A prospective evaluation of occult disorders in obstructed defecation using the ''iceberg diagram''

OBJECTIVE: Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders, in order to alert the clinician of these and minimize failures. METHOD: One hundred consecutive constipated patients with OD symptoms, 81 women, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry and anal/vaginal ultrasound (US). Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultations. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded. RESULTS: Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three of them: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33%, respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most cases. Surgery was carried out in 14 (14%) patients. CONCLUSION: The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.     

Obstructive defecation. Diagnostic methods and treatment

Obstructive defecation is observed in approximately half of all patients with functional constipation. Functional constipation has been related to alterations in intestinal motility (slow transit constipation) and to pelvic floor disorders leading to obstructive defecation associated with anatomical alterations of the pelvic floor (rectocele, posterior perineal hernia, enterocele and sigmoidocele, internal rectal intussusception, occult mucosal prolapse, solitary rectal ulcer and descending perineum syndrome), or obstructive defecation without anatomical alterations (pelvic floor dyssynergy or anismus). The diagnostic methods used (history and physical examination, colonic transit time, balloon expulsion test, proctography, anorectal manometry and electromyography) are reviewed. Conservative medical treatment and the indications for surgical treatment and its results are also discussed.     

Surgical treatment of rectocele with the use of mesh implants by the obstructive defecation syndrome

The aim of current study was to evaluate in complex the effectiveness of transvaginal mesh implants in women with obstructed defecation (OD) syndrome based on the comparison of preoperative and postoperative results of objective diagnostic tools and quality of life parameters. Methods: from prospectively collected database of patients treated in our department those who were treated for OD by means of transvaginally placed mesh implants were chosen. The comparison of pre- and postoperative results of objective evaluation (prolapse stage according to POP-Q system, X-ray defecography - XR-DG and MRI defecography - MRI-DG) as well quality of life parameters (Wexner constipation score and validated Russian version of King's Health Questionnaire) was undertaken. Treatment effectiveness was evaluated using Сlinical Global Impression - Improvement (CGI-I) и Patient Global Impression - Improvement (PGI-I) scales. Results: In 2007-2011 40 women (mean age 51.8±10.7 years) underwent transvaginal pelvic floor reconstruction with mesh implants. All of them had ≤3 stage pelvic prolapse (POP-Q) and rectocele. Preoperative XR-DG and MRI-DG helped reveal rectocele >4 cm in 85 and 43% of women respectively, 68% of patients had cystocele and 18% - genital prolapse. In 21 case mesh implants for posterior pelvic floor reinforcement were used, in other cases mesh implants for total pelvic floor repair were placed. At a mean of 19 months after the operation manual examination revealed that 90% of women had 1 stage posterior pelvic proplapse, at XR-DG and MRI-DG significant reduction of rectocele size and depth of pelvic floor descent was noted. Besides that significant decrease in mean values of Wexner constipation score and King's health questionnaire was demonstrated. Though mean values of global treatment effectiveness assessment on CGI-I and PGI-I scales didn't significantly differ (2.13±0.85 и 2.68±1.42, р=0.06), the rate of agreement between these scales measured at each single case was very low (κ-0.154), this reflects that clinician has more positive perception of disease dynamics due to treatment than the patient. When mean values of dynamics in different indexes of King's health questionnaire were compared it was demonstrated that the index of quality of life influence (3.53±0.96) was significantly higher than the indexes of OD influense (2.63±1.08) and mechanical symptoms (2.58±1.04), this suggests that while the manifestations of OD syndrome are significantly improved patient quality of life doesn't change substantially. Conclusions: XR-DG is more specific than MRI-DG in evaluating the size of rectocele and the depth of pelvic floor descent; the use of mesh implants in surgical treatment of OD syndrome results in significant reduction of rectocele and prolapse stage in 90% of patients; clinical evaluation of treatment effectiveness based on objective examination is more optimistic than subjective perception of treatment results by the patient, this indicates that anatomic correction does not always lead to quality of life improvement.     

