Anorectal ergotism: another cause of solitary rectal ulcers

Anorectal ulceration was observed in 6 patients who excessively used suppositories containing ergotamine tartrate. The mucosal lesions of the rectum resembled those observed in the "solitary rectal ulcer syndrome." However, characteristic features of ergotamine-induced ulcers are absence of a mucosal prolapse, lack of a history of constipation, and rapid healing after discontinuation of the drug. Furthermore, the rectal lesion may be associated with anal ulceration, which occasionally presents as the only clinical manifestation of "anorectal ergotism."     

Anorectal stenosis in patients with prolonged use of suppositories containing paracetamol and acetylsalicylic acid

We report five cases in which anorectal stenosis was associated with chronic administration of suppositories containing paracetamol and acetylsalicylic acid. All patients were females taking suppositories for chronic migraine. Patients experienced anal pain, tenesmus, fecal incontinence, and, in two cases, intestinal obstruction. Lesions were characterized by a severe circular narrowing of the distal rectum with superficial ulcerations. Radiographs demonstrated the presence of sinus-tract-like formations in the diseased segment and thickening of the rectal wall. Histologic examination showed signs of chronic inflammation with deep ulcerations associated with obliteration of the lamina propria by a fibromuscular proliferation, as was described in the solitary ulcer syndrome of the rectum. Rectal administration of suppositories was discontinued in all the patients. Two patients were improved by anorectal dilatation, but the remaining three required a left proctocolectomy with subsequent coloanal anastomosis. The use of such suppositories must be restricted.     

Rectal stenosis following the use of suppositories containing paracetamol and acetylsalicylic acid

The authors report the case of a 74-year-old woman presenting a rectal stenosis that arose after the prolonged use of suppositories containing an association of paracetamol and acetylsalicylic acid (Perdolan). On the basis of a review of the literature, the clinical, histological, and radiological features are discussed.     

Anal Sphincter Morphology in Patients With Full-Thickness Rectal Prolapse

PURPOSE: The aim of this study was to assess the morphologic change of the anal canal in patients with rectal prolapse. METHODS: The endoanal ultrasound scans of 18 patients with rectal prolapse were compared with those of 23 asymptomatic controls. The thickness and area of the internal anal sphincter and submucosa were measured at three levels. RESULTS: Qualitatively, patients with rectal prolapse showed a characteristic elliptical morphology in the anal canal with anterior/posterior submucosal distortion accounting for most of the change. Quantitatively, internal anal sphincter (IAS) and submucosa (SM) thicknesses and area were greater in all quadrants of the anal canal (especially upper) in patients with rectal prolapse compared with controls. There was statistical evidence (in a regression model) of a relationship between increases in all measured variables and the finding of rectal prolapse. CONCLUSIONS: The cause of sphincter distortion in rectal prolapse is unknown but may be a response to increased mechanical stress placed on the sphincter from the prolapse or an abnormal response by the sphincter complex to the prolapse. Patients found to have this feature on endoanal ultrasound should undergo clinical examination and defecography to look for rectal wall abnormalities.     

Manometric evaluation of rectal prolapse and faecal incontinence.

Sixty-three patients with complete rectal prolapse and/or faecal incontinence have undergone anal manometry and the results have been compared with an equal number of age- and sex-matched controls. Maximal basal pressure (MBP) and maximum squeeze pressure (MSP) were measured before and at four months and a year after treatment. The anal pressures of normal subjects are presented. Patients with rectal prolapse alone had normal anal pressures, whereas patients with incontinence with or without prolapse had significantly lower basal and squeeze pressures than controls. Successful surgical treatment of prolapse or incontinence did not produce significant change in anal canal pressures, whereas the combination of pelvic floor exercises and a continence aid was associated with a significant rise in MSP.     

