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10 Complete Rectal Prolapse in Adults
143
10.9 Summary
In addition, the aim of treatment for complete rectal prolapse should be not only to correct the prolapse but also to rectify the functional disturbances.
Thorough preoperative evaluation including rectal
physiology is useful. Selection of procedure is
very important and should be based on patient’s
age, comorbidity, and associated disturbances like
constipation, incontinence, associated cystocele,
and surgeon’s familiarity with the procedure.
Predisposing factors like constipation and straining should be avoided to reduce recurrence rate.
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Pelvic Floor Dysfunction
Brij B. Agarwal and P. Sivalingam
1 1
11.1 Introduction
The pelvic fl oor is a tunnel or dome-shaped muscular sheath made up of striated muscle and is
positioned to enclose and support the genitourinary and anorectal compartments. The pelvic fl oor
forms the inferior boundary of the abdominopelvic cavity extending from the pubic symphysis
anteriorly to the coccyx posteriorly and between
the two pelvic side walls. There are four layers:
the endopelvic fascia, the muscular diaphragm or
levator plate, the perineal membrane or urogenital
diaphragm, and the superfi cial transversus perinei.
The pelvic fl oor has a dynamic mechanization of
complex voluntary and involuntary muscles, supporting ligaments, fascial encasings, and complex
neural wiring. Pelvic fl oor dynamics is crucial in
maintaining continence and evacuation of the bladder/bowel, supporting the pelvic organs, maintaining the dynamics of the birth canal, and optimized
sexual function. The functional dynamics of the
B. B. Agarwal , MBBS, MS (*)
Department of Laparoscopic & General Surgery ,
GRIPMER & Sir Ganga Ram Hospital ,
New Delhi , India
endosurgeon@gmail.com
e-mail:
P. Sivalingam , MBBS, MS, MNAMS(Surgery)
Department of Surgery , Madurai Medical College ,
Madurai , TN , India
Government Rajaji Hospital , Madurai , TN , India
drpsivalingam@yahoo.com
e-mail:
pelvic fl oor results in myriad clinical presentations. It is necessary to understand the possible
symptom complexes in relation to different compartments of the pelvic fl oor. The three compartments, i.e., anterior, middle, and posterior, relate to
symptomatology arising from the urinary, genital,
and defecatory system complexes, respectively.
These three compartments act like “the spokes of a
wheel,” i.e., the pelvic fl oor (Agarwal et al. 2012 ).
The colorectal surgeon deals mostly with the defecatory aspect of the pelvic fl oor. Constipation is
an index symptom of anorectal dysfunction which
in itself is an index parameter of pelvic fl oor dysfunction (Agarwal et al. 2013 ). Pelvic fl oor dys-
function refers to a wide range of disorders which
occur due to weakness or tightness of muscles of
the pelvic fl oor. Apart from constipation, pelvic
fl oor dysfunctions include fecal incontinence,
urinary incontinence, overactive bladder, pelvic
discomfort/pain syndromes, sexual dysfunction,
and pelvic organ prolapse (rectocele, cystocele,
urethrocele, and rectal prolapse). The most common and defi nable conditions include fecal incontinence, urinary incontinence, and pelvic organ
prolapse. The interdependence and interplay of
all these symptoms are clinically relevant as they
are just like different spokes in the wheel of pelvic
fl oor dysfunction (Aschkenazi and Goldberg
Keller and Lin 2012 ).
The current understanding of pelvic fl oor
functioning is based upon the anatomy of the
female pelvis as pelvic fl oor dysfunction is seen
2009 ;
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_11
145
146
B.B. Agarwal and P. Sivalingam
more frequently in females. The female preponderance has been attributed to the effects of
pregnancy. The mode of childbirth has not been
shown to have any signifi cant determining effect
on pelvic fl oor dysfunction (Nelson et al 2010 ).
Pelvic fl oor laxity may result from the hormonal
collagenous changes in the pelvic structures
leading to lack of connective tissue integrity
supporting the pelvic contents. Such loss of supporting integrity will lead to herniation of organs
from one compartment to another pelvic compartment. It has been reported that >10 %
women have one or two surgical procedures for
pelvic fl oor dysfunction in their lifetime. A suboptimal understanding of the “three spokes of
the pelvic wheel” concept can lead to clinical
neglect of accompanying symptoms, low prioritization of pelvic fl oor disorders, and unsatisfactory treatments. This leads to a major public
health issue with signifi cant psychosocial and
economical issues resulting in poor quality of
life outcomes (Nygaard and Barber 2008 ). Given
the multi- compartmental yet synergistically
functional nature of pelvic fl oor dysfunctions, a
proper evaluation for various components is
mandatory for optimizing clinical outcomes.