儿童盆底失弛缓综合征的诊断与治疗

目的探讨儿童盆底失弛缓综合征的诊断与治疗。方法对2001年11月至2004年11月间29例便秘患儿经结肠造影和直肠肛门测压诊断为盆底失弛缓综合征的临床资料进行回顾性分析。结果本组男13例,女16例,年龄(6．7±4．0)岁。所有病例经过结肠造影和直肠肛门抑制反射(RAIR)检查均排除先天性巨结肠症。29例患儿排便弛缓反射均为上升相(正常为下降相),RAIR正常(注气5～10 m1)21例,RAIR减弱(注气15～30 ml)8例；20例直肠初始感觉和最大耐受量均正常。明确诊断后采用排便诱导训练法,配合饮食调节、乳果糖或福松等缓泻剂软化大便等治疗1-2个月,痊愈4例,好转5例,有效率31．0%；开塞露依赖20例。有4例病史在1年以上、长期依赖开塞露的学龄期患儿做了肛门内括约肌和直肠平滑肌部分切除术(Lynn术),术后随访5—24个月,平均每1-2日自行排便1次,疗效满意；其中2例术后复查直肠肛门测压、肛管静息压及括约肌功能长度均较术前下降,排便弛缓反射仍为上升相。结论儿童盆底失弛缓综合征的诊断主要依据便秘病史、结合直肠肛门测压和结肠造影；排便诱导训练法等治疗不满意者可选择Lynn术。     

The role of biofeedback therapy in functional proctologic disorders.

BACKGROUND AND AIMS: The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation. MATERIAL AND METHODS: Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database. RESULTS: Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes. CONCLUSIONS: Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.     

Transperineal repair of rectocele with prosthetic mesh. A prospective study

PURPOSE: To assess the long term results of a transperineal repair of rectocele with a prosthetic mesh and the criteria for selecting the patients. METHODS: Twenty-five consecutive patients (median age: 60 years) with a symptom-giving rectocele have been operated upon. Indication for surgery was: an obstructed defecation (N = 22); a fecal incontinence (N = 1); a pelvic heaviness with dyspareunia (N = 1) or a severe rectal syndrome (N = 1). Patients were evaluated by physical examination and, preoperatively, by defecography and anorectal manometry. The rectovaginal septum was repaired, through a perineal approach, with an absorbable (N = 5) or non absorbable (N = 20) prosthetic mesh. Long term results were assessed after a median follow-up of 45 (range 12-120) months by physical examination and a standardized questionnaire. The presence of the following three symptoms was evaluated: feeling of incomplete emptying, prolonged and unsuccessful straining at stool, digital assistance. Outcome was considered as successful when none of these symptoms were present, as good when minor emptying difficulties persisted, as moderate when emptying difficulties were associated with straining, as a failure when the symptomatic triad was unchanged. A general satisfaction score was established. RESULTS: All the patients had the defect of the rectovaginal septum corrected. Four patients had a low residual rectocele associated, in two cases, with a rectal prolapse subsequently treated by a Delorme's operation. Outcome in patients complaining of obstructed defecation was considered excellent or good in 80% of patients, moderate in 9% and poor in 9%. Subjective scoring showed a significantly better result in cases of success. Among 11 incontinent patients, seven (63.5%) improved or regained full continence. Dyspareunia in three cases was corrected. Age, parity, digital assistance, previous gynecologic surgery, use of laxatives, size of rectocele, type of mesh, anatomical result of repair had no significant prognostic value. On the other hand, in patients with obstructed defecation, clinical and manometric signs of anal hyperactivity of the pelvic floor or anismus (N = 4) were significantly related to a poor result (P < 0.001). CONCLUSION: Surgical repair with a prosthetic mesh is an efficient therapy in patients with obstructed defecation and/or incontinence caused by a rectocele. Clinical and defecographic parameters have no influence on outcome. Preoperative manometric data may help in selecting patients. In case of anal hyperactivity or anismus, given the risk of functional failure, behavioral retraining must be considered as first-line treatment.     

