rectum
Sphincter
A
C
d
AB C
DE F
Fig. 7.4 (continued)
7 Functional Anorectal Disorders
125
To avoid the morbidity of a perineal incision,
operations utilizing staplers have been developed. One randomized trial examined the use of
the hemorrhoidal stapler by comparing single
Stapled Trans-Anal Prolapsectomy associated
with Perineal Levatorplasty (STAPL) with double Stapled Transanal Rectal Resection (STARR)
in patients with outlet obstruction, including
patients with perineal descent. Constipation
symptoms improved with both operations, but
the STARR procedure was associated with less
pain and dyspareunia [51].
Transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS)
is another stapler technique in patients with
obstructed defecation syndrome caused by rectocele and rectal mucosal prolapse. In this procedure, the rectocele and associated mucosa are
resected transanally and the defect is then closed
with the aid of a single circular stapler [52]. The
TRREMS procedure has been shown to be safe
and effective in appropriately selected patients
with improvement in measures of constipation
[53, 54].
As in the case of anismus, a nal surgical
option may be the creation of a diverting stoma.
We propose a treatment algorithm with core
focus on nonsurgical therapy (Fig.7.1). If unsuccessful, surgery is considered, but should be limited to those with substantial experience. A
multidisciplinary evaluation may be useful and
may involve colorectal surgery, urogynecology
and gynecology.
Solitary Rectal Ulcer Syndrome
Solitary rectal ulcer syndrome (SRUS) is a term
introduced by M.R. Madigan in 1964 [55]. Both
‘solitary’ and ‘ulcer’ are misnomers, as the condition may not be solitary in nature and does not
always produce an ulcer. Moreover the ulcers are
rarely typical. Because it is an uncommon entity,
diagnosis is often delayed and a high clinical suspicion is necessary for timely diagnosis. A related
entity, colitis cystic profunda (CCP) is marked by
inamed areas lled with mucin resulting in a
cystic-appearing neoplasm. CCP and SRUS are
related diagnoses that some clinicians consider
interchangeable. Both SRUS and CCP are seen
more commonly in women and usually affect
those between the third and seventh decade,
though patients as young as 3years with SRUS
have been reported [56–58].
Local chronic ischemia is thought to be the
underlying etiology of SRUS, with causes ranging from internal rectal intussusception, trauma
from digitation or instrumentation of the rectum,
or even the use of strong vasoconstricting agents
such as ergotamine suppositories. The classic
etiologic sequence begins with straining that
induces rectal intussusception or prolapse. Direct
pressure at the point of prolapse leads to local tissue congestion and ischemia, ultimately causing
ulcer formation.
The symptoms of SRUS are nonspecic, but
usually include some combination of bloody or
mucous rectal secretions, chronic constipation
with a feeling of outlet obstruction, tenesmus,
and pelvic or abdominal pain. These patients usually have a history of signicant straining to defecate. During digital examination in a patient
with SRUS, there may be a palpable area of induration. Endoscopic assessment typically demonstrates a solitary ulcer on the anterior rectal wall,
though lesions may be multiple and variably
located. An ulcer is not mandatory for diagnosis:
manifestations range from shallow ‘punched-out’
gray-white lesions with a hyperemic base to rectal erythema to rectal pseudopolyps.
Imaging studies may aid in the diagnosis of
SRUS.Defecography is especially useful but is
often only available at specialized centers. The
dynamic images of defecography are more specic than the static views of a barium enema [59].
Characteristic features of SRUS include intussusception, nonrelaxing puborectalis muscle, or
incomplete or delayed rectal emptying. Though
magnetic resonance (MR) defecography is a now
available in some centers, it has not shown any
advantage over conventional defecography and
may overdetect incomplete evacuation in 30% of
patients [36, 60]. Endoscopic anorectal ultrasound is another adjunct in SRUS diagnosis that
typically demonstrates a hyperechoic layer
between the circular and longitudinal muscle
126
Fig. 7.5 Solitary rectal ulcer syndrome. Endoscopy ndings—anterior ulcer with white sloughy base. With permission from [57] © 2006 Springer
layer of muscularis propria and may aid in differentiating SRUS from rectal cancer (Fig.7.5).
