Simultaneous defecography and peritoneography in defecation disorders

A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel. PURPOSE: This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders. METHODS: Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed. RESULTS: All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas—a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele. CONCLUSIONS: Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.Supported by grants from Marianne and Marcus Wallenbergs Stiftelse, Kjell and Märta Beijers Stiftelse, and Karolinska Institutet's research funds.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Internal rectal intussusception—Fact or fancy?

PURPOSE: There is still considerable debate whether internal intussusception represents a functional disorder. We have reviewed our results in an effort to define its symptomatology and to assess defecography. METHODS: Rectopexy has been performed for internal intussusception in 37 patients. Eighteen had solitary rectal ulcer syndrome (SRUS), and 31 had anterior rectal wall prolapse. Defecography demonstrated anterior wall prolapse in 13, circular prolapse in 21, and no disorders in 3 patients. Pelvic floor function was normal. Follow-up varied from one to nine years. RESULTS: Twenty-six patients became asymptomatic. Anterior wall prolapses could not be palpated anymore. All SRUS lesions healed. Patients with SRUS (P<0.001) or circular prolapse (P<0.001) became significantly more asymptomatic. Results in patients with anterior rectal wall prolapse were significantly worse (P<0.001). CONCLUSIONS: Internal intussusception is a distinct functional rectal disorder. Its symptomatology and findings during physical examination are aspecific. Characteristic defecographic features and presence of SRUS are indications for surgery, provided pelvic floor function during straining is normal.     

Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction

Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil^® (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.Read at the meeting of The American College of Gastroenterology, San Francisco, California, October 1990.     

Enterocele is correctable using the Ripstein rectopexy

PURPOSE: About one-third of the patients with rectal prolapse or rectal intussusception have concurrent enterocele at defecography. The purpose of this study was to evaluate the effect of the Ripstein procedure on the concurrent enterocele and to study the outcome of the procedure with respect to the patients' symptoms. METHODS: Twenty-two patients with enterocele and either rectal prolapse or rectal intussusception at defecography were treated using the Ripstein procedure. Postoperatively, the patients were evaluated with clinical examination (22 patients) and defecography (16 patients). RESULTS: None of the patients had recurrence of enterocele, rectal prolapse, or intussusception at postoperative follow-up. Continence was improved in 15 of 16 incontinent patients. Emptying difficulties were unchanged in eight patients, improved in five patients, and had deteriorated in four patients. CONCLUSIONS: Enterocele is corrected by using the Ripstein rectopexy. Persisting defecation difficulties after the Ripstein procedure are unlikely to be secondary to enterocele. The Ripstein procedure can be an alternative in the treatment of enterocele, as a majority of these patients also have rectal prolapse or rectal intussusception.     

Rectopexy is an ineffective treatment for obstructed defecation

The symptoms of obstructed defecation have been attributed to rectal intussusception, and thus rectopexy has been advocated in the surgical management. In this study, patients with obstructed defecation underwent manometry and proctography before and after rectopexy. Seventeen patients (16 females and one male, mean age 51.6 years) were studied. Eleven underwent anterior and posterior fixation of the rectum and six had posterior fixation only. Preoperatively five patients demonstrated rectoanal intussusceptions. Fifteen had significant pelvic descent. No significant change in maximum resting pressure, maximum voluntary contraction, pelvic descent, or anorectal angle was seen postoperatively. In the initial follow-up, many patients had significant amelioration of symptoms. However, on longer follow-up (mean 30.8 months) only two had long-term improvement. The remainder had a poor clinical result in spite of complete resolution of rectal intussusception. Many reported a worsening of symptoms as reflected by an increase in tenesmus and stool frequency. In the two cases with a satisfactory result, both could empty the rectum completely and demonstrated rectoanal intussusception on preoperative evacuation proctography. In those with poor results, four had complete emptying and three had rectoanal intussusception. In conclusion rectopexy is an ineffective treatment for obstructive defecation in most patients.Read at the Tripartite Meeting, Birmingham, United Kingdom, June 19 to 22, 1989.Work is attributed to the Bristol Royal Infirmary, Bristol, United Kingdom.     