腹腔镜下直肠脱垂悬吊固定治疗直肠全层脱垂32例临床疗效分析

目的探讨腹腔镜下经腹直肠脱垂悬吊固定治疗直肠全层脱垂的临床疗效。 方法回顾性分析南京中医药大学附属南京中医院肛肠科从2010年6月至2018年3月采用腹腔镜下经腹直肠脱垂悬吊固定术治疗中重度直肠全层脱垂32例患者的资料。采用肛门直肠压力测定、Wexner便秘评分及Wexner肛门失禁评分指标评价术前、术后1个月、3个月及随访期间患者的肛门功能。 结果32例直肠全层脱垂患者均在全麻下顺利完成腹腔镜下经腹直肠脱垂悬吊固定手术,无中转开腹。手术时间平均（115.94±23.34）min;术中出血量平均（20.16±10.74）mL。住院时间平均（12.84±2.10）天。术后当天的VAS评分平均（4.56±1.08）分。32例患者腹部切口愈合良好,无肠梗阻、腹腔感染等并发症。32例患者中成功随访31例,随访成功率96.97%（31/32）,随访时间为平均（47.56±31.29）个月。31例患者,在术后6个月以上的痊愈率为90.32%（28/31）。患者术后1个月、3个月及随访期Wexner便秘评分（t=6.135,10.448,10.348;均P<0.05）和患者术后1个月、3个月及随访期Wexner肛门失禁评分（t=7.211,7.789,10.089;均P<0.05）均较术前改善。12例直肠脱垂合并肛门失禁患者术后3月肛管静息压（t=-3.477,P<0.05）和肛管最大收缩压（t=-2.311,P<0.05）均高于术前。 结论腹腔镜下经腹直肠脱垂悬吊固定治疗直肠全层脱垂术后肛门直肠功能改善显著。     

Proktitis aus Sicht der Proktologie*

Proctitis may cause anal bleeding, anal mucus secretion, diarrhea, urge incontinence, pain at defecation, etc. At digital rectal examination a thickened mucosal lining may be palpated and blood is found on the examination glove. At endoscopy erosive or ulcerative lesions are found that bleed easily on contact. Also polyp-like or even tumor-like lesions, telangiectasias and atypical fistulas can be seen. The symptoms and the findings on examination are quite often unspecific; a detailed history of the patient is most important in the work-up for the differential diagnosis. Serological and microbiological examinations should be done as well as biopsies (except for radiation proctitis). Proctitis may occur after applying external agents that cause chemical, thermal as well as pharmaceutical reactions in the rectum. Proctitis may occur after fecal diversion. Ischemic proctitis causes severe pain and fecal incontinence and may occur postoperatively, after shock/anaphylaxis, etc. The solitary rectal ulcer (syndrome) has a more or less mechanical etiology and shows clearly defined pathohistological lesions. It often occurs in women with outlet obstruction and/or rectal, mucosal or hemorrhoidal prolapse. Except for rectal prolapse, treatment of the solitary rectal ulcer is not always simple or successful. The same applies to radiation proctitis that may occur after radiotherapy. Radiated anorectal tissue regenerates slowly or not at all. Therefore invasive procedures should not be performed because of the high risk for the development of ulceration or fistula. Treatment of radiation proctitis is not always simple and it does not have a high level of evidence. In most cases therapy should be performed individually, according to the severity of complaints.     

Frequency of anal incontinence and results of pelvic viscerography in 291 women with pelvic organ prolapse

OBJECTIVES: To determine the prevalence of anal incontinence in a population of 291 women with pelvic organ prolapse and evaluate the results of pelvic viscerogram in this situation. MATERIALS AND METHODS: Each patient answered a standardized questionnaire on medical, obstetric and surgical past histories and answers were logged in a database. The viscerograms were performed by a single specialized radiologist. RESULTS: All patients but one were parous. The prevalence of anal incontinence was 26.1%. Stress urinary incontinence and urge urinary incontinence were significantly associated with anal incontinence. No obstetric or surgical risk factor for anal incontinence was demonstrated. Viscerography demonstrated rectoceles (n=86, 29.1%), enteroceles (n=77, 26.5%), cystoceles (n=174, 59.8%), and intra-anal rectal prolapse (n=106, 36.4%). A significant association was found between intra-anal rectal prolapse and anal incontinence. CONCLUSION: Anal incontinence is frequent in patients with pelvic organ prolapse, even more so in the presence of urinary incontinence, and should be investigated by pelvic viscerography. Pelvic floor dysfunction is frequently associated with enteroceles, rectoceles and rectal prolapse. Pelvic viscerograms should be systematically performed in the diagnostic work-up in patients with pelvic organ prolapse when surgical treatment is considered.     