Rectocele repair by anterolateral rectopexy: long‐term functional outcome

Introduction Rectoceles are frequently associated with feelings of pelvic discomfort and symptoms of obstructed defaecation (OD). Repair by a transvaginal or transanal approach might result in de novo dyspareunia in up to approximately 40% of the cases. This study was designed to investigate whether anterolateral rectopexy provides an adequate rectocele repair without dyspareunia as a side effect. Method A consecutive series of 33 women (median age 55 years; range: 37–73) with a symptomatic rectocele (depth > 3 cm) underwent anterolateral rectopexy. Before the operation, all patients underwent evacuation proctography (EP), which was repeated 6 months after the repair in all but three patients. A standardized questionnaire concerning pelvic discomfort, OD and dyspareunia was used to assess the long‐term effect of rectocele repair. The response rate was 91%. Results Six months after the procedure, EP revealed a recurrent or persistent rectocele in six patients (20%). However, in four of these six patients, the depth of the rectocele was < 3 cm. The median duration of follow‐up was 74 months (range: 2–96). Among the patients with an adequate repair, signs of OD persisted in 55%. None of the patients encountered de novo dyspareunia after the procedure. Conclusion Anterolateral rectopexy provides an effective tool for anatomical correction of rectoceles and does not result in dyspareunia as a side effect. However, despite adequate repair, OD persist in the majority of patients.     

Persistent symptoms of functional outlet obstruction after rectocele repair

BACKGROUND: Rectocele is frequently associated with constipation, but it is not known whether a causal relationship exists. OBJECTIVE: To determine the effect of rectocele repair on symptoms of constipation. METHOD: Thirty-five women (28-79 years) consecutively operated for rectocele repair (11 transanal approach and 24 transperineal) were included in the prospective study. Using a structured questionnaire, the following criteria for constipation were evaluated: (a) straining, (b) sensation of anal blockage, (c) sensation of incomplete evacuation, (d) manual manoeuvres to facilitate defecation, (e) stool consistency and (f) stool frequency. The evaluation was performed before and 1 year after rectocele repair. RESULTS: Before the operation all patients had two or more constipation criteria, including sensation of anal blockage. One year after the operation, the incidence of all symptoms significantly improved (from 3.9 +/- 0.2 to 1.9 +/- 0.3; P < 0.01). However, in 18 patients two or more criteria of constipation persisted, two patients presented one criterion, and only 15 patients became asymptomatic. Neither parity nor the type of surgical approach (endorectal vs transperineal) was related to the response to treatment. In eight patients who had a previous hysterectomy the result was significantly worse. CONCLUSION: In a considerable proportion of patients, constipation persists after rectocele repair, suggesting that these symptoms are related to an underlying dysfunction.     

特发性便秘197例临床分析

目的探讨特发性便秘的治疗。方法手术治疗特发性便秘１９７例,其中慢传输型便秘２４例,出口梗阻型便秘１７３例,后者包括直肠内套叠７５例,直肠粘膜脱垂５７例,耻骨直肠肌痉挛２５例,直肠前膨出１６例。慢传输型便秘２４例,行结肠次全切除术２０例,行左半结肠切除术４例。采用硬化剂注射治疗直肠粘膜脱垂５４例、直肠内套叠２３例。直肠粘膜缩缝术治疗直肠粘膜脱垂３例。改良式Ｏｒ’ｓ直肠悬吊治疗直肠内套叠５２例,其中加行乙状结肠切除术３１例,加行结肠次全切除术５例,女患者加行子宫悬吊３２例。直肠前膨出行直肠修补１６例。耻骨直肠肌痉挛２５例均采用生物反馈治疗。结果慢传输型便秘痊愈１００％（２４／２４）。直肠粘膜脱垂痊愈７９％（４５／５７）,好转２０％（１１／５７）,无效２％（１／５７）。直肠内套叠痊愈６３％（４７／７５）,好转２９％（２２／７５）,无效８％（６／７５）。直肠前膨出痊愈６９％（１１／１６）,好转３１％（５／１６）。耻骨直肠肌痉挛好转７２％（１８／２５）,无效２８％（７／２５）。结论慢传输型便秘手术治疗效果较好,而出口梗阻型便秘的疗效还有待进一步提高。     

Role of age, bowel function and parity on anorectocele pathogenesis according to cinedefecography and anal manometry evaluation

