Manometric studies in rectal prolapse

Manometric studies of internal sphincter responses were carried out on 15 patients−14 with rectal prolapse and one with mucosal prolapse with proctitis cystica profunda. In all 12 patients studied preoperatively, the internal sphincter reflexes (inhibitory reflex) were absent or markedly obtunded. Anterior resection was performed on three of the patients in whom preoperative and postoperative manometric studies could be carried out. In one, the inhibitory reflex returned to normal after successful corrective surgery and in one, absence of the reflex persisted after anterior resection and this patient eventually had recurrent rectal prolapse. Poster Presentation at the meeting of the American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5 to 9, 1983.     

Sphincter denervation in anorectal incontinence and rectal prolapse.

Biopsies of the external anal sphincter, puborectalis, and levator ani muscles have been examined in 24 women and one man with long-standing anorectal incontinence, 18 of whom also had rectal prolapse, and in two men with rectal prolapse alone. In 16 of the women anorectal incontinence was of unknown cause, but in eight there was a history of difficult labour. Similar biopsies were examined in six control subjects. In all the incontinent patients there was histological evidence of denervation, which was most prominent in the external anal sphincter muscle biopsies, and least prominent in the levator ani muscles. Myopathic features, which were thought to be secondary, were present in the more abnormal biopsies. There were severe histological abnormalities in small nerves supplying the external anal sphincter muscle in the three cases in which material was available for study. We suggest that idiopathic anorectal incontinence may be the result of denervation of the muscles of the anorectal sling, and of the anal sphincter mechanism. This could result from entrapment or stretch injury of the pudendal or perineal nerves occurring as a consequence of rectal descent induced during repeated defaecation straining, or from injuries to these nerves associated with childbirth.     

Impaired rectal sensation in idiopathic faecal incontinence

In 15 patients suffering from idiopathic faecal incontinence and in 15 matched controls, manometric studies of anorectal pressure and studies of the rectoanal reflex and rectal sensitivity were carried out. Patients with idiopathic faecal incontinence had normal resting pressure but reduced squeeze and stress pressures; the anal sphincter relaxed before a sensation of rectal distension occurred. The conclusion is that both reduced voluntary muscle contraction and impairment of rectal sensation are conducive to soiling in idiopathic faecal incontinence.     

Results of treatment for rectal prolapse and fecal incontinence

Fifty-six patients were treated for rectal prolapse or incontinence. Rectal prolapse was present in 32 patients and was associated with fecal incontinence in 24 (75 per cent). Incontinence without prolapse was present in 24 patients, 12 of whom were less than 40 years old. Rectopexy was used for treatment of rectal prolapse. Surgical treatment of fecal incontinence was by post-anal repair; external sphincter reconstruction and surgery was advised only if control of diarrhea and electrical therapy had been of no benefit. Rectopexy was completely successful at controlling rectal prolapse in all cases, and only four of the 20 (20 per cent) patients with incontinence and prolapse remained incontinent after rectopexy alone. Incontinence was completely controlled by postanal repair in 58 per cent of patients and by external sphincter repair alone or in combination with postanal repair in 67 per cent. Using a combination of therapies 45 of 48 patients who were initially incontinent were improved (94 per cent), and 42 of the patients have complete control of defecation (87 per cent).     

Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse

PURPOSE: The aim of this study was to determine the prevalence, severity, and associations between urinary incontinence and genital prolapse in females after surgery for fecal incontinence or rectal prolapse. METHODS: All patients who underwent surgery for fecal incontinence (Group I) or rectal prolapse (Group II) were compared with a control group of females (Group III) by 43 questions regarding demographic data, past medical and surgical history, and diagnosis and treatment of anal and urinary incontinence and genital and rectal prolapse. The type (stress, urge, and total) of urinary incontinence was determined and graded using an incontinence severity questionnaire (Individual Incontinence Impact Questionnaire). RESULTS: Overall response rate in the three groups of patients was 40.1 percent. The questionnaire was sent to 240 patients operated on for fecal incontinence or rectal prolapse, and 83 of them responded (34.5 percent). The patients were distributed into three groups: Group I consisted of 51 patients (mean age 56.7 +/- 14); Group II consisted of 32 patients (69.7 +/- 11); and Group III consisted of 40 patients (60.5 +/- 16). The prevalence of urinary incontinence in Group I was 27 (54 percent), in Group II was 21 (65.6 percent), and Group III was 12 patients (30 percent; P = 0.003). Genital prolapse was present in 9 (17.6 percent), 11 (34.3 percent), and 5 patients (12.5 percent), respectively (P = 0.03). The prevalence of coexistent urinary incontinence and genital prolapse in both study groups was 22.8 percent (19 patients). There were no statistically significant differences between Groups I and II relative to prevalence, type, and severity of urinary incontinence and genital prolapse, but there were significant differences between the two study groups and the control group. Of the patients in the study group, 67 percent had urinary incontinence before or at the time of surgery. CONCLUSION: There is a higher prevalence and severity of urinary incontinence and pelvic genital prolapse in females operated on for either fecal incontinence or rectal prolapse than in a control group. Therefore, female patients with fecal incontinence or rectal prolapse should be evaluated and treated by a multidisciplinary group of pelvic floor clinicians, including a gynecologist or urologist with special training in female pelvic floor dysfunction and a colorectal surgeon.     