Experience with Laparoscopic Rectopexy for Rectal Prolapse

Abstract: A 48-year old man was admitted to our hospital for rectal prolapse and anal bleeding. A diagnosis of type III complete rectal prolapse with two carcinomatous lesions had been made, based on examinations at his hospitalization. However, he refused abdominoperineal resection with colostomy, despite the probability of death due to carcinoma. Therefore, per anal local excision of the lesions was the method of first choice, as the patient hoped to maintain fecal continence for as long as possible. At the second operation, the rectum was fully mobilized with great care, so as to avoid injuring the testicular vessels, ureter and seminal vesicle, under laparoscopic control. The mobilized rectum was wrapped in a sheet of Teflon mesh which was fixed to the presacral fascia, and the rectum was fixed to the mesh by suturing. The front side of the rectum was not sutured to the Teflon mesh, with the aim of preventing subsequent stricture. There were no perioperative complications and the postoperative course was uneventful. Laparoscopic rectopexy for rectal prolapse is thought to be effective and worthy of trial in special situations such as that of the patient described herein.     

Helicoidal suture: alternative treatment for complete rectal prolapse in high-risk patients

BACKGROUND AND AIMS: Optimal treatment for rectal prolapse is controversial. We describe a novel alternative treatment for high-risk patients with complete rectal prolapse. PATIENTS AND METHODS: Sixteen high-risk patients over 60 years old with complete rectal prolapse were examined. All patients had significant past medical history and were classified as grade III (ASA) surgical risk. The helicoidal suture technique is described. Postoperative parameters evaluated were morbidity, mortality, postoperative symptoms, recurrence and anal incontinence score. Median follow-up was 60 months. RESULTS: There were no operative complications or mortality in the series; one patient experienced recurrence. Median postoperative anal incontinence score was 6.06 (range 1-30; preoperative 23.6). CONCLUSION: This technique provides adequate functional outcomes and could be an effective therapeutic strategy against rectal prolapse in high-risk patients.     

Anorectal Physiology in Solitary Ulcer Syndrome: A Case-Matched Series

PURPOSE Solitary ulcer syndrome is a rare condition characterized by inflammation and chronic ulcer of the rectal wall in patients suffering from outlet constipation. Despite similar surgical options (rectopexy, anterior resection), solitary ulcer syndrome may differ from overt rectal prolapse with regard to symptoms and pathogenesis. The present work analyzed differences between these conditions in a case-control physiology study. METHODS From 1997 to 2002, 931 consecutive subjects were investigated in a single physiology unit for anorectal functional disorders. Standardized questionnaires, anorectal physiology, and evacuation proctography were included in a prospective database. Diagnosis of solitary ulcer syndrome was based on both symptoms and anatomic features in 25 subjects with no overt rectal prolapse (21 females and 4 males; mean age, 37.2 ± 15.7 years) and no past history of anorectal surgery. They were compared with age-matched and gender-matched subjects: 25 with outlet constipation (also matched on degree of internal procidentia), 25 with overt rectal prolapse without any mucosal change, and 14 with overt rectal prolapse and mucosal changes. RESULTS Subjects with solitary ulcer syndrome reported symptomatic levels (digitations, pain, incontinence) similar to those of patients with outlet constipation, but they had significantly more constipation and less incontinence than patients with overt rectal prolapse. Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3, and 1, respectively ; P < 0.01) and a paradoxical puborectalis contraction (15 vs. 9, 1, and 1, respectively; P < 0.05). With respect to evacuating proctography, complete rectal emptying was achieved less frequently in this group (5 vs. 12, 23, and 10, respectively; P < 0.05). Compared with patients with overt rectal prolapse, mean resting and squeezing anal pressures were significantly higher in both groups of subjects with solitary ulcer syndrome and with outlet constipation. Prevalence and levels of anatomic disorders (perineal descent, rectocele) did not differ among the four groups except for rectal prolapse grade and prevalence of enterocele (higher in overt rectal prolapse group). Interestingly, and despite matched controls for degree of intussusception, individuals with solitary ulcer syndrome had circular internal procidentia more often compared with those suffering from outlet constipation without mucosal lesions (15 vs. 8, P < 0.05). CONCLUSION This case-controlled study quantifies functional anal disorders in patients suffering from solitary ulcer syndrome. Despite no proven etiologic factor, sphincter-obstructed defecation and circular internal procidentia both may play an important part in the pathogenesis and an exclusive surgical approach may not be appropriate in this context. Presented at the meeting of the American Gastroenterology Association, New Orleans, Louisiana, May 18, 2004.     