Biopsy and histopathologic examination is
key to both the diagnosis of SRUS and to excluding other pathologies, such as inammatory
bowel disease or cancer. Microscopically, SRUS
appears as so-called ‘bromuscular obliteration’, which is characterized by an obliterated,
brotic lamina propria that contains excess collagen and disorganized hypertrophy of the
smooth muscle bers from the muscularis mucosae towards the lumen. The presence of collagen
inltration of the lamina propria distinguishes
SRUS from other inammatory, infectious and
ischemic colitides [57]. In contrast, mucus-lled
cystic spaces are seen in CCP with thickened,
brotic submucosa with mixed inammatory
inltration.
The initial treatment for SRUS is non-operative. Interventions that decrease straining, such as
patient education, bulk laxatives, and stool softeners, can be effective in about 20% of patients.
Topical enemas and agents containing steroids,
5-ASA, sucralfate, or sulfasalazine may not heal
the lesions because they are not true ulcers.
Biofeedback may alleviate associated pelvic
oor dysfunction. In a series of 11 patients, biofeedback decreased straining effort and stool frequency and improved quality-of-life measures; 6
B. L. Bello et al.
patients had at least 50% healing of their ulcers
[61]. Although these non-operative therapies may
be effective initially, they do not often produce
good long term results. In one series of 23
patients, 16 failed nonsurgical measures [56].
If the outlet obstruction and ulceration of
SRUS is caused by prolapse, this may need denitive treatment. Abdominal rectopexy has a
reported 55–60% long-term improvement in
symptoms [62]. Traditionally, this involved a low
short midline incision and suture proctopexy to
the sacrum at the distal third of the rectum. This
can also be done laparoscopically, though some
early efforts were not entirely successful.
However, a recent series of 39 patients reported
70% success rate after laparoscopic rectopexy
[63]. There may also be a large role for roboticassisted laparoscopic ventral rectopexy as experience with this technology increases worldwide.
Sigmoidocele
Sigmoidocele, a type of enterocele in which a
loop of sigmoid colon herniates through the pelvic oor, is another cause of outlet obstruction.
Hysterectomy predisposes patients to develop
enterocele generally, including sigmoidocele.
Among patients undergoing defacography, the
incidence of sigmoidocele is about 5% with an
overwhelming predominance in women [64].
The suggested mechanism of outlet obstruction in sigmoidocele is complex and not all
patients with sigmoidocele have symptoms. In
symptomatic patients, several factors, including
collapse of the rectal wall due to extrinsic compression of the hernia contents and stasis of the
sigmoid loop, as well as rectoanal intussusception, rectocele and paradoxical contraction of
puborectalis, frequently contribute to the
symptomatology.
Sigmoidocele is best diagnosed with conventional defecography, as physical examination is
not reliable [65]. Jorge and colleagues proposed a
sigmoidocele classication system based on
extent of sigmoid herniation in relation to
anatomic landmarks. In rst-degree sigmoidocele, the intrapelvic sigmoid loop remains above
the pubococcegeal line, in second-degree
7 Functional Anorectal Disorders
127
between the pubococcygeal and ischiococcygeal
lines, and in third-degree the loop is below the
ischioccygeal line. The cinedefecographic degree
of sigmoidocele correlates well with symptoms
(Fig.7.6a–c) [66].
