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404 Benign Anorectal Diseases
Solitary Rectal Ulcer
In patients with obstructed defecation, a solitary
rectal ulcer can be diagnosed at a rate ranging
from 6% to 39%. The symptoms improve significantly after behavioral therapy consisting of
biofeedback and attempts to discourage the use of
laxatives, enemas, and suppositories. The success
rate correlates to an increase of rectal mucosal
blood flow as a consequence of improved activity
of extrinsic innervations of the rectum [16].
Growing attention has been paid to the psychological aspect [17]. Fifty patients (eight with
slow-transit constipation, 36 with obstructed
defecation, and six with mixed symptoms) were
given biofeedback training: 70% found biofeedback helpful, and 62% improved, irrespective of
the type of constipation. The results were related
to psychological state rather than anorectal tests
[17]. It has been demonstrated that in patients
with functional intestinal disorders, modification
of mucosal blood flow depends on the psychological state and autonomic innervations [18].
Improvement of mucosal blood flow could be secondary to both a better psychological equilibrium
and better autonomic nerve stimulation.
Management of Obstructed
Defecation
Treatment of outlet obstruction is often disappointing, and many authors reported no encour-
aging results after surgery [19, 20]. As a conse-
quence, an initial conservative approach has been
encouraged: high-fiber diet, biofeedback, and
rehabilitation of the pelvic floor muscles can help
to reduce symptoms of outlet obstruction [19, 20].
Rectocele
When it has been demonstrated that the predom-
inant alteration is the rectocele,repair of the anterior rectal wall through the different approaches
described (transvaginal, perineal, or transanal)
should be performed. We believe that transanal
techniques are to be chosen for simultaneous
repair of exuberant mucosal or full-thickness rectal wall [21]. The simplest operation is the
transanal suture of the anterior rectal wall [22],
with satisfactory results in more than 80% of
patients [23]. Depending on the size and in
absence of a large rectal intussusception, Sarles
operation may be carried out and combined with
an anterior levatorplasty in case of contextual
presence of fecal incontinence [24].
Taking into consideration new technologies,
rectocele and rectal occult mucosal prolapse may
be also resected with a GIA stapled with satisfactory short-term results [25]. Transanal stapled prolapsectomy and anterior levatorplasty have been
successfully carried out in a small series with short
follow-up [26]. The stapled transanal rectal resection (STARR) for the treatment of symptomatic
rectocele was presented in 2002 [27]. After 3
months, 30% of patients had no complaints, 40%
had only one to two episodes per month of
a b
Section X • Current Concepts in Management of Outlet Obstruction 405
c d
e f
g h
Fig. X.1. A 43-year-old woman with obstructed defecation and digital evacuation. Defecography confirmed the presence of a
large rectocele associated to a posterior mucosal rectal prolapse (a). Stapler transanal rectal resection (STARR) procedure was
performed. Three series of suture were passed through the anterior rectal wall at a distance of 5 cm from the dentate line (b).
Anterior rectal bulging (c). The 33-mm circular stapler (PPH-01, Ethicon EndoSurgery) was then introduced for the anterior rectal resection (d). Similarly, two series of sutures were passed through the posterior rectal wall (e). Posterior rectal mucosal prolapse (f). The stapler was introduced for the second time for the posterior rectal resection (g). At the end of the operation, the
rectum appeared unobstructed (h)
obstructed defecation, 13.3% had evacuation only
using laxatives, and 16.6% were unchanged [27].
Afterward, a double stapler technique (Fig. X.1) was
proposed and compared with STARR plus levatorplasty: the results were encouraging on outlet
obstruction; however. 4/25 (16%) patients were
complicated by the urge to defecate [28]. In a multicenter study, 90 patients with rectocele and rectal
intussusception were treated by performing the
same technique. Symptoms of obstructed defeca-
406 Benign Anorectal Diseases
tion improved in 90% of patients, but 17.8% of
patients were complicated with fecal urgency, and
8.9% complained of incontinence to flatus [29]. In
a recent paper, preliminary results on seven
patients appeared to be promising after treatment
with the double stapler procedure [30].
Nevertheless, some reports have published disappointing results for the STARR procedure
[31–34]. Anismus and neuroticism were related to
severe postoperative pain and recurrent obstructed defecation [31]. In another report from four
Italian centers [32], after performing the STARR
technique in 65 patients with obstructed defecation, more than 60% were still on laxatives after 1-
year follow-up. Further studies are needed to clarify the usefulness and the proper indications of
the STARR procedure [33] because the diffusion of
the technique is, to date, not justified by the criteria of evidence-based medicine [34].