Sacral Nerve Stimulation for Fecal Incontinence Following Surgery for Rectal Prolapse Repair: A Multicenter Study

PURPOSE: A proportion of patients have fecal incontinence secondary to a full-thickness rectal prolapse that fails to resolve following prolapse repair. This multicenter, prospective study assessed the use of sacral nerve stimulation for this indication. METHODS: Patients had to have more than or equal to four days with fecal incontinence per 21-day period more than one year after surgery. They had to have failed conservative treatment and have an intact external anal sphincter. RESULTS: Four female patients aged 42, 54, 68, and 65 years met the inclusion criteria. Three of the four patients had had more than one operation for recurrent full-thickness rectal prolapse before sacral nerve stimulation, one of whom had undergone a further operation for recurrence following stimulation. One patient had undergone one operation for prolapse repair. The preoperative duration of symptoms was ten, eight, three, and nine years, respectively. Although patients had an intact external anal sphincter, one patient had a fragmented internal anal sphincter. The frequency of fecal incontinent episodes changed from 11, 24.7, 5, and 8 per week at baseline to 0, 1.5, 5.5, and 1 per week at latest follow-up. Ability to defer defecation was also improved in two of three patients who had this documented. Fecal incontinence-specific quality of life assessment showed an improvement in all four domains. CONCLUSION: Sacral nerve stimulation should be considered for patients with ongoing fecal incontinence following full-thickness rectal prolapse repair if they prove resistant to conservative treatment.     

Mesh invasion of the rectum: an unusual late complication of rectal prolapse repair

Various surgical techniques have been described for repair of rectal prolapse; however, there is no agreement on a standard treatment method. In the Ripstein procedure, the rectum is fixed to the sacrum with a piece of mesh material. We describe the case of a patient who had undergone a Ripstein procedure to address rectal prolapse 6 years before admission to our clinic. His complaints were anal discomfort, abdominal discomfort, and tenesmus of 2 years duration. Rectoscopy and abdominal computed tomography (CT) revealed that the mesh had penetrated the rectal wall and was located within the rectal lumen 7–8 cm from the anal verge. Once the mesh was endoscopically, and the patient’s symptoms resolved completely. Various complications of mesh implantation for rectal prolapse repair have been documented, but rectal wall penetration has not been reported to date. This report presents our case of this unusual complication and reviews the relevant literature.     

A rare case of rectal prolapse associated with rectal adenocarcinoma: case report.

Despite the fact that colorectal polyps and solitary rectal ulcers may be present in conjunction with rectal prolapse, association between rectal prolapse and rectal cancer is very rare. As far as we could determine, there are only a few articles concerning rectal cancer in association with rectal prolapse in the literature. This case, a 63-year-old female patient, had suffered from a rectal prolapse since childhood and presented as a case of rectal cancer. At presentation, she complained of constipation and rectal bleeding for the previous six months. At physical examination there was a relaxed anal sphincter and a large reddish mass protruding via the anal canal when the patient strained. There was a fungating lesion in the upper left part of the rectal mucosa. An incisional biopsy was performed, the histopathological result of which was adenocarcinoma of the rectum. Changes in bowel habits, chronic constipation and chronic irritation seen in rectal prolapse may be responsible for the development of rectal cancer. Thus, a detailed history, digital rectal examination and rectosigmoidoscopic examination are important, particularly in patients with long-term rectal prolapse.     