Biofeedback therapy is the mainstay of treatment in symptomatic patients with rst- and second-degree sigmoidocele, with approximately a
50% success rate. Surgical repair is rarely indi-
a
cated. Third-degree sigmoidoceles may also benet from biofeedback therapy, but sigmoid
resection is often indicated. The surgical results
are excellent, resolving symptoms in nearly all
patients in the experience of one editor (SDW)
[66]. Laparoscopic sigmoidectomy can be performed for these patients, with shorter hospitalization and less disability when compared to
laparotomy. Coexisting intussusception can be
b
c
Fig. 7.6 Sigmoidocele. (a) First degree, (b) Second degree, (c) Third degree
128
B. L. Bello et al.
treated with rectopexy at the time of sigmoidectomy [67]. Rectocele coexisting with third-degree
sigmoidocele is usually a small outpouching with
minimal clinical signicance and likely can be
observed.
Conclusion
Functional anorectal disorders can produce
signicant symptoms. Improvements in our
knowledge of these disorders and experience
with physiologic testing has allowed more
accurate diagnosis and in many cases success-
ful therapy.
References
1. Ramkumar D, Rao S.Efcacy and safety of traditional
medical therapies for chronic constipation: systematic
review. Am J Gastroenterol. 2005;100(4):936–71.
2. Bove A. Consensus statement AIGO/SICCR diag-
nosis and treatment of chronic constipation and
obstructed defecation (Part II: Treatment). World J
Gastroenterol. 2012;18(36):4994.
3. Loening-Baucke V. Persistence of chronic constipa-
tion in children after biofeedback treatment. Dig Dis
Sci. 1991;36(2):153–60.
4. Dahl J, Lindquist B, Tysk C, Leissner P, Philipson L,
Järnerot G.Behavioral medicine treatment in chronic
constipation with paradoxical anal sphincter contraction. Dis Colon Rectum. 1991;34(9):769–76.
5. Turnbull G, Ritvo P. Anal sphincter biofeed-
back relaxation treatment for women with intractable constipation symptoms. Dis Colon Rectum.
1992;35(6):530–6.
6. Papachrysostomou M, Smith A.Effects of biofeed-
back on obstructive defecation—reconditioning of the
defecation reex? Gut. 1994;35(2):252–6.
7. Keck J, Staniunas R, Coller J, Barrett R, Oster M,
Schoetz D, et al. Biofeedback training is useful in
fecal incontinence but disappointing in constipation.
Dis Colon Rectum. 1994;37(12):1271–6.
8. Glia A, Gylin M, Gullberg K, Lindberg G.Biofeedback
retraining in patients with functional constipation
and paradoxical puborectalis contraction. Dis Colon
Rectum. 1997;40(8):889–95.
9. Gilliland R, Heymen S, Altomare D, Park U,
Vickers D, Wexner S. Outcome and predictors of
success of biofeedback for constipation. Br J Surg.
1997;84(8):1123–6.
10. Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman
D, Whitehead W.Randomized, controlled trial shows
biofeedback to be superior to alternative treatments
for patients with pelvic oor dyssynergia-type constipation. Dis Colon Rectum. 2007;50(4):428–41.
11. Chiarioni G, Salandini L, Whitehead W.Biofeedback
benets only patients with outlet dysfunction, not
patients with isolated slow transit constipation.
Gastroenterology. 2005;129(1):86–97.
12. Rao S, Valestin J, Brown C, Zimmerman B, Schulze
K.Long-term efcacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am
J Gastroenterol. 2010;105(4):890–6.
13. Hart S, Lee J, Berian J, Patterson T, del Rosario A,
Varma M. A randomized controlled trial of anorectal biofeedback for constipation. Int J Color Dis.
2011;27(4):459–66.
14. Hallan R, Melling J, Womack N, Williams N,
Waldron D, Morrison J. Treatment of anismus in
intractable constipation with botulinum a toxin.
Lancet. 1988;332(8613):714–7.
15. Maria G, Brisinda G, Bentivoglio A, Cassetta E,
Albanese A.Botulinum toxin in the treatment of outlet obstruction constipation caused by puborectalis
syndrome. Dis Colon Rectum. 2000;43(3):376–80.