Delorme's operation and sphincteroplasty for rectal prolapse and fecal incontinence

Clinical and manometric results of Delorme's operation and sphincteroplasty were assessed retrospectively in patients undergoing this procedure for fecal incontinence and rectal prolapse. A series of 33 patients (11 males, 22 females; aged 18–83 years, mean 59) with external rectal prolapse were treated by Delorme's operation between 1989 and 1996. Mean follow-up was 39 months (range 7–84). Sphincteroplasty was associated in 12 cases with severe fecal incontinence due to striated muscle defects. Good results were achieved in 27 patients (79%); prolapse recurrence was observed in 6 (21%), the mean recurrence time being 9 months (range 1–24 months). There were no postoperative deaths. Minor complications occurred in 15 patients. Changes in preoperative and postoperative manometric patterns were as follows (mean±SEM): voluntary contraction from 59±6.9 to 66±7.1 mmHg (P=0.05), resting tone from 33±5 to 32±4.3 mmHg, rectal sensation from 59±5 to 61±5.2 ml of air (n.s.). A solitary rectal ulcer syndrome was detected in five patients. The histological pattern demonstrated pathological changes in 40% of cases. Fecal incontinence was resolved in 6 of 20 cases (30%) and chronic constipation in 4 of 9 (44%). Failure (n=3) was related primarily to postoperative sepsis. The incontinence score showed a mean improvement of 35% decreasing, from 4.5±0.39 to 2.9±0.44 after surgery (P<0.01). In conclusion, Delorme's procedure did not lead to constipation and improved anal continence when associated with sphincteroplasty. Accepted: 20 January 1998     

Anal encirclement with polypropylene mesh for rectal prolapse and incontinence

Seventeen selected patients (mean age, 74 years)—14 with rectal prolapse and 3 with persisting anal incontinence after previous operations—underwent high anal encirclement with polypropylene mesh. There was no operative mortality. Prolapse recurred in 2 (15 percent) of the 13 patients followed up for 6 months or more (mean, 3.5 years). Three (27 percent) of the 11 patients with associated anal incontinence improved functionally, as did the three operated on for persisting incontinence, but only one patient regained normal continence. No breakage, cutting out, or infection related to the mesh was observed. Because of the risk of fecal impaction encountered in three of our patients, the procedure is not advocated for severely constipated patients. Despite the somewhat disappointing results regarding restoration of continence, we find this method useful in patients with rectal prolapse who are unfit for more extensive surgery, in controlling the prolapse to an acceptable degree.     

Relation between rectal sensation and anal function in normal subjects and patients with faecal incontinence.

The relation between sensory perception of rapid balloon distension of the rectum and the motor responses of the rectum and external and internal anal sphincters in 27 normal subjects and 16 patients with faecal incontinence who had impaired rectal sensation but normal sphincter pressures was studied. In both patients and normal subjects, the onset and duration of rectal sensation correlated closely with the external anal sphincter electrical activity (r = 0.8, p less than 0.0001) and with rectal contraction (r = 0.51, p less than 0.001), but not with internal sphincter relaxation. All normal subjects perceived a rectal sensation within one second of rapid inflation of a rectal balloon with volumes of 20 ml or less air. Six patients did not perceive any rectal sensation until 60 ml had been introduced, while in the remaining nine patients the sensation was delayed by at least two seconds. Internal sphincter relaxation occurred before the sensation was perceived in three of 27 normal subjects and 11 of 16 patients (p less than 0.001), and could be associated with anal leakage, which stopped as soon as sensation was perceived. The lowest rectal volumes required to induce anal relaxation, to cause sustained relaxation, or to elicit sensations of a desire to defecate or pain were similar in patients and normal subjects. In conclusion, these results show the close association between rectal sensation and external anal sphincter contraction, and show that faecal incontinence may occur as a result of delayed or absent external anal sphincter contraction when the internal anal sphincter is relaxed.     