Internal rectal intussusception: Results of surgical repair

Twenty-four patients with obstructed defecation due to rectal intussusception diagnosed by defecography were treated with rectopexy either by the Wells technique (9 patients) or by Orr's operation (15 patients). After follow-up from one to eight years, defecography demonstrated disappearance of the intussusception in 22 patients. None of the patients were completely relieved of their symptoms. Nine (41 percent; 95 percent confidence limits: 21–64) were improved and 13 were unchanged (59 percent; 95 percent confidence limits: 36–79), with no difference between the two procedures. One patient with solitary rectal ulcer was improved, and the ulcer disappeared. Four patients with moderate preoperative incontinence became continent postoperatively, but obstructed defecation was only improved in two of these patients. It is concluded that rectal intussusception is probably a secondary phenomenon in patients with obstructed defecation and that a conservative attitude toward surgery should be adopted.     

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation

Aims The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC).Patients and methods Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured.Results Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation.Conclusion Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.     

Defecography

PURPOSE: This study was designed to analyze the frequency of different findings at defecography in patients with defecation disorders and see in what way the evaluation could be improved. METHODS: The reports of investigations in 2,816 patients were analyzed. RESULTS: Twenty-three percent of the investigations were considered normal. Thirty-one percent of the patients had rectal intussusception, 13 percent had rectal prolapse, 27 percent had rectocele, and 19 percent had enterocele. Twenty-one percent of the patients had a combination of two or three of these diagnoses. The combination of rectocele and enterocele was rare. The majority of patients with enterocele had other concomitant findings. Patients with or without abnormal perineal descent had similar frequencies of rectal prolapse, rectal intussusception, and enterocele. Rectocele was more common in patients with abnormal perineal descent. CONCLUSIONS: Defecography is valuable when investigating patients with defecation disorders. Pathologic findings were found in 77 percent of the patients. A standardized protocol should ensure a complete evaluation of defecography.Read in part at the 14th Biennial Congress of University Colon and Rectal Surgeons, Crete, Greece, October 25 to 29, 1992.     

Four-contrast defecography: Pelvic “floor-oscopy”

PURPOSE: This study was designed to determine the accuracy of physical examination (as judged by four-contrast defecography) for women with pelvic floor relaxation disorders. METHODS: Sixty-two women (mean age, 59 years) who had obstructed defecation or constipation, vaginal prolapse, urinary difficulty, or pelvic pain underwent four-contrast defecography. Oral, vaginal, bladder, and rectal contrast were administered selectively and fluoroscopy was performed. Radiographic findings were compared with physical examination diagnosis. RESULTS: Four-contrast defecography changed the diagnosis in 46 patients (75 percent); 26 percent of presumed cystoceles, 36 percent of enteroceles, and 25 percent of rectoceles were not present on defecography. Defecography also revealed unsuspected coexisting defects in addition to known abnormalities detected on physical examination. In contrast, when physical examination was negative for these defects, 63 percent of patients were found to have cystoceles, 46 percent to have enteroceles, and 73 percent to have rectoceles on four-contrast defecography. The discovery of Grade 2 or 3 unsuspected abnormalities was significant, especially so for enteroceles. For posterior vaginal eversions extending to or past the introitus, physical examination was accurate in only 61 percent. Physical examination of large anterior defects was more accurate, with 74 percent of patients being correctly diagnosed. CONCLUSIONS: Physical examination diagnosis of pelvic floor relaxation disorders is frequently inaccurate, especially for large vaginal eversions. Four-contrast defecography improves diagnostic accuracy, helps to identify all pelvic floor defects before surgery, and can assist with planning the correct operative approach.     

Translabial ultrasound in the assessment of pelvic floor and anorectal function in women with defecatory disorders

This article shows how modern ultrasound imaging can contribute to the investigation of patients with posterior vaginal wall prolapse, obstructed defecation, fecal incontinence and rectal intussusception/prolapse, conditions that should be similarly relevant and of interest to colorectal surgeons, gastroenterologists and gynecologists. Translabial/perineal ultrasound, a simple, universally available technique, may serve as a first-line diagnostic tool in women with posterior compartment prolapse and/or symptoms of obstructed defecation, largely replacing defecation proctography and magnetic resonance proctography. This has advantages for healthcare systems, since sonographic imaging is less expensive, non-invasive, less time-consuming and does not involve radiation exposure. However, there is a substantial need for teaching that remains unmet to date. This article illustrates in details the technique of translabial ultrasonography adopted by our unit and reviews the literature supporting this method of assessing pelvic floor and anorectal function in women with defecatory disorders.     

