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400
S. Maslekar and D.G. Jayne
or intussusception. Nevertheless, papers that have reported on bowel function suggest
it improves in up to 90%. Durability following repair is still uncertain, as there are few
long-term studies, but reported rates as high as 80% have been described [ 35 ] .
There are two RCTs comparing transvaginal approaches with transrectal repair
[
36, 37 ] . Both studies favored the transvaginal approach in terms of durability and
improved vaginal symptoms. The bowel symptoms were equally good.
In an effort to improve durability, some advocate the use of a mesh [ 38 ] , but the
evidence for this is controversial with RCT evidence suggesting no difference [ 38 ] .
The risk of mesh erosion, which occurs in up to 25%, should be borne in mind.
Recent interest in discrete fascial repair rather than nonspecifi c repair in the hope
of reducing dyspareunia does not appear to be as effective in resolving ODS symp-
toms and perineal descent associated with vaginal vault prolapse [ 39 ] .
27.5.2.2 Transperineal
A transperineal approach allows both levaroplasty as well as sphincter repair if
appropriate. In addition, the procedure can be combined with the insertion of a syn-
thetic mesh. The main disadvantage of this procedure is the high incidence of wound
dehiscence and the risk of dyspareunia. It is impossible to correct internal intussus-
ception which might alleviate ODS.
27.5.2.3 Transrectal
Repair of the rectal side of a rectocele has been advocated in an attempt to improve
bowel symptoms. Transrectal approaches have the advantage of allowing augmen-
tation of the ventral wall as well as mucosal resection of both the anterior and pos-
terior rectal mucosa and plication of the lax muscular wall of the lower rectum.
However, access is diffi cult, and the procedure is not appropriate for the manage-
ment of high rectoceles. In addition, there is a risk of anal incontinence, presumably
due to excessive anal dilation during the procedure. Improvement of anorectal
symptoms ranges from 38% to 100% [ 35 ] , but these deteriorate with time.
Stapled Transanal Rectal Resection
The STARR procedure is a relatively new transanal technique. It was fi rst described
by Antonio Longo, based on observations following stapled hemorrhoidopexy in
patients with obstructed defecation and internal rectal prolapse [ 40 ] . It is proposed
that excessive straining at defecation leads to laxity and thinning of the distal rec-
tum, which in turn results in internal rectal prolapse and obstructed defecation.
Transanal resection of the prolapse together with any associated abnormality (recto-
cele and internal rectal prolapse) was advocated to correct the anatomy and restore
normal evacuatory function. In addition, distal rectal resection results in a “-pexy,”
which at least partially corrects any perineal descent.
401
27 The Management of Constipation
STARR was originally described using two fi rings of a PPH-01
®
stapler
(Procedure for Prolapse and Hemorrhoids, PPH, Ethicon Endosurgery, Cincinnati,
USA). Subsequently, a specially designed curved stapling device became available,
the Contour30 Transtar
®
(Ethicon Endosurgery, Cincinnati, USA). Both PPH-
STARR and Transtar techniques appear to produce similar results, namely, a full-
thickness, circumferential resection of the distal rectum together with any internal
prolapse and rectocele.
In PPH-STARR, the prolapsing distal rectum is resected as separate anterior and
posterior specimens, using two PPH-01 staplers (Fig. 27.2a, b ). In the Transtar tech-
nique, the internal prolapse is resected with sequential fi rings of the Contour30
a
c
d
b
Fig. 27.2 ( a , b ) Stapled transanal rectal resection (STARR). ( c , d ) Transtar procedure. In the
STARR procedure, traction sutures are applied to the anterior prolapse ( a ) to bring it into the hous-
ing of the PPH stapler ( b ). The prolapse is resected and the procedure repeated for the posterior
prolapse, resulting in a circumferential full-thickness resection. In the Transtar procedure, traction
sutures are placed circumferentially around the apex of the prolapse ( c ). Circumferential full-
thickness resection of the prolapse is performed by sequential fi ring of the Contour 40 stapler ( d )
(No copyright required)
402
S. Maslekar and D.G. Jayne
stapler (Fig. 27.2c, d ). The advantages claimed for Transtar include an ability to
tailor the extent of resection, as there is no stapler housing to limit the amount of
tissue to be resected, better visualization of the resection, and a lack of the lateral
“dog-ears” inherent in the PPH-01 method. Whether a tailored resection and lack of
lateral “dog-ears” results in improved outcomes is debatable, with current evidence
seeming to suggest this may not be the case [
41 ] .