Evaluation of the pelvic fl oor has been revolutionized by the availability of MR pelvicography which needs a basic understanding of pelvic
fl oor anatomy.
Fig. 11.1 Muscles and ligament of the pelvic fl oor. 1
uterosacral ligament, 2 levator plate, 3 longitudinal mus-
cle of anus, 4 perineal body, 5 rectovaginal fascia, 6 mus-
cle of perineal membrane, 7 anterior portion of
pubococcygeus muscle, 8 ligament and fascia of puboure-
thral ligament
Fig. 11.2 Role of vaginal connective tissue in bladder
and anorectal dysfunction
11.2 Anatomical Footprint for Pelvic Floor Surgical Navigation
All the three compartments of the pelvic fl oor
share a very intimate relationship. Based upon
the leading manifestation of the disorders, they
are compartmentalized into the urinary, genital,
or defecatory dysfunctions. There are very
dynamic and functional contiguous structures
between these compartments as shown in
Figs. 11.1 and 11.2 .
These help in understanding of concomitancy
of the symptoms manifesting primarily from
one compartment but may be originating from a
structural lacunae in other compartments. It may
appear clinically that defecation disorders are
caused by posterior compartment dysfunction,
but at times a prolapse in other two compartments may cause pudendal stretch neuropathy
resulting in anal sphincter dysfunction. Similarly
a predominantly defecatory dysfunction with
disproportionate straining may be associated
with rectocele leading to genital laxity resulting in sexual dysfunction. Sexual dysfunction
in males may also be a manifestation of pelvic
fl oor dysfunction. Denonvillier’s fascia is intimately attached to the anterior mesorectal fat
but loosely attached to the seminal vesicles. In
defecatory dysfunction with disproportionate
straining with accompanying internal prolapse,
11 Pelvic Floor Dysfunction
147
intussusceptions, or rectocele, the deep parasympathetic nerves lying between the rectum and
prostate, seminal vesicle complex, may undergo
stretch neuropathy leading to sexual dysfunction.
Any of these can lead to disalignment of bladder outlet dynamics causing urinary symptoms.
Hence, it is clinically important to evaluate all the
three compartment- based symptoms, whenever
faced with a predominant symptoms from any
one compartment. The pelvic dynamics and tricompartmental association of various manifestations are unique as the pelvic nerves traveling to
sacral segments are more important for conveying
sensations. This is due to higher density of neurons traveling towards sacral segments. Sensory
traffi c is conveyed by small C fi bers and larger A
fi bers, both being unmyelinated and more vulnerable to stretch insult.
The major known causes for pelvic fl oor disorders include obesity, pregnancy, menopause,
childbirth, and chronic straining at stools and urination. Some patients have congenital weakness
of connective tissue and fascia.
11.3 Clinical Features
11.3.3 Voiding/Micturition Symptoms
Patient may present with h esitancy, low stream,
intermittency, straining, spraying/splitting of
stream, sense of incomplete evacuation, need to
immediately re-void, position-dependent micturition, dysuria, or retention.
11.3.4 Pelvic Organ Prolapse Symptoms
These include vaginal bulge, pelvic drag/pressure/
bulge, bleeding/discharge/infection unrelated to
menstruation, need for splinting/digitations, or low
backache (or period-like sensation).
11.3.5 Sexual Dysfunction Symptoms
Dyspareunia, superfi cial/introital dyspareunia, deep
dyspareunia, obstructed penetration, vaginal symptoms, or vague symptoms during coitus can occur.
The plethora of manifestations of pelvic fl oor
dysfunction defi es any comprehension of the
symptomatology (Haylen et al. 2010 ). For ease of
clinical evaluation and planning of treatment, the
symptoms may be classifi ed as below.
11.3.1 Urinary Continence
This may be stress, postural, urge, nocturnal, or
coital incontinence. These symptoms may occur
alone or in combination.
11.3.2 Bladder Storage/Sensation Symptoms
This may present as increased daytime frequency,
nocturia, urgency, overactive bladder syndrome,
increased bladder sensation, reduced bladder
sensation, or absent bladder sensation
11.3.6 Anorectal Dysfunction Symptoms
These include incontinence (involuntary fl atus or
fecal escape), rectal urgency, diminished rectal
sensation, rectal prolapse, perianal dyshygeine/
irritation, and symptoms of obstructed defecation
syndrome (ODS).