16. Joo J, Agachan F, Wolff B, Nogueras J, Wexner
S.Initial North American experience with botulinum
toxin type A for treatment of anismus. Dis Colon
Rectum. 1996;39(10):1107–11.
17. Ron Y, Avni Y, Lukovetski A, Wardi J, Geva D,
Birkenfeld S, etal. Botulinum toxin type-A in therapy of patients with anismus. Dis Colon Rectum.
2001;44(12):1821–6.
18. Hompes R, Harmston C, Wijffels N, Jones O,
Cunningham C, Lindsey I.Excellent response rate of
anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus (‘pseudoanismus’) is excluded.
Color Dis. 2012;14(2):224–30.
19. Farid M, El Monem H, Omar W, El Nakeeb A, Fikry
A, Youssef T, etal. Comparative study between biofeedback retraining and botulinum neurotoxin in
the treatment of anismus patients. Int J Color Dis.
2008;24(1):115–20.
20. Maria G, Anastasio G, Brisinda G, Civello I.Treatment
of puborectalis syndrome with progressive anal dilation. Dis Colon Rectum. 1997;40(1):89–92.
21. Wasserman I. Puborectalis syndrome (rectal stenosis due to anorectal spasm). Dis Colon Rectum.
1964;7(2):87–98.
22. Barnes P, Hawley P, Preston D, Lennard-Jones
J.Experience of posterior division of the puborectalis
muscle in the management of chronic constipation. Br
J Surg. 1985;72(6):475–7.
23. Kamm M, Hawley P, Lennard-Jones J. Lateral division of the puborectalis muscle in the management of
severe constipation. Br J Surg. 1988;75(7):661–3.
24. Liu Y, Zang J, Li Y.Treatment of musculi puborectalis
syndrome with partial resection of musculi puborectalis: analysis in 149 cases. J LuoYang Med Coll.
2001;19:17–8.
25. Yu D, Jin H. Surgical treatment for puborectalis hypertrophy. In: Wexner S, Duthie G, editors.
Constipation: etiology, evaluation and management.
2nd ed. London: Springer; 2006. p.247–56.
7 Functional Anorectal Disorders
129
26. Faried M, El Nakeeb A, Youssef M, Omar W, El
Monem H. Comparative study between surgical
and non-surgical treatment of anismus in patients
with symptoms of obstructed defecation: a prospective randomized study. J Gastrointest Surg.
2010;14(8):1235–43.
27. Parks A, Porter N, Hardcastle J. The syndrome
of the descending perineum. Proc R Soc Med.
1966;59(8):477–82.
28. Thapar R, Patankar R, Kamat R, Thapar R,
Chemburkar V. MR defecography for obstructed
defecation syndrome. Indian J Radiol Imaging.
2015;25(1):25.
29. Alves-Ferreira P, Gurland B, Zutshi M, Hull
T.Perineal descent does not imply a more severe clinical disorder. Color Dis. 2012;14(11):1372–9.
30. Pucciani F, Boni D, Perna F, Bassotti G, Bellini
M. Descending perineum syndrome: are abdominal
hysterectomy and bowel habits linked? Dis Colon
Rectum. 2005;48(11):2094–9.
31. Ho Y, Goh H. The neurophysiological signicance of perineal descent. Int J Colorectal Dis.
1995;10(2):107–11.
32. Kiff E, Barnes P, Swash M. Evidence of pudendal
neuropathy in patients with perineal descent and
chronic straining at stool. Gut. 1984;25(11):1279–82.
33. Jorge M, Wexner S, Ehrenpreis E, Nogueras J,
Jagelman D. Does perineal descent correlate
with pudendal neuropathy? Dis Colon Rectum.
1993;36(5):475–83.
34. Vaccaro C, Wexner S, Teoh T, Kyung Choi S, Cheong
D, Salanga V. Pudendal neuropathy is not related
to physiologic pelvic outlet obstruction. Dis Colon
Rectum. 1995;38(6):630–4.