Perineal excision of rectal procidentia in elderly high-risk patients

PURPOSE: This report presents a ten-year experience with perineal excision and posterior levator ani repair in elderly, high-risk patients with complete rectal procidentia. METHODS: Seventy-two patients with rectal prolapse were treated with perineal excision. Nine presented with acute incarcerated rectal prolapse. Mortality, morbidity, recurrence rates, and improvement of anal continence were assessed. RESULTS: Recurrence rate was 5.5 percent. Improvement in anal continence was seen in 66.7 percent of patients. Morbidity and mortality was low. CONCLUSIONS: Perineal excision of rectal prolapse is safe and has a low recurrence rate. Posterior levator ani repair seems to improve anal continence.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Treatment of external anorectal mucosal prolapse with circular stapler

PURPOSE: The aim of this study was to demonstrate the feasibility, effectiveness, and reliability of a new technique for treating overt rectal mucosal prolapse using a stapler device. METHODS: Eighteen consecutive patients with overt rectal mucosal prolapse were selected for the study. Preoperative anal manometry and cinedefecography demonstrated no anal incontinence and the absence of full-thickness rectal prolapse. One or two purse strings were prepared 3 to 4 cm distally to the dentate line and tied on a 33 mm circular stapler introduced through the anus and then fired. RESULTS: The operation lasted an average of 15 minutes, and no local complications were recorded. Supplementary hemostatic sutures (2 to 6 stitches) were sometimes necessary. Seven patients did not require postoperative analgesia, whereas eight patients received one or two administrations of analgesics. Longer-lasting analgesic treatment (4 days) was necessary in only three patients. Sixteen patients were discharged after 48 hours, and only 1 after four days because of pulmonary infection. Patients resumed normal activities after a median period of three days. Median follow-up was 20 months. The prolapse was eliminated in all cases. No stricture was found at anal exploration, and no episodes of anal incontinence or bleeding were recorded. Postoperative manometry did not show significant changes compared with preoperative findings. CONCLUSIONS: This new surgical technique is safe, effective, and rapid, causing minimum or no postoperative pain and could be proposed to replace traditional surgery for this common condition.     

Management of recurrent rectal prolapse

PURPOSE: Many operations have been described for the management of rectal prolapse. Despite an overall recurrence rate of greater than 15 percent, few reviews address how to deal with this problem. This report summarizes our experience with recurrent rectal prolapse and includes suggestions for reoperative management of failed repairs from both abdominal and perineal approaches. PATIENTS AND METHODS: Fourteen patients (3 male) ranging in age from 22 to 92 (mean, 68) years underwent operative correction of recurrent rectal prolapse. Average time from initial operation to recurrence was 14 (range, 6–60) months. Initial operations (before recurrence) were as follows: perineal proctectomy and levatorplasty (10), anal encirclement (2), Delorme's procedure (1), and anterior resection (1). Operative procedures performed for recurrence were as follows: perineal proctectomy and levatorplasty (7), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (2), Delorme's procedure (1), and anal encirclement (1). Average length of follow-up was 50 (range, 9–115) months. RESULTS: No further episodes of complete rectal prolapse were observed during this period. Preoperatively, three patients were noted to be incontinent to the extent that necessitated the use of perineal pads. The reoperative procedures failed to restore fecal continence in any of these three individuals. One patient died in the postoperative period after anal encirclement from an unrelated cause. CONCLUSION: Surgical management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence. Perineal proctectomies can be safely repeated. Resectional procedures may result in an ischemic segment between two anastomoses, unless the surgeon can resect a previous anastomosis in the repeat procedure. Nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed.     