Streamlining the management of defecation disorders

Obstinate constipation is a frequent but elusive gastrointestinal symptom. Increased understanding of defecation physiology and recent availability of simple, ready-to-use tools have increased specificity of both diagnosis and treatment. This patient series includes over 700 severely constipated patients with over 70 percent overall therapeutic success. Cinedefecography, pelvic floor electromyography, and determination of rectoanal inhibitory reflex were performed with simple and readily available equipment to document outlet anatomy and dynamics. Colonic transit time was examined in patients whose defecography and electromyography results were nondiagnostic and/or whose response to medical management was suboptimal, using a commercially available marker capsule, followed by abdominal x-rays. Retention of markers throughout the colon suggested colonic hypomotility or inertia; rectosigmoid retention confirmed functional outlet obstruction. With careful history, physical examination, and exclusion of organic causes, orderly application of readily available techniques can afford rapid, objective, and anatomically specific evidence upon which treatment of disordered defecation may be based.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 15, 1989.     

Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management

Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung's disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery.     

Fecoflowmetry: A new parameter assessing rectal function in normal and constipated subjects

Fecoflowmetry is a new technique by which the fecal flow rate is studied through recorded curves representing the changes that occur in the flow against time. Fecal flow rate is the product of rectal detrusor action against outlet resistance. The technique was performed on 36 normal volunteers and 88 chronically constipated patients. Simultaneous recording of the fecal flow rate and intra-abdominal and rectal neck pressures were performed. A water or paste enema was given to the individual. Upon feeling the desire to defecate, he or she was placed on a fecoflowmeter commode and was asked to defecate. Evaluation of the obtained defecation flow curve comprises the reporting on the defecated volume, flow time, mean and maximum flow rates, time to maximum flow, and shape of the curve. In the 88 constipated patients, two fecoflowmetric patterns were recognized: nonobstructive (inertia) and obstructive. They differ from each other in parameters and curve configuration. The defecated volume as well as mean and maximum flow rates were lower in outlet obstruction than in the inertia type, whereas flow time and time to maximum flow were longer. The ascending limb in the obstructive-type curve rose less steeply than in inertia; the curve had a long plateau, and the descending limb sloped more gradually. To conclude, fecoflowmetric studies could differentiate between defecation of normal and constipated subjects, and in the latter between the obstructive and inertia types of constipation. The technique was developed to simulate natural defecation. It provides quantitative and qualitative data concerning the defecation act. The technique is simple, easy, noninvasive, and nonradiologic. It can be used as a screening tool in defecation disorders.     

Videoproctographic assessment after restorative proctocolectomy

Videoproctography was performed in 40 patients after restorative proctocolectomy to evaluate pouch emptying, anopouch angle, and pelvic floor movement in relationship to functional outcome. Results were compared between the two different pouch designs tested and a control group of 26 patients who had an intact rectum. There was no difference in emptying between the two pouch designs or compared with the control subjects. Emptying did not influence either the frequency of defecation or patient soiling rate. The presence of an anal stricture was associated with poor emptying in each case in the pouch group. Anorectal angle was no different between the different pouch designs or compared with the control group at rest, during pelvic floor contraction, or attempted defecation. A similar finding was obtained with anorectal angle position and movement during pelvic floor contraction and attempted defecation in both pouch design groups and when compared with normal rectum. This study shows that the only factor that is consistently associated with poor pouch emptying is the presence of an anal stricture.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Excellent outcome using selective criteria for rectocele repair

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16–78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1–8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5–64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test,P < 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.No reprints are available.     

Anorectal dysfunction in patients with urologic disturbance due to multiple sclerosis

Anorectal function was evaluated in 11 patients with voiding dysfunction due to multiple sclerosis. In six patients with constipation, three also had symptoms of obstructed defecation and one patient was incontinent due to stercoral diarrhea. One patient was only fecal incontinent and one patient had obstructed defecation as the only symptom. Three patients had no anorectal symptoms. Anal manometry in the women compared with a control group revealed significant lower anal resting and squeeze pressures, although no significant difference of rectal sensation to distention with air was found. Pudendal nerve terminal latencies were obtained in seven patients and were all normal. In four patients latency could not be demonstrated due to poor contraction of the sphincter on stimulation of the pudendal nerve. Two of these patients were incontinent and two had both constipation and obstructed defecation. It is concluded that patients with voiding symptoms due to multiple sclerosis often reveal anorectal symptoms or motility disorders. Although anal sphincter function is reduced, fecal incontinence is not prevalent in this group. The reason for this lies probably in the fact that many of the patients are constipated, thus securing fecal continence.     