The evidence in support of STARR is increasing, with reports of several personal
series, randomized trials [ 42, 43 ] , and a large European Registry [ 44 ] . Initial con-
cerns regarding safety, and in particular the risk of septic complications and rec-
tovaginal fi stulation, have not been borne out in the larger studies. Overall morbidity
is in the region of 30%, which includes all minor and major complications. The most
frequently observed complications include anorectal pain (7.1%), urinary retention
(6.9%), bleeding (5%), septic events (4.4%), and staple line complications (3.5%)
[ 44 ] . The current evidence suggests a short-term effi cacy in the region of 80%, with
signifi cant improvements in obstructed defecation scores and health-related quality
of life. However, concern has been expressed regarding the rate of postoperative
defecatory urgency, which can affect 30% or more of patients postoperatively, at
least on a temporary basis. A reasonable proportion of these patients will have suf-
fered urgency and poor sphincter function preoperatively, although some instances
of de novo urgency are also apparent. With appropriate patient investigation and
selection, it should be possible to minimize this unwanted occurrence [ 45 ] .
27.5.2.4 Abdominal Approach
Abdominal rectopexy for ODS involves mobilization of the rectum with or without
placement of a mesh. It is effective in the treatment of full-thickness rectal prolapse,
and as a consequence has been tried for rectal intussusception. Unfortunately, the pro-
cedure often results in constipation (probably as a result of autonomic nerve damage),
unless combined with sigmoid resection, which signifi cantly increases morbidity.
With the introduction of laparoscopic techniques, the procedure was modifi ed to
limit posterior dissection of the rectum and minimize autonomic denervation [ 46 ] .
The indication for laparoscopic ventral rectopexy was subsequently extended to
internal rectal prolapse for obstructed defecation [ 47 ] .
The procedure involves a resuspension of the prolapsing distal rectum and any
associated rectocele or enterocele using a prosthetic mesh (Fig. 27.3 ). The right
pararectal gutter is dissected from the sacral promontory and extended across the
anterior peritoneal refl ection of the pouch of Douglas, opening up the rectovaginal
septum (rectoprostatic in the male). The rectovaginal septum is dissected as far as
the pelvic fl oor, and a strip of mesh is sutured to the anterior rectal wall and the
posterior vaginal vault. The mesh is put under tension and sutured or tacked to the
bony sacral promontory, in effect, providing resuspension and support to the pos-
terior and middle pelvic fl oor compartments. The peritoneum is reconstituted in
403
27 The Management of Constipation
an attempt to minimize adhesive small bowel complications. If necessary, a
“Y”-shaped mesh can be used to provide simultaneous support to the anterior
vaginal vault and bladder.
The results of laparoscopic ventral rectopexy for internal rectal prolapse are dif-
fi cult to interpret due to heterogeneity in patient selection and operative technique.
Short-term results suggest an improvement in both incontinence and constipation
[ 47 ] , and avoidance of posterior rectal mobilization appears to protect against new
onset evacuatory problems [ 48 ] .
27.5.3 Repair of Intussusception
Some of the techniques for repair of an internal intussusception, such as ventral
rectopexy and STARR, have already been covered. Other procedures include the
internal Delorme’s procedure [ 49 ] . This is technically very demanding and concer-
tinas rather than straightens the rectum, which may be a disadvantage. As men-
tioned earlier, a technique of perineal external pelvic suspension using collagen
strips (the EXPRESS procedure) has been proposed as a more anatomical procedure
with less morbidity than abdominal surgery [ 33 ] .
a
c
d
b
Fig. 27.3 Operative steps in laparoscopic ventral rectopexy. ( a ) Dissection of the rectovaginal
septum. ( b ) Suturing mesh to anterior rectal wall. ( c ) Securing mesh to fascia at sacral promontory.
( d ) Reconstruction of pelvic peritoneum to cover the mesh
404
S. Maslekar and D.G. Jayne
27.6 Summary
Constipation is a common and chronic disorder with few effective treatment strate-
gies. There is a clear lack of high-quality evidence to support the use of any one of
the numerous available treatment options. We suggest a simple algorithm for the
management of constipation, with particular focus on idiopathic slow transit and
obstructive defecation disorders (Fig. 27.4 ).
Chronic constipation
Clinical examination & investigation
to exclude secondary causes
Conservative treatment
(bulking agents, laxatives,
enemas etc.)