Perception of and adaptation to rectal isobaric distension in patients with faecal incontinence

BACKGROUND: Perception of, and adaptation of the rectum to, distension probably play an important role in the maintenance of continence, but perception studies in faecal incontinence provide controversial conclusions possibly related to methodological biases. In order to better understand perception disorders, the aim of this study was to analyse anorectal adaptation to rectal isobaric distension in subjects with incontinence. PATIENTS/METHODS: Between June 95 and December 97, 97 consecutive patients (nine men and 88 women, mean (SEM) age 55 (1) years) suffering from incontinence were evaluated and compared with 15 healthy volunteers (four men and 11 women, mean age 48 (3) years). The patients were classified into three groups according to their perception status to rectal isobaric distensions (impaired, 22; normal, 61; enhanced, 14). Anal and rectal adaptations to increasing rectal pressure were analysed using a model of rectal isobaric distension. RESULTS: The four groups did not differ with respect to age, parity, or sex ratio. Magnitude of incontinence, prevalence of pelvic disorders, and sphincter defects were similar in the incontinent groups. When compared with healthy controls, anal pressure and rectal adaptation to distension were decreased in incontinent patients. When compared with incontinent patients with normal perception, patients with enhanced perception experienced similar rectal adaptation but had reduced anal pressure. In contrast, patients with impaired perception showed considerably decreased rectal adaptation but had similar anal pressure. CONCLUSION: Abnormal sensations during rectal distension are observed in one third of subjects suffering from incontinence. These abnormalities may reflect hyperreactivity or neuropathological damage of the rectal wall.     

Treatment of rectal prolapse.

There are two schools of thought concerning the aetiology of rectal prolapse. On the one hand it was conceived to be a sliding hernia through a defect in the pelvic fascia, while on the other hand radiological studies have demonstrated prolapse to be represented by an intussusception of the rectum. Various operative procedures have been proposed for the treatment of rectal prolapse based on the belief in one or the other of these concepts. The anatomic defects which have been described with prolapse include a defect in the pelvic floor with diastasis of the levatores ani, loss of the normal horizontal position of the rectum, an abnormally deep cul-de-sac of Douglas, a redundant rectosigmoid, and a patulous anal sphincter. The popularly used procedure in Great Britain is that in which a sheet of Ivalon sponge is sutured to the sacrum and wrapped around the rectum thus anchoring it in place. Various authors have reported good results using this technique. The mortality and morbidity rate appear to be acceptable. In the U.S.A. a popular procedure is the Ripstein technique where a sheet of Teflon is wrapped around the rectum anteriorly anchoring the rectum to the sacrum. This technique also has its proponents who rport satisfactory results. Abdominal proctopexy and sigmoid resection, although not in common general use, has been found to be effective with an acceptable morbidity and mortality rate. These three procedures have some drawbacks but the one problem common to all the repairs so far developed for prolapse is their inability to guarantee to restore continence. Probably half the patients operated upon continue to be incontinent. Faradic stimulation of the sphincter has not proved to be as helpful as initially hoped.     

Why do patients with faecal impaction have faecal incontinence.

To elucidate the phenomenon of faecal incontinence in impacted patients, manometric, radiological and other investigations were carried out in 55 elderly patients, who had impacted masses of faeces in the rectum and were incontinent of faeces and 36 elderly control subjects with no anorectal problems. Maximum basal pressure and the maximum squeeze pressure in impacted patients were not significantly different from elderly controls. Sphincter pressures were no different after disimpaction than they were with faecal masses in situ, suggesting that leakage and soiling were not caused by stretching of the anal ring or prolonged reflex inhibition of anal tone by the faecal mass. The anorectal angle was more obtuse in impacted patients than in elderly controls though there was no greater degree of perineal descent. Anal and perianal sensation was impaired in impacted patients compared with controls. Rectal sensation was also impaired in the impacted patients in that the volume in a rectal balloon that could be perceived by the subject and the volume that gave rise to a desire to defecate were much higher in impacted patients than in controls. The rectal volume required to cause anal relaxation was lower in impacted patients compared with controls though there was no reduction in the volume at which anal relaxation failed to recover its resting tone. Rectal distension elicited external sphincter contractions in 53% impacted patients compared with 80% of controls. In conclusion, faecal soiling in patients with faecal impaction is probably related to the combination of an obtuse anorectal angle and the low anal pressures, normally found in the elderly and to impaired anorectal sensation which prevents conscious contraction of the external sphincter when the internal sphincter is relaxed.     