Defecography in patients with anorectal disorders

To evaluate the results and clinical impact of defecography in patients with anorectal disorders, 100 results of defecographic examinations from 92 patients were reviewed. The defecographic results were screened for the anorectal angle, defined both at rest and during straining, perineal descent, and abnormalities of the rectal configuration during straining. Anal manometry, saline infusion test, rectal capacity measurement, and anal electromyography (EMG) were also performed. There was a significant difference (P<0.001) both at rest (22°) and during straining (12°) between the two anorectal angle measurements. Incontinent patients had a larger anorectal angle, both at rest and during straining, than continent patients (P<0.04), but with a large overlap. The anorectal angle was not influenced by gender or age. An abnormal rectal configuration was found in 62 defecographic examinations. From the 8 patients with rectopexy performed for a large rectocele or intussusception, incontinent patients with an intussusception had the best results. In four patients, anal EMG showed an increased activity of the external sphincter during straining. Two of these four patients had abnormal defecograhic results. No correlations were found between anorectal angle and the other function tests. In conclusion, the anorectal angle lacks clinical relevance. In patients with defecation problems, defecography may be indicated whenever other investigations (physical examination, anal manometry, anal EMG) have excluded local pathology or a spastic pelvic floor syndrome. In these situations, defecography could detect an intussusception, which could easily be treated with rectopexy.Read in part at the meeting of the Dutch Society of Gastroenterology, Noordwijkerhout (The Netherlands), March 25 to 26, 1988.     

Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders

OBJECTIVE: Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion. METHODS: We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4-2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography. RESULTS: Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and perineal descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive perineal descent in two patients. CONCLUSIONS: Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.     

The influence of age on posterior pelvic floor dysfunction in women with obstructed defecation syndrome

Background

Knowledge of risk factors is particularly useful to prevent or manage pelvic floor dysfunction but although a number of such factors have been proposed, results remain inconsistent. The purpose of this study was to evaluate the impact of aging on the incidence of posterior pelvic floor disorders in women with obstructed defecation syndrome evaluated using echodefecography.

Methods

A total of 334 patients with obstructed defecation were evaluated using echodefecography in order to quantify posterior pelvic floor dysfunction (rectocele, intussusception, mucosal prolapse, paradoxical contraction or non-relaxation of the puborectalis muscle, and grade III enterocele/sigmoidocele). Patients were grouped according to the age (Group I?=?patients up to 50?years of age; Group II?=?patients over 50?years of age) to evaluate the isolated and associated incidence of dysfunctions. To evaluate the relationship between dysfunction and age-related changes, patients were also stratified into decades.

Results

Group I included 196 patients and Group II included 138. The incidence of significant rectocele, intussusception, rectocele associated with intussusception, rectocele associated with mucosal prolapse and 3 associated disorders was higher in Group II, whereas anismus was more prevalent in Group I. The incidence of significant rectocele, intussusception, mucosal prolapse and grade III enterocele/sigmoidocele was found to increase with age. Conversely, anismus decreased with age.

Conclusions

Aging was shown to influence the incidence of posterior pelvic floor disorders (rectocele, intussusception, mucosa prolapse and enterocele/sigmoidocele), but not the incidence of anismus, in women with obstructed defecation syndrome.     

Abdominal rectopexy for complete prolapse: Prospective study evaluating changes in symptoms and anorectal function

The effect of abdominal rectopexy on bowel function is difficult to assess in retrospective studies because preoperative bowel habit cannot be determined accurately. This study examined bowel symptoms and physiologic tests of anorectal function prospectively in 23 patients before and at three months after rectopexy. Rectopexy eliminated complete prolapse in all and stopped bleeding in 16 of 18 patients. Incontinence improved significantly. Constipation (<3 bowel actions per week or straining for more than 25 percent of defecation time) was relieved in 4 of 11 affected patients but developed in 5 of the 12 who were not constipated preoperatively. Since the median bowel frequency was 21 motions per week before surgery and 17 afterward, the main determinant of constipation was straining. Abdominal pain was relieved after rectopexy in 6 of 12 patients but developed in 3 of 13 who were pain-free before surgery. Three patients (13 percent) had a first-degree relative with rectal prolapse. Perineal descent decreased significantly. Maximal anal resting pressure increased significantly, but this did not correlate significantly with improved continence. Twenty-one patients (91 percent) could expel a 50-ml balloon preoperatively; 18 of those 21 could still do so postoperatively. The two patients who could not expel the balloon preoperatively were able to do so postoperatively. This study shows that rectal prolapse is associated with profoundly abnormal defecation and abdominal pain. While abdominal rectopexy improved continence, it may improve or worsen other bowel symptoms, including constipation.Support for this study was received from the Imperial Cancer Research Fund, ICI Pharmaceuticals (SA) Ltd., the St. Mark's Research Foundation, and the Medical Research Council of South Africa.