Rectal Prolapse
Perineal Approach
Positive results have been reported by using the
Delorme technique for the treatment of rectal pro-
lapse [35, 36]. Among 20 operated patients, after a
follow-up of at least 6 months, only 8.3% (1/12)
reported fecal incontinence, and 5% of patients
with preoperative constipation still complained of
outlet obstruction. The negative predictive preoperative data were proximal internal prolapse with
rectosacral separation at defecography, chronic
diarrhea, fecal incontinence, and major perineal
descent (>9 cm on straining) [35]. The Delorme
procedure for the treatment of rectal outlet
obstruction can be carried out with minimal morbidity and short hospital stay, with good functional results and overall patient satisfaction above
75% [36]. These are the conclusions of a study on
34 patients complaining of outlet obstruction confirmed by defecography. Twenty-six patients
(76.4%) reported good to excellent overall result
after the Delorme procedure, and eight (23.6%)
reported fair to poor results. Symptomatic
improvement was observed in 89.7% of patients
who had incomplete evacuation and in 88.5% of
patients with constipation [37]. Our unpublished
results demonstrated that in 27 patients selected
on the basis of the criteria reported in Table X.1
(STARR procedure is not included, as it is awaiting
scientific placing, which makes valid the most
appropriate indication [34]), all symptoms signifi-
Table X.1. Selection criteria for the choice of surgery in patients with outlet constipation after failure of conser-
vative treatment (Modified from [38])
Procedure Selection criteria
Sarles • Predominance of rectocele (distension >2 cm)
• Prolapse 1–10 mm (mainly mucosal and anterior)
• Absence of rectoanal dyssynergy
• Absence of prolapse of the uterus or vaginal vault or absence of enterocele
Delorme • Predominance of rectal intussusception (>10 mm)
•High surgical risk
• Absence of prolapse of the uterus or vaginal vault or absence of enterocele
•Male
Orr • Ample rectosacral space
• Enterocele
• Descending perineum >9 cm during straining (at defecography)
• Genital prolapse
Frykman-Goldberg • Colonic diverticular disease
• Colonic associated constipation (prevalently left at transit-times study)
Section X • Current Concepts in Management of Outlet Obstruction 407
a b
c d
Fig. X.2. Patient complaining of outlet constipation. Cystocolpodefecography at rest (a), during straining (b), and during evac-
uation (c). The isolated mucosa of the rectum during the Delorme procedure in this patient was 18 cm (d)
cantly disappeared or dramatically improved,with
a high rate (89%) of patient’ satisfaction and no
relapse evident after a medium follow-up of 30
months.We believe that these results can be justified because we included only rectal intussusception and not overt prolapse for the stringent criteria of indication for treatment according to
Sielzneff et al. [38] and for the long, isolated cylin-
complications after the Delorme procedure for
rectal intussusception is reported to be between
37% and 38.2 % [37, 38]. In our experience, the
complication rate was 29.6% and consisted of
anastomotic substenosis (six patients), acute urinary retention (two patients), hemorrhagia (one
patient),and pelvic abscess (one patient).Only this
latter complication required reoperation.
der of rectal mucosa excised (from 11 cm to 21 cm)
(Fig. X.2). Indeed, one possible causes of relapse
Abdominal Approach
could be the incomplete dissection of the rectal
and, in some cases, sigmoid wall. The good functional results on outlet obstruction are in contrast
to the reduced rectal compliance after the Delorme
procedure for full-thickness rectal prolapse [39].
In our study, no patients complained of postoperative fecal incontinence or urgency, and the symptoms of rectal tenesmus,false call to toilet,or inappropriate call for a very little amount of rectal content, was reduced from 21% to 4% postoperatively
(p<0.003).In the literature, the incidence of minor
It is generally asserted that the abdominal
approach is considered to be the choice for
patients in health conditions while the perineal
approach is reserved for older patients or patients
with compromising health conditions [40].
Ripstein rectopexy, however, can be performed
with low mortality and recurrence rate.Increased
constipation is a problem with this procedure,
especially in patients with internal rectal intussusception.In a recent study, the number of bowel
408 Benign Anorectal Diseases
movements per week significantly decreased
postoperatively (p<0.001) [41]. The section of rectal lateral ligaments has been advocated as a cause
of prolonged intestinal transit time that occurs
after this operation [42, 43], even if this hypothesis has not been confirmed by a more recent paper
[44]. In patients with a solitary rectal ulcer, the
presence of a rectal intussusception at proctography seems to be a positive predictive factor for
good surgical outcome after sacral rectopexy [45]
(Fig. X.3). The anatomical correction of rectal
intussusception is obtained in almost 100% of
cases, but postoperative constipation has been
described in up to 38–47% of patients [46–48].