Objective  The study aimed to verify the role of parity, age and bowel function in the pathogenesis of anorectocele.
Method  A cross-sectional study was conducted regarding age, obstetrical history, Cleveland Clinic Constipation Score (CCCS), cinedefecography and anal manometry findings. Forty-five adult women complaining of obstructed defecation were evaluated; the median age was 46 years and median CCCS, 13. Fifteen patients were nulliparous and 23 multiparous (median parity 2). Eighteen had a history of episiotomy, fourteen delivered large babies and two had forceps-assisted delivery. Statistical analysis was performed using Spearman's correlation test and Fisher's exact test.
Results  Anal hypertonia was found in 14 (31.1%) patients, anal hypotonia in eight (17.8%), anismus in 13 (28.9%) and anorectoceles in 34 (75.6%) [median size 2.8 cm (0–6.4)]. There were no correlations between anorectocele and anal hypertonia ( P  = 0.7171), anismus ( P  = 0.4666), parity comparing nulliparous and multiparous patients ( P  = 1.000), episiotomy ( P  = 1.0000), forceps assistance ( P  = 1.0000), delivery of a large baby ( P  = 1.0000) anal resting pressure ( P  = 0.0883), anal voluntary pressure ( P  = 0.7327), parity ( P  = 0.4987) and age ( P  = 0.8603). There were correlations between anorectocele and the CCCS ( P  = 0.0082) and anal hypotonia ( P  = 0.0141).
Conclusion  Anorectocele is not correlated with parity, age, episiotomy, delivery of a large baby and anismus. It was more frequent in patients with severe constipation and less common in patients with anal hypotonia.     

Anismus in patients with normal and slow transit constipation

This study examined differences in anorectal function, with particular reference to anismus, which might explain why some patients with intractable constipation have slow and others have normal whole gut transit times. Twenty-four patients were studied; 13 with slow transit (all female, median age 32 years, range 16-52 years) and 11 with normal transit (eight women, three men, median age 37 years, range 21-60 years). Videoproctography with synchronous sphincteric electromyography and anorectal manometry was performed. There were no differences between the two groups, suggesting that slow transit constipation is not secondary to any abnormality in anorectal function and may therefore be a primary disorder of colonic motility. There was no correlation between electromyographic evidence of anismus (pelvic floor contraction on defaecation) and the ability of the patient to evacute the rectum or symptoms of obstructed defaecation. Electromyography findings alone can be misleading and should be related to proctographic evidence of incomplete rectal evacuation before functional anismus can be said to be present.     

PPH治疗出口梗阻型便秘的临床效果评价

为探讨PPH治疗出口梗阻型便秘的临床效果,回顾性分析PPH治疗出口梗阻型便秘患者400例的临床资料,其中直肠黏膜内脱垂型320例,直肠前突型80例。术后患者平均随访1年,复查排粪造影,评估手术疗效。结果显示,术后治愈392例,好转6例,无效2例,治愈率98．0％,有效率99．5％。结果表明,PPH治疗直肠前突型和直肠黏膜内脱垂型的出口梗阻型便秘,创伤小,恢复快,疗效肯定,并发症少。     

消痔灵注射加后位内括约肌松解术治疗直肠前突所致出口梗阻型便秘

为观察消痔灵注射加后位内括约肌松解术治疗直肠前突的可行性和优越性．将药物注射和合并多种肛门疾病联合治疗的方法治疗直肠前突32例。结果显示，32例中治愈25例。好转7例，有效率100％。结果表明，消痔灵注射加后位内括约肌松解术是治疗直肠前突和同时治疗多种肛门疾病的有效方法。     

Rectoceles: value of videodefaecography in selection of treatment policy

Videodefaecography allows identification of three different types of rectoceles: type I or digitiform rectocele, type II or rectocele with a lax rectovaginal septum, an anterior mucosal prolapse and a deep pouch of Douglas, and a type III in which a rectocele is associated with intussusception or even rectal prolapse. Furthermore, videodefaecography gave information on functional mechanisms resulting in incontinence or constipation. Surgical treatment should be tailored to the radiological and clinical findings: endoanal approach in type I, posterior colpomyorhaphy in type II and double abdomino-vaginal approach in type III. One hundred and fifty cases were prospectively treated according to this policy. Recurrence occurred in one out of 150 cases (1.3%). Incontinence was cured in 93% and constipation in 88%.     