11.3.7 Pelvic Pain Syndrome/ Pudendal Neuralgia (Nantes Criteria)
Pain in the anatomical region of pudendal innervations that is worse on sitting is the classical
symptom. However, there is no waking at night
with pain and no sensory defi cit on examination.
Symptoms are relieved with pudendal block.
Recurrence with demonstrated pelvic fl oor dysfunction may occur.
148
B.B. Agarwal and P. Sivalingam
11.3.8 Erectile Tissue Denervation (S2–S4) Symptoms
These patients may present with sexual arousal
disorder, f emale orgasonic disorder,
devascularization- led pelvic fl oor dyssynergy,
and erectile dysfunction in males
11.4 Evaluation for Pelvic Floor Dysfunction
A patient with pelvic fl oor dysfunction should
undergo the standard clinical history and examination in addition to symptom-specifi c evaluation. Since pelvic fl oor dysfunction involves all
three compartments of the pelvic fl oor, thorough
history and clinical examination of the three
compartments are necessary. For a pelvic fl oor
colorectal surgeon, special emphasis needs to be
given to symptoms of pelvic organ prolapse and
those of anorectal dysfunction apart from complete urodynamic assessment.
11.4.1 Examination for Pelvic Organ Prolapse
Examination for pelvic prolapse should be done
with an empty bladder and in a position that the
patient reports as best for demonstration of prolapse, i.e., left lateral, supine, standing, or lithotomy. The hymen is the index point for prolapse
staging (Figs.
Stage 0: No demonstrable prolapse
Stage I: Prolapse ends more than 1 cm above the
hymen level
Stage II: Prolapse reaches within 1 cm or beyond
the hymen level
Stage III: Prolapse reaches more than 1 cm
beyond the hymen level
Stage IV: Complete eversion of total length of the
lower genital tract
With stage IV, pelvic prolapse can further be
defi ned as uterine/cervical prolapse, vaginal
vault/cult scar prolapse, anterior vaginal wall/
11.3 and 11.4 ).
Fig. 11.3 Stages of pelvic organ prolapse (Front view)
Fig. 11.4 Stages of pelvic organ prolapse (Lateral view)
bladder prolapse, or posterior vaginal wall/rectal
prolapse.
11 Pelvic Floor Dysfunction
Table 11.1 The Wexner score
Frequency
Type of incontinence Never Rarely Sometimes Usually Always
Solid 0 1 2 3 4
Liquid 0 1 2 3 4
Gas 0 1 2 3 4
Wears pad 0 1 2 3 4
Lifestyle alteration 0 1 2 3 4
Never 0; rarely, <1/month; sometimes, <1/week, >=1/month, <1/day, >=1/week, always, >=1/day
0, perfect; 20, complete incontinence
149
11.4.2 Evaluation for Anorectal Dysfunction
Achieving of perfect continence with perfect
evacuation is the aim of any treatment protocol.
Hence, due diligence is needed to clinically evaluate these two aspects of anorectal function
(Agarwal et al. 2011 ).
11.4.3 Evaluation for Anorectal Incontinence
Several scoring systems have been described. We
have found Wexner scoring system to be easy for
patient compliance (Table 11.1 ).
11.4.4 Evaluation for Functional Defecation Syndromes
Obstructed defecation syndrome (ODS) is a
functional disorder leading to defecatory dysfunction leading to sense of outlet obstruction in
the absence of any pathological fi ndings.
Constipation is a very common presentation to a
practicing surgeon. Any constipation that defi es
the existing understanding merits consideration
for evaluation for ODS. The constipation can be
of primary or secondary variety.
Three pathophysiological subtypes of primary
constipation have been described:
1. Constipation predominant irritable bowel syn-
drome (C-IBS)
2. Slow-transit constipation
3. Dyssynergic defecation
Before proceeding to evaluate primary constipation, a thorough history and examination must
be undertaken for all the known causes of secondary constipation.
11.4.4.1 Approach to Rule Out
Secondary Constipation
Secondary constipation may be due to several
factors in isolation or combination. These may be
lifestyle and diet-related factors, medical drug
intake-related factors, behavioral or psychiatric
factors, metabolic or endocrinal disturbances, or
neurological or other structural pathologies. A
problem-specifi c history and physical examination should be performed in such patients (level
of evidence IV: grade of recommendation B).
These should proceed as shown in Table 11.2 .