Different authors have reported a statistically
significant improvement in constipation and
incontinence after rectopexy and resection of the
sigma (Frykman-Goldberg technique) associated
with a low complication rate [49–51]. An increase
in anal resting and squeezing pressure has been
shown and directly correlated to improvement of
continence [51], which was more evident at 6
months’ follow-up [52]. The incidence of postoperative constipation in patients who underwent
rectopexy with resection of the sigma was
reduced when compared with rectopexy without
resection [50, 53,54].
The laparoscopic approach in comparison with
the laparotomic approach has shown the following
advantages: reduction of postoperative pain and
minor use of analgesics, reduction of surgical morbidity, minor aesthetic damage, minor recovery
time, and earlier return to work [50]. Similar, however, are the results regarding the cure of a complete
rectal prolapse. Access via laparoscopy seems to
have a minor postoperative morbidity of between
4% and 9% but presents a more prolonged operative time, especially during the learning curve [55,
56]. Recent studies have confirmed that the retrospective [51, 57–59] or prospective comparison
between the “open” technique and laparoscopy is in
favor of the latter. In addition, a study on economic
impact demonstrated that laparoscopic rectopexy
in comparison with the open procedure,other than
giving better clinical results, cost less [60].
The role of the laparoscopic approach for the
treatment of rectal prolapse has been studied
extensively since the end of the 1980’s but only
recently comparative studies with laparotomy considering the different procedures (direct suture,
use of a mesh, and resection rectopexy) have been
conducted. Most of the literature seems to assert
that the benefits of the abdominal approach con-
sist, principally, in the reduced occurrence of
relapses and in the best functional results for the
complete prolapse of the rectum [61, 62].
Unfortunately, many studies are not comparable
due to the different classifications used, the definitions of success, and for the often short follow-up.
In 72 patients with intestinal transit time prolonged on the left side, direct rectopexy and resection rectopexy resulted, at an average follow-up of
30 months, in an improvement or a recovery in
76% of cases and a worsening in 9% of cases [63].
Constipation and symptoms of difficult evacuation have been solved or alleviated in 70% of
patients who underwent sacral rectopexy and in
64% of those who underwent colonic resection,
both with a laparoscopic approach [64]. In a retrospective study comparing use of mesh,direct suture,
and resection rectopexy, the latter offered better
functional results,in particular for the improvement
of constipation. The use of mesh did not seem to
add any particular advantage [65],even considering
the incidence of recurrences of prolapse [66]. A
more empiric approach, based on the preoperative
clinical evaluation,seems to give a greater guarantee
of success; in fact, by performing the Wells tech-
nique in patients with fecal incontinence and the
resection rectopexy in those with constipation,after
an average follow-up of 18 months, anal incontinence and constipation improved in 80% and 91%
of cases, respectively [67].
To avoid the posterior dissection of the rectum,
a possible cause of postoperative constipation due
to lesion of the autonomic nerves, an alternative
technique has recently been proposed consisting
of a ventral rectopexy performed by a laparoscop-
ic approach [68]. After a medium follow-up of 61
months, 16/19 patients with obstructed defecation
resulted asymptomatic and 28/31 incontinent
patients improved significantly their continence.
However, two patients developed symptoms of
constipation in the postoperative period [68]. Age
had no influence on the functional results
obtained.The results did not differ in patients who
were older or younger than 70 years [69].
Combined Repair
As already underlined, the combined repair of
anterior and posterior perineum is mandatory in
order to avoid multiple operations with higher
risk of complications [70]. Eighty-nine patients
underwent combined surgery, and 60 of these
patients had a concurrent vaginal repair.
Section X • Current Concepts in Management of Outlet Obstruction 409
a b
c d
Fig. X.3. A 62-year-old woman afflicted by obstructed defecation. Cystocolpodefecography confirms suspicion of rectoanal
intussusception and a large enterocele (a).Videolaparoscopic view of the very deep pouch of Douglas (b). After isolation of the
rectum, sparing the hypogastric nerves, the lateral ligaments, and the uterosacral ligaments, the polypropylene mesh is fixed
below the sacral promontorium and distally to the lateral wall of the rectum and the posterior vaginal fornix (c). End of the
operation after obliteration of the pouch of Douglas by two purse-string sutures (d)
Improvement occurred in all major symptoms,
and for all patients, this operation provided considerable relief of symptoms, with no evidence of
recurrence of rectal or vaginal-vault prolapse at
follow-up [71]. In case of vaginal-vault prolapse or
enterocele, the associated abdominal colposacropexy with mesh has a cure rate of 90 %
and a risk of mesh erosion of 3.3% [72–74].
global alteration of intestinal motility, not only
limited to the function of the large bowel [75].