会阴重建及肛门松解术治疗直肠前突引起的出口梗阻型便秘的疗效观察

为探讨会阴重建及肛门松解术治疗直肠前突引起的出口梗阻型便秘的疗效,回顾2008年6月至2010年8月行会阴重建及肛门松解术治疗的103例直肠前突患者资料,患者术前便秘症状严重,均符合罗马Ⅲ标准,多数依赖服用泻药排便。结果显示,经治疗,痊愈82例,好转17例,无效4例,总有效率为96．1％（99／103）。结果表明,行会阴重建及肛门松解术治疗直肠前突引起的出口梗阻型便秘安全可行,效果肯定。     

The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients

Introduction and hypothesis

Symptoms of obstructive defecation (OD) are common in women. Transperineal ultrasound (TPUS) has been used for the evaluation of defecatory disorders. The aim of our study was to determine the overall prevalence of anatomical abnormalities of the posterior compartment and their correlations with OD in women seen in a tertiary urogynecology clinic.

Methods

This is a retrospective study on 750 women seen at a tertiary urogynecological unit who had undergone a standardized interview, clinical examination, and 4D TPUS. Univariate and multivariate logistic regression analyses were undertaken to study the association between examination findings and symptoms of OD. This study was approved by the local human research ethics committee (Nepean Blue Mountains Local Health District Human Research Ethics Committee, IRB approval no. 13–16).

Results

The datasets of 719 women were analyzed. Mean age was 56.1 (18.4–87.6) years. Ninety-seven patients (13 %) reported fecal incontinence, 190 (26 %) constipation, and 461 (64 %) symptoms of OD. On examination, 405 women (56 %) were diagnosed with significant posterior compartment prolapse (POP-Q ≥ stage 2), which was associated with symptoms of OD (p?<?0.0001). On ultrasound, 103 (14 %) patients had an enterocele, 382 (53 %) a true rectocele and 31 (4.3 %) had rectal intussusception. On multivariate analysis true rectocele (p?=?0.003) and rectal intussusception (p?=?0.004) remained significantly associated with symptoms of OD.

Conclusion

Both symptoms of OD and anatomical abnormalities of the posterior compartment are highly prevalent in urogynecological patients. Ultrasound findings of a true rectocele and rectal intussusception are significantly associated with obstructed defecation.

     

自动痔疮套扎术(RPH)治疗Ⅱ、Ⅲ度直肠前突的临床观察

目的:探讨自动痔疮套扎术(RPH)治疗中度及中度以上直肠前突症(Rectocele)的临床价值.方法:应用自动痔疮套扎器对22例中重度直肠前突患者施行自动痔疮套扎术,观察手术疗效、并发症.结果:手术均一次成功,平均手术时间20 min,平均住院5 d,无严重并发症,有效缓解便秘症状.结论:自动痔疮套扎术(RPH)治疗直肠前突症,效果可靠,操作简单,术后痛苦轻微,并发症少.     

改良Block手术在治疗直肠前突致便秘的应用

目的观察改良Block修补术在直肠前突型便秘治疗中的疗效。方法将43例直肠前突型便秘病人(女性,年龄46岁-71岁,平均56岁)随机分成试验组和对照组。实验组21例采用改良Block修补术治疗,对照组22例采用经典的Block修补术治疗。观察两组病例的手术并发症、痊愈时间、排便情况、术后肛门外形与有无畸形、术后复发及手术治疗效果。结果实验组治疗后的有效率为85.7%,对照组为63.61%,它提示实验组明显优于对照组,两组相比有显著性差异(P     

PPH技术在出口梗阻性排便障碍中的应用(附60例分析)

目的：探讨PPH技术治疗出口梗阻性排便障碍的手术方法及疗效。方法：回顾分析了60例出口梗阻性排便障碍病例，其中直肠黏膜脱垂患者45例，直肠前突患者5例，直肠黏膜脱垂 直肠前突患者10例，均行PPH手术。结果：58例一次PPH术后症状明显缓解，治愈率96．7％。结论：PPH技术对于治疗出口梗阻性排便障碍具有明显疗效。