The drug intake history should include various
drugs as shown in Table 11.3 .
Abnormal colonic transit study will show
large amounts of stool and retention of more than
fi ve radiopaque markers mostly in the right colon
in a subject with constipation.
11.4.4.2 Ruling Out Constipation
Predominant Irritable Bowel
Syndrome (C-IBS)
Irritable bowel syndrome can present as
Constipation predominant, diarrhoea predominant or alternating diarrhoea with constipation.
Irritable bowel syndrome needs to be excluded
as per Rome II criteria. Rome II criteria defi ne
irritable bowel syndrome as symptoms in the
absence of any identifi able structural or metabolic disturbances to explain the symptoms.
These symptoms include abdominal discomfort/
pain of more than 12 weeks duration consecu-
150
Table 11.2 Etiology of acquired constipation
Lifestyle-related
causes
Diet
Pace of life
Medications
Weight loss/
anorexia/laxative
abuse
Infectious
etiology
Trypanosomiasis Neoplasms
Anatomic
abnormalities
Strictures
Adhesions
Volvulus
Rectal prolapse –
full thickness,
internal
Rectocele
B.B. Agarwal and P. Sivalingam
Functional abnormalities Physiological and
other abnormalities
Non-relaxing puborectalis
Slow-transit colonic
constipation
Megacolon/megarectum
Descending perineum
Diabetes mellitus
Hypothyroidism
Hypopituitarism
Porphyria
CNS trauma
Parkinson’s disease
Brain and CNS
tumors
Table 11.3 Medical causes and medicines leading to
constipation
Amiodarone Carboplatin
Antacids (e.g.,
aluminum)
Anticholinergics Erythropoietin
Anticonvulsants Filgrastim [granulocyte
Antidepressants Iron
Calcium channel blockers Lovastatin
Diuretics Mesalamine
Ganglionic blockers Narcotics/opiates
Antiparkinsonians Pravachol
Bismuth Sandostatin
Bromocriptine Valproic acid
Bulk laxatives with
inadequate hydration
Abnormal colonic transit study with large amount of stool
and retention of more than fi ve radiopaque markers mostly
in the right colon in a subject with constipation
Cholestyramine
colony-stimulating factor
(G-CSR)]
Vincristine
tively or nonconsecutively in the last 1 year along
with any two of the following three features:
1. Symptoms are relieved by defecation/passage
of fl atus.
2. Onset of symptoms is associated with a
change of stool frequency.
3. Onset of symptoms is associated with change
in stool form in the absence of laxative usage.
11.4.4.3 Ruling Out Dyssynergic
Defecation
In normal defecation there is increase in intrarectal pressure (IRP) with simultaneous fall in
Table 11.4 Types of dyssynergic defecation
Type IRP IAP RAG
I Rise (+IRP) Rise (+IAP) 0
II No rise (=IRP) Rise (+IAP) –ve
III Rise (+IRP) No fall or <20 % fall 0 or –ve
IV No rise (=IRP) Fall 0 or –ve
Normal Rise (+IRP) Fall (−IRP) +ve
intra- anal pressure. This recto-anal pressure
synergy leads to a propulsive recto-anal pressure
gradient (RAG). The pressure is estimated by
rectal manometry.
There are four types of dyssynergic defecation
as given in Table
11.4 .
11.4.4.4 Rule Out Slow-Transit Constipation
Slow-transit constipation needs specialized
investigation. It can be suspected on clinical
history by absence of normal bowel urge that is
experienced either getting up in the morning or
having a meal. If it is suspected, further evaluation should be done. Assessment of the speed
at which stool moves through the colon provides objective measurement of colonic transit.
Colon transit time can be measured by three
methods:
1. Radiopaque marker test: A single capsule
with 24 plastic markers is given for the patient
to ingest followed by a plain abdominal radiograph on day 6 (120 h later). Retention of at
least 20 % markers or more than six markers
after 120 h is indicative of slow-transit constipation, as shown in Fig.
11.5 .
11 Pelvic Floor Dysfunction
151
2. Radioisotope scintigraphy provides noninvasive quantitative evaluation of total and region
colonic transit. The isotope used is Indium III
or 99Tc and is ingested as a capsule that dissolves in the terminal ileum. Gamma images
are obtained at specifi c time intervals to give
an objective transit data.
3. Wireless motility capsule (WMC) provides a
noninvasive method of measuring gastric,
small bowel, and colonic transit times. In
addition to transit time, it provides the pH
changes and intraluminal pressure changes as
it courses through the gut. It is very sensitive
and specifi c modality but is not available commercially as of yet. A typical tracing obtained
from WMC is shown in Fig. 11.6 .