35. Ambrose S, Keighley M. Outpatient measurement of perineal descent. Ann R Coll Surg Engl.
1985;67(5):306–8.
36. Foti P, Farina R, Riva G, Coronella M, Fisichella E,
Palmucci S, etal. Pelvic oor imaging: comparison
between magnetic resonance imaging and conventional defecography in studying outlet obstruction
syndrome. Radiol Med. 2013;118(1):23–39.
37. Vanbeckevoort D, Hoe L, Oyen R, Ponette E, De
Ridder D, Deprest J.Pelvic oor descent in females:
comparative study of colpocystodefecography and
dynamic fast MR imaging. J Magn Reson Imaging.
1999;9(3):373–7.
38. Kelvin F, Maglinte D, Hale D, Benson J.Female pelvic
organ prolapse. Am J Roentgenol. 2000;174(1):81–8.
39. Healy J, Halligan S, Reznek R, Watson S, Bartram
C, Phillips R, etal. Dynamic MR imaging compared
with evacuation proctography when evaluating anorectal conguration and pelvic oor movement. Am J
Roentgenol. 1997;169(3):775–9.
40. Roos J, Weishaupt D, Wildermuth S, Willmann
J, Marincek B, Hilker P. Experience of 4 years
with open MR defecography: pictorial review of
anorectal anatomy and disease. Radiographics.
2002;22(4):817–32.
41. Fiaschetti V, Squillaci E, Pastorelli D, Rascioni M,
Funel V, Salimbeni C, etal. Dynamic MR defecography with an open-conguration, low-eld, tilting MR
system in patients with pelvic oor disorders. Radiol
Med. 2011;116(4):620–33.
42. Harewood G, Coulie B, Camilleri M, Rath-Harvey
D, Pemberton J. Descending perineum syndrome:
audit of clinical and laboratory features and outcome of pelvic oor retraining. Am J Gastroenterol.
1999;94(1):126–30.
43. Lesaffer L, Milo R.Descending perineum syndrome:
control defecogram with a “perineum device”, perspective in prevention and conservative therapy. J
Belg Radiol. 2007;71(6):709–12.
44. Schey R, Cromwell J, Rao S.Medical and surgical
management of pelvic oor disorders affecting defecation. Am J Gastroenterol. 2012;107(11):1624–33.
45. Guillemot F, Bouche B, Gower-Rousseau C, Chattier
M, Wolschies E, Lamblin M, et al. Biofeedback
for the treatment of fecal incontinence. Dis Colon
Rectum. 1995;38(4):393–7.
46. Cundiff G, Harris R, Coates K, Low V, Bump R,
Addison W. Abdominal sacral colpoperineopexy:
a new approach for correction of posterior compartment defects and perineal descent associated
with vaginal vault prolapse. Am J Obstet Gynecol.
1997;177(6):1345–55.
47. Link R, Su L, Bhayani S, Wright E. Laparoscopic
sacral colpoperineopexy for treatment of perineal
body descent and vaginal vault prolapse. Urology.
2004;64(1):145–7.
48. Parks A.Post-anal perineorrhaphy for rectal prolapse.
Proc R Soc Med. 1967;60(9):920–1.
49. Nichols D. Retrorectal levatorplasty with colporrhaphy. Clin Obstet Gynecol. 1982;25(4):939–47.
50. Beco J. Interest of retro-anal levator plate myorrhaphy in selected cases of descending perineum syndrome with positive anti-sagging test. BMC Surg.
2008;8(1):13.
51. Boccasanta P, Venturi M, Salamina G, Cesana B,
Bernasconi F, Roviaro G.New trends in the surgical
treatment of outlet obstruction: clinical and functional
results of two novel transanal stapled techniques
from a randomised controlled trial. Int J Color Dis.
2004;19(4):359–69.
52. Regadas F, Regadas S, Rodrigues L, Misici R, Silva
F, Regadas Filho F. Transanal repair of rectocele
and full rectal mucosectomy with one circular stapler: a novel surgical technique. Tech Coloproctol.