Preoperative electrophysiologic assessment cannot predict continence after rectopexy

PURPOSE: The aim of this study was to evaluate preoperative electrophysiologic assessment for prediction of anal continence after rectopexy. METHODS: Forty-three patients with rectal prolapse (n=26) or internal rectal intussusception (n=17) underwent concentric-needle electromyography, fiber density determination by single-fiber electromyography of the external anal sphincter, and pudendal nerve terminal motor latency evaluation before Ripstein rectopexy. A detailed history was obtained from each patient preoperatively and postoperatively. RESULTS: Anal continence was improved after rectopexy, both in patients with rectal prolapse (P=0.06) and in those with internal rectal intussusception (P=0.003). Abnormal results were registered in one or several aspects of the electrophysiologic assessment in 31 (72 percent) of the patients. However, functional outcome with respect to continence was not predicted by preoperative electromyography or pudendal nerve terminal motor latency assessment results. CONCLUSION: Electrophysiologic examinations in the preoperative assessment of patients with rectal prolapse and internal rectal intussusception do not predict continence after the Ripstein rectopexy. The routine use of electrophysiologic assessment requires further definition.Supported by grants from the Kjell and Märta Beijer Foundation, the Marianne and Marcus Wallenberg Foundation, Karolinska Institute, and Bert von Kantzow's Research Foundation.Read at the XVII Biennial Congress of The International Society of University Colon and Rectal Surgeons, Malmö, Sweden, June 7 to 11, 1998.     

Continence is improved after the ripstein rectopexy

PURPOSE: This study was undertaken to evaluate anal manometric changes after Ripstein's operation for rectal prolapse and rectal intussusception and to study the clinical outcome following the operation, with special reference to anal incontinence. METHODS: Forty-two patients with rectal prolapse or rectal intussusception were subjected to anorectal manometry preoperatively and seven days and six months postoperatively. A detailed history was obtained from each patient preoperatively and six months postoperatively. RESULTS: Preoperatively, patients with rectal intussusception had higher maximum resting pressure (MRP) (52±23 mmHg) than patients with rectal prolapse (34±20 mmHg;P <0.01). In the group of patients with rectal prolapse, there was a postoperative increase in MRP after six months (P <0.001) but not after seven days. Maximum squeeze pressure (MSP) did not increase. Neither MRP nor MSP increased postoperatively in patients with internal rectal procidentia. Continence was improved postoperatively both in patients with rectal prolapse (P <0.01) and rectal intussusception (P <0.01). There was no postoperative increase in rectal emptying difficulties. CONCLUSION: Ripstein's operation often improved anal continence in patients with rectal prolapse and rectal intussusception. This improvement was accompanied by increased MRP in patients with rectal prolapse, indicating recovery of internal anal sphincter function. No postoperative increase in MRP was found in patients with rectal intussusception. This suggests an alternate mechanism of improvement in patients with rectal intussusception.Supported by grants from Kjell and Märta Beijers Stiftelse and Marianne and Marcus Wallenbergs Stiftelse.     

Anorectal dysfunction and rectal prolapse in progressive systemic sclerosis

Our aim was to characterize the clinical spectrum of anorectal dysfunction among eight patients with progressive systemic sclerosis (PSS) who presented with altered bowel movements with or without fecal incontinence. The anorectum was assessed by physical examination, proctosigmoidoscopy, and anorectal manometry. There was concomitant involvement of the other regions of the digestive tract in all patients as determined by barium studies, endoscopy, or manometry: eight esophageal, three gastric, four small bowel, and two colonic. Seven patients had fecal incontinence, and four also had second-degree complete rectal prolapse. Abnormal anorectal function, particularly abnormal anal sphincter resting pressures, were detected in all patients; anal sphincter pressures were lower in those with rectal prolapse. Rectal capacity and wall compliance were impaired in seven of seven patients. Successful surgical correction of prolapse in three patients resulted in restoration of incontinence for six months and seven years in two of the three patients. We conclude that rectal dysfunction and weakness of the anal sphincters are important factors contributing, respectively, to altered bowel movements and fecal incontinence in patients with gastrointestinal involvement by PSS. Rectal prolapse worsens anal sphincter dysfunction and should be sought routinely as it is a treatable factor aggravating fecal incontinence in patients with PSS.This work was presented in part at the Annual Meeting of the American Gastroenterological Association, May 1992, and appears in abstract form in Gastroenterology 1992;102:A473.Supported in part by the General Clinical Research Center Grant 00585 from the National Institutes of Health.