Obstructed defecation syndrome as a possibil-
ity is a consideration of exclusion, i.e., only after
excluding all above should a possibility of ODS
be clinically entertained. There are well-defi ned
Rome II criteria for clinical inclusion of
ODS. They defi ned ODS as constipation of at
least 12 weeks duration in the preceding 12
months with two or more of following features:
• Straining at defecation for more than 25 % of
defecations
• Passage of hard stools for more than 25 % of
defecations
• Sense of incomplete evacuation for more 25 %
of defecations
• Sense of outlet obstruction for more 25 % of
defecations
• Need for mechanical maneuvers like vaginal
splinting defecation, digital evacuation, or use of
implements for more than 25 % of defecations
• Less than three defecations per week
Fig. 11.5 Abnormal colonic transit study with large
amount of stool and retention of more than fi ve radiopaque markers mostly in the right colon in a subject with
constipation.
Horizontal axis: Time
Fig. 11.6 Assessment of
colonic transit with a wireless
motility capsule. GET gastric
emptying time, SBTT small
bowel transit time, CTT
colonic transit time. The
colonic transit time is delayed
in this subject (normal CTT,
<59 h)
Blue: temperature changes
Green: pH changes
Red: pressure changes
Once the constipation fi ts into the Rome II criteria for ODS, an objective scoring for ODS is
done using ODS scales. Various ODS scoring
systems have been defi ned. A patient-friendly
and easy to compile ODS score, i.e., constipation
and bowel activity score or CABAS score, is used
as shown in Table
11.5 .
152
Table 11.5 Surgical constipation score, constipation and bowel activity score (CABAS)
Frequency
Symptoms Never Rarely Sometimes Usually Always
Excessive straining 0 1 2 3 4
Incomplete evacuation 0 1 2 3 4
Use of laxatives 0 1 2 3 4
Digital pressure 0 1 2 3 4
Constipation 0 1 2 3 4
Never 0; rarely, <1/month; sometimes, <1/week, >=1/month, <1/day, >=1/week, always, >=1/day
A collective score of >5 is suspicious, >10 indicative, >15 diagnostic of ODS
B.B. Agarwal and P. Sivalingam
Fig. 11.7 Evaluation for surgical constipation. 1 uterus,
2 vagina, 3 anterior rectocele, 4 rectum
Even after complete evaluation all of the
above is being complied, it is prudent for the
surgeon to revise a checklist for suspected ODS
candidates as follows:
• The constipation has been refractory to medi-
cal management for more than 3 months.
• Complete gastrointestinal workup is normal
including colonoscopy.
• DRE to exclude omit has been done (Fig
to exclude perianal pathologies: gross and
dyssynergia or spasm and intraluminal
pathologies. Pelvic examination with DRE
should look for any excessive perineal
descent, rectocele, gross internal prolapse/
intussusceptions, mucosal prolapse, exterior-
ization of dentate line, genitourinary pro-
lapse, and any enterocele or bidigital
examination. In addition to conventional
DRE, a DRE in squatting position with the
clinician standing on the backside of the
11.7 )
Table 11.6 DRE observations in ODS
Exam
component
Inspection Inspect perineum under good light
Perineal
sensation and
anocutaneous
refl ex
Digital
palpation
Resting tone Normal, weak (decreased), or
Squeeze
maneuver
Pushing and
bearing down
maneuver
Technique: fi ndings and grading of
response(s)
Excoriation, skin tags, anal fi ssure,
scars, or hemorrhoids
Normal: brisk contraction of the
perianal skin, the anoderm, and the
external anal sphincter
Impaired: no response with the soft
cotton bud, but anal contractive
response seen with the opposite
(wooden) end
Absent: no response with either end
Tenderness, mass, stricture, or stool
consistency
increased
Ask the patient to squeeze and hold
up to 30 s
Normal, weak (decreased), or
increased
1. Push effort: normal,
weak(decreased), excessive
2. Anal relaxation: normal, impaired,
paradoxical contraction
3. Perineal descent: normal, excessive,
absent
patient can give a fairly good indication of
internal prolapse and intussusception.
Some of the important observations on DRE
are shown in Table 11.6 .
11.4.4.5 Imaging for Pelvic Floor Dysfunction with ODS
Imaging modalities like ultrasound, X-rays, and
MRI have been applied for assessment of pelvic