2005;9(1):63–6.
53. Cruz J, Regadas F, Murad-Regadas S, Rodrigues L,
Benicio F, Leal R, etal. TRREMS procedure (transanal repair of rectocele and rectal mucosectomy with
one circular stapler): a prospective multicenter trial.
Arq Gastroenterol. 2011;48(1):3–7.
54. Leal V, Regadas F, Regadas S, Veras L. Clinical
and functional evaluation of patients with rectocele
and mucosal prolapse treated with transanal repair
of rectocele and rectal mucosectomy with a single
130
B. L. Bello et al.
circular stapler (TRREMS). Tech Coloproctol.
2010;14(4):329–35.
55. Madigan Morson B.Solitary ulcer of the rectum. Gut.
1969;10(11):871–81.
56. Torres C, Khaikin M, Bracho J, Luo C, Weiss E,
Sands D, etal. Solitary rectal ulcer syndrome: clinical
ndings, surgical treatment, and outcomes. Int J Color
Dis. 2007;22(11):1389–93.
57. Chiang J, Changchien C, Chen J. Solitary rectal
ulcer syndrome: an endoscopic and histological
presentation and literature review. Int J Color Dis.
2006;21(4):348–56.
58. Perito E, Mileti E, Dalal D, Cho S, Ferrell L,
McCracken M, etal. Solitary rectal ulcer syndrome
in children and adolescents. J Pediatr Gastroenterol
Nutr. 2012;54(2):266–70.
59. Halligan S, Nicholls R, Bartram C.Evacuation proctography in patients with solitary rectal ulcer syndrome: anatomic abnormalities and frequency of
impaired emptying and prolapse. Am J Roentgenol.
1995;164(1):91–5.
60. Otto S, Oesterheld A, Ritz J, Gröne J, Wolf K, Buhr
H, et al. Rectal anatomy after rectopexy: cinedefecography versus MR-defecography. J Surg Res.
2011;165(1):52–8.
61. Rao S, Ozturk R, De Ocampo S, Stessman
M.Pathophysiology and role of biofeedback therapy
in solitary rectal ulcer syndrome. Am J Gastroenterol.
2006;101(3):613–8.
62. Sitzler K, Nicholls M.Long-term clinical outcome of
surgery for solitary rectal ulcer syndrome. Br J Surg.
1998;85(9):1246–50.
63. Kargar S, Salmanroughani H, Binesh F, Taghipoor S,
Kargar S. Laparoscopic rectopexy in solitary rectal
ulcer. Acta Med Iran. 2011;49(12):810–3.
64. Kelvin F, Maglinte D, Hornback J, Benson J.Pelvic
prolapse: assessment with evacuation proctography
(defecography). Radiology. 1992;184(2):547–51.
65. Fenner D. Diagnosis and assessment of sigmoidoceles. Am J Obstet Gynecol. 1996;175(6):1438–42.
66. Jorge J, Yang Y, Wexner S. Incidence and clinical signicance of sigmoidoceles as determined
by a new classication system. Int J Color Dis.
1994;37(11):1112–7.
67. Laubert T, Kleemann M, Roblick U, Bürk C, Hildebrand
P, Lewejohann J, et al. Obstructive defecation syndrome: 19 years of experience with laparoscopic resection rectopexy. Tech Coloproctol. 2013;17(3):307–14.
Rectal Prolapse
andIntussusception
JonathanR.Snyder andIanM.Paquette
8
Introduction
Rectal prolapse is the full thickness, circumferential protrusion of the rectum through the anus. This
relatively uncommon disorder is estimated to
occur in 0.5% of the population [1]. The true incidence of this condition may be under-reported
because patients are often too embarrassed to seek
medical attention. Full thickness rectal prolapse is
one of the many pelvic oor disorders, which
mostly affects women and the elderly. Though
prolapse can occur in multiple clinical settings,
some of the risks factors that have been described
include chronic constipation, obstetric related pelvic oor dysfunction, and chronic straining with
defecation [1–7]. Rectal prolapse obviously has a
great impact on quality of life [3], and as such,
many attempts have been made to develop a surgical solution that can alleviate the symptoms,
including incontinence to stool or mucus, constipation, sensation of incomplete evacuation, rectal
bleeding, pain, or urgency [1, 2, 4].