Manometric and clinical evaluation of patients after low anterior resection for rectal cancer

The aim of this study was to examine the anorectal physiological and clinical changes that occur after low anterior resection for rectal cancer. Since 1998, 30 patients underwent laboratory tests of anorectal function, preoperatively and 1 month and 6 months after low anterior resection. Postoperatively all patients presented with increased bowel frequency, 60% of the patients with mild soiling and 30% with urgency for defecation. Six months after surgery there was a significant improvement of these symptoms. The anal resting pressure was significantly decreased postoperatively, while maximum squeezing pressure remained unchanged. The rectoanal inhibitory reflex was absent in 80% of the patients and at 6 months after surgery it tended to recover. Rectal capacity and compliance were reduced in all patients. In the current study, the majority of patients demonstrated manometric anorectal changes and clinical anorectal function disorders during the first year after surgery. We observed that these disorders correlated with the low level of the anastomosis.     

内镜下直肠黏膜多点烧灼术治疗直肠内脱垂疗效评价

目的与直肠黏膜纵行折叠加硬化剂注射术对比,评价内镜下直肠黏膜多点烧灼术治疗直肠内脱垂的疗效。方法前瞻性选取2013年8月至2018年10月东平县人民医院收治的直肠内脱垂患者80例。随机均分为对照组与治疗组2组,每组各40例。对照组患者采用直肠黏膜纵行折叠加硬化剂注射术治疗,治疗组患者采用内镜下直肠黏膜多点烧灼术治疗。对照组2例患者失访,最终38例患者纳入本研究。比较术前及术后3、6、12、18个月两组患者便秘症状评分。结果术前、术后3个月两组患者便秘症状评分差异均无统计学意义;治疗组患者术后6、12、18个月便秘症状评分均低于对照组患者[(2.0±0.2)分vs (2.2±0.3)分,(1.5±0.1)分vs (1.9±0.2)分,(0.7±0.1)分vs (1.7±0.1)分],且差异均有统计学意义(t=4.773、11.841、48.474,P均<0.001)。结论内镜下直肠黏膜多点烧灼术治疗直肠内脱垂操作简便,临床症状明显改善,长期疗效远优于直肠黏膜纵行折叠加硬化剂注射术。     

Urinary and faecal incontinence in community-residing elderly women.

The prevalence of urinary and faecal incontinence was investigated in a sample of 1049 women aged 60 years and over in the municipality of Amstelveen, the Netherlands; 719 postal histories were completed. The overall prevalence of urinary incontinence was 23.5%. Daily urine loss was reported by 14.0% of all women. In women aged 60 to 84 years and 85 years and over 4.2% and 16.9% were faecally incontinent, respectively. In all age groups poor mobility and frequency were associated with urinary incontinence. Urgency was independently associated in women aged 60-85 years as was nocturia in women aged 85 years and over.     

Impaired anal sensation and early diabetic faecal incontinence.

Faecal incontinence develops in up to 20% of diabetic patients. To try to determine the relative contributions of sensory and motor neuropathy in this troublesome complication, anorectal function was examined in 10 male diabetic patients with early faecal incontinence (mucus leakage or faecal staining without the need to wear a pad), 10 asymptomatic male diabetic patients, and 10 normal control subjects. Motor function was tested using anal manometry to determine the resting and maximum squeeze pressure, and the functional anal canal length. No significant differences were found between the groups. Sensory function was tested by measuring the mucosal sensitivity to electrical stimulation, and the response to inflation of a balloon in the rectum. In the mid-anal canal position the symptomatic patients had a significantly higher sensory threshold at 6.6 +/- 2.8 mA compared with 3.0 +/- 1.2 mA in the normal control subjects (p less than 0.002), and in the high anal zone symptomatic patients had a significantly elevated sensory threshold at 9.1 +/- 2.0 mA compared with 4.6 +/- 1.6 mA in asymptomatic patients and 3.6 +/- 1.3 mA in the normal control subjects (both p less than 0.001). There were no significant differences in the first sensation of fullness, maximum tolerated volume or percentage fall from resting pressure between the groups on inflation of the balloon. Elevation of the sensory threshold in the upper anal canal is an early abnormality in the development of diabetic faecal incontinence.