Failure Success
Continue
Mixed
Functional Mechanical
Obstructed defaecation
Further investigation
(transit studies, proctography,
anorectal physiology)
Slow transit constipation
Consider:
• Biofeedback
therapy
• Botox
• Rectal
irrigation
Consider:
• STARR
• Lap ventral
rectopexy
Consider:
• Biofeedback therapy
• Rectal irrigation
• Sacral nerve
modulation
• Prucalopride
• Subtotal colectomy &
IRA
Fig. 27.4 Suggested algorithm for investigation and treatment of patients with chronic
constipation
Key Points
Careful history examination and investigation to categorize constipation •
into four subgroups
Institute conservative measures including:•
General measures –
Drugs –
405
27 The Management of Constipation
Retrograde colonic lavage –
Biofeedback –
Consider surgical options for slow transit constipation:•
Sacral neuromodulation –
ACE procedure –
Resectional surgery as a last resort –
Consider surgical options for obstructed defecation:•
Botox for anismus –
Transvaginal, transperineal, transanal (STARR), or transabdominal –
(laparoscopic ventral rectopexy) repair of a rectocele
Transanal (STARR) or transabdominal (laparoscopic ventral rectopexy) –
repair of an intussusception
Case Scenario Answers
The clinical history and the investigations are consistent with slow transit
constipation. It would be useful to confi rm that the colon is of normal caliber,
and this may be evident from the transit marker studies. A megacolon or rec-
tum would potentially be less likely to respond to conservative management,
which would be the fi rst line of therapy.
It is important to analyze carefully that the patient is taking appropriate mea-
sures to help with her bowel function. Is she eating adequate fi ber? Does she
avoid fi ber because it simply makes her bloated? Soluble fi ber may reduce
bloating while regulating bowel function more effectively. She may require
supplementary fi ber.
Is she drinking enough, is she overweight or exercising enough?
Are there psychological issues or logistical issues (i.e., access to a private
toilet)?
Has she tried adequate laxatives or used enemas/suppositories?
Once lifestyle is optimized persisting constipatory symptoms may require
more intense input. Biofeedback may not be benefi cial in all cases but does no
harm. The support offered by such services and the opportunity to analyze
lifestyle in detail is often helpful to the patient and the treating physician.
Retrograde colonic lavage may be time-consuming and hence inappropriate
for a young woman but should be explored.
Alternative drug therapy may be considered. Prucalopride could be effective
in this patient subgroup. A test dose of 2 mg/day should be prescribed for
4 weeks. If effective, the drug may need to be continued indefi nitely.
Only after all of these conservative managements have been considered should
surgery be contemplated. The patient needs to be counseled carefully at this
stage, and the options with their various benefi ts and potential complications
discussed carefully.
406
S. Maslekar and D.G. Jayne
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considered fi rst. However, the patient should be aware that the procedure involves
implantation of an artifi cial device and may require regular adjustments to achieve
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407
27 The Management of Constipation
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409
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_28, © Springer-Verlag London Limited 2012
28.1 Introduction
Solitary rectal ulcer syndrome (SRUS) is a benign functional bowel disorder. It was
fi rst described by Madigan and Morson from St. Mark’s Hospital in 1969 [ 1 ] . The
term is misleading as none or multiple ulcers may be present. Etiological theories
have included hormonal, behavioral, structural, and mechanical causes.
Unfortunately, there is very little defi nitive evidence regarding not only the etiology
but also the treatment of this condition.
It does seem likely that the condition is caused by a combination of a behavioral
bowel disorder involving chronic straining, combined with a predisposition for pel-
vic organ prolapse, most often manifested in some form of rectal prolapse which may
be internal or external, mucosal, or full thickness.
M. Farmer , FRCS
Department of General Surgery , University Hospital North Staffordshire ,
Princes Rd. , Stoke-on-Trent, North Staffs , ST4 7LN , UK
e-mail: rsyadtrh@aol.com
Chapter 28
Solitary Rectal Ulcer Syndrome and Pelvic Pain
Martin Farmer
Case Scenario
A 50-year-old female is referred to you by a local urogynecologist with
chronic pelvic/perineal pain. He states he has excluded all possible gyneco-
logical causes with a normal MRI, normal urodynamics and cystoscopy, and
a normal laparoscopy. The patient has always had a tendency to constipate
and strain at stool. On examination, she has marked perineal descent but oth-
erwise the examination was normal. How would you manage this patient?
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