Motility alterations can be, at times, identified by
anorectal manometry. Rectal hyposensitivity and
sensory threshold volumes elevated beyond the
normal range have been found in 33% of patients
with rectocele, in 40% of rectal intussusception,
and in 53% of patients with no mechanical
obstruction evident on defecography [76]. This
suggests that damage to the rectal wall can be
Final Considerations
associated with, and not only consequential to,
rectal intussusception.
The not always encouraging results of surgery for
outlet obstruction are probably not linked only to
problems of technique.The centrality of the problem is not exclusively mechanic but is also, if not
mostly, biological. This is confirmed by the
involvement of the psyche [17, 18] and also by the
In conclusion, medical treatment must be
absolutely considered at the beginning: correction
of diet, implementation of fiber and water, and
biofeedback, along with great attention to the
patients’psychological aspects. Only after the failure of this phase should a workup for the static
410 Benign Anorectal Diseases
and dynamic evaluation of organs of the pelvis
and perineum be carried out.If necessary, surgery
should be proposed after a clear discussion with
the patient regarding advantages and disadvantages. If it confirmed that there is no overwhelming clinical evidence that tends to suggest one
form of surgical procedure over another [77], per-
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Invited Commentary
U. Karlbom, L. Påhlman
The majority of constipated patients experience
some or several symptoms related to obstructed
defecation.A sense of incomplete rectal emptying
is also a symptom coherent with irritable bowel
syndrome (IBS). Both constipation and IBS are
common in the general population, so symptoms
of obstructed defecation will be encountered frequently.
When defining slow-transit constipation, a
radiological measurement of colonic transit time is
always used. The transit study may also be repeated for correct diagnosis if surgery is planned.
Objective measurements of rectal evacuation are
not used as frequently as transit-time studies. The
evacuation capacity can be assessed by a balloon
expulsion tests or by defecography. Time to expel
(evacuate), completeness of evacuation, or evacuation rate are examples of parameters to measure.
The correlation between subjectively obstructed
defecation and objectively measured evacuation is
not strong. Several factors (i.e., psychological,
bowel motility, sensibility) may thus be of importance when evaluating obstructed defecation,
which also has been pointed out in the text.
In the workup of obstructed defecation, some
diagnoses are associated with impaired rectal
evacuation. Paradoxical puborectalis contraction
(anismus) can be diagnosed by sphincter electromyogram (EMG) or defecography. The importance of this diagnosis has been debated, but irrespective of the diagnostic method used, the diagnosis has been related to impaired rectal evacuation. In a similar way,a rectocele has been related
to delayed and incomplete evacuation. Other findings at defecography, such as mucosal infolding,
internal rectal intussusception, prolapse, and
enterocele, do not seem to affect rectal emptying.
One possible explanation that these conditions
may be a cause of symptoms is that they are occupying space in or adjacent to the rectum, which
can give a sensation of incomplete emptying.
There are numerous surgical techniques –
laparoscopic or traditional – for treatment of the
above-mentioned conditions. The results of surgical correction of anatomy,i.e., internal rectal intussusception, are difficult to predict although some
patients are relieved of symptoms whereas others
have aggravated symptoms of constipation. On the
other hand, repair of a rectocele seems to be associated with a high success rate, both via the anal
and the vaginal route.The best technique for rectal
prolapse surgery has been debated for many years.
Evaluation of results is complex because local control of prolapse, fecal incontinence, and constipation has to be assessed. At present, there are some
larger ongoing, randomized trials comparing surgical techniques in the treatment of rectal prolapse. This will hopefully give us a better rationale
for selecting technique. The new emerging stapled
transanal rectal resection (STARR) for obstructed
defecation seems promising but has finally to be
evaluated in a randomized manner. Optimally,
these studies should not only address symptoms
but also an objective measurement of rectal evacuation and a postoperative assessment if anatomical
correction is achieved.
We agree with Infantino and colleagues that
primary treatment of obstructed defecation is conservative. Biofeedback may be highly successful in
selected patients but still have a 40–60 % success
rate when used more generally.A large, nonemptying rectocele is an indication for surgery.
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