J. R. Snyder
Department of Surgery, Division of Colon and Rectal
Surgery, University of Cincinnati Medical Center,
Cincinnati, OH, USA
I. M. Paquette (*)
Division of Colon and Rectal Surgery, University of
Cincinnati College of Medicine, Christ Hospital
Center for Pelvic Floor Disorders,
Cincinnati, OH, USA
e-mail: ian.paquette@uc.edu
Before discussing the surgical treatment of
rectal prolapse, one must be able to differentiate
a full thickness rectal prolapse from rectal intussusception, or partial thickness mucosal prolapse. The main feature differentiating full
thickness prolapse from mucosal prolapse is the
presence of concentric mucosal rings with
Rectal prolapse:full thickness prolapse
(Fig. 8.1). Internal rectal intussusception is
known as the intussusception of the middle or
upper portion of the rectum, which does not prolapse through the anal canal. This nding is
most often diagnosed in the setting evaluating
constipation with defecography (Fig. 8.2).
Mucosal prolapse is simply prolapse of the distal rectal mucosa, which is noted by radial folds
in the tissue when a patient is examined on the
commode (Fig. 8.3). Differentiating among
these disorders is critical, as the treatment of
these conditions varies.
Over 100 procedures have been described to
treat rectal prolapse [5], suggesting there is no
universally accepted panacea [1, 2, 4–6]. Most
often, the debate lies in whether to use an
abdominal or a perineal surgical approach.
These decisions are often made based on the
overall health of the patient and on whether
there are any other associated bowel abnormalities present, as well as a review of any prior
surgical procedures [2, 4, 6, 7, 9]. In general,
abdominal procedures have lower recurrence
rates but may have a higher incidence of
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_8
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132
Fig. 8.1 Full thickness rectal prolapse characterized by
circumferential mucosal folds
Fig. 8.2 Defecography demonstrating internal intussusception of the rectum as demonstrated by the white arrows
postoperative complications compared to perineal surgery [10]. Russell etal. used the NSQIP
database to examine 1485 patients who underwent surgery for rectal prolapse. A total of 706
patients underwent an abdominal approach
J. R. Snyder and I. M. Paquette
Fig. 8.3 Mucosal prolapse is characterized by radial
folds of tissue protruding from the anus. With permission
[8] © Springer 2014
versus 779 with a perineal approach.
Complications (12.9% vs. 7.6%) and infection
rates (9.8% vs. 3.7%) were higher following
the abdominal approach [10]. Since this study
focused only on 30-day postoperative outcomes, there was no long-term recurrence data
available. Another recent trial, the PROSPER
trial randomized patients to different treatment
methods. Patients were rst randomized to
abdominal vs. perineal surgery. Abdominal
surgery patients were randomized to suture vs.
resection rectopexy, and perineal surgery
patients were randomized to Altemeier vs.
Delorme procedure. There were no differences
in recurrence rates between abdominal and
perineal approaches, though it was difcult to
recruit patients to this study and it was likely
underpowered to detect clinically meaningful
differences in outcomes [11].
Based upon available evidence, perineal
approaches may be best suited for patients who
are not ideal candidates for abdominal surgery, as
they may be potentially safely performed without
the need for general anesthesia [12–16]. There is
mounting evidence that these decisions are best
made by taking the patient’s overall condition and
perceived physiologic reserve into account rather
than simply using chronologic age, as excellent
outcomes have been shown with abdominal
approaches even in octogenarians [17–20].