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.     

Rectal compliance as a routine measurement

PURPOSE: The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance. METHODS: Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests. RESULTS: No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P=0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P<0.0001 andP<0.01). Patients with a rectocele had a larger volume at first sensation (P=0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P<0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P=0.003). Patients with ileoanal pouches also had a lower compliance (P<0.0001). In the 17 patients where a maximal toleration volume<60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume>500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found. CONCLUSION: Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume<60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume>500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.Drs. Sloots and Poen were supported by a grant from Janssen-Cilag. Presented at the meeting of the Dutch Society of Gastroenterology, Veldhoven, the Netherlands, October 7 to 8, 1999.     

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."     

Radiation-Induced Sequelae Affecting the Continence Organ: Incidence,Pathogenesis, and Treatment

Introduction Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians. Review This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea. Conclusion Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option. Presented at the meeting of the Coloproctology Group in the German Society of Visceral Surgery, Berlin, Germany, October 1, 2005. Reprints are not available.     

The pathogenesis and pathophysiology of rectal prolapse and solitary rectal ulcer syndrome

Rectal prolapse and solitary rectal ulcer syndrome are both benign conditions affecting the rectum, mainly in women; prolapse tends to occur late in life, while solitary rectal ulcer syndrome has a predilection for the younger adult. Complete rectal prolapse probably starts as a mid-rectal intussusception, although a combination of this theory and the 'sliding hernia' theory has been proposed by Altemeier et al (1971). The pelvic floor weakness associated with prolapse, which gives rise to incontinence, is most likely due to a traction injury to the pudendal nerve. Anorectal manometry will indicate those incontinent patients likely to benefit from rectopexy. Abnormal descent of the perineum may be found in rectal prolapse and solitary rectal ulcer syndrome as well as descending perineum syndrome per se. The clinical features of these three conditions can overlap. Solitary rectal ulcer syndrome is essentially due to prolapse and traumatization of the rectal mucosa. Inappropriate puborectalis contraction, abnormal perineal descent, and overt rectal prolapse have all been cited as possible mechanisms of development of the condition. Defecography is the radiologic investigation of choice. Electromyography, as in rectal prolapse, may show evidence of pudendal nerve damage although incontinence is rare.     

A case of rectal cancer arising from long-standing prolapsed mucosa of the rectum

Mucosal prolapse syndrome (MPS) has been recognized as a chronic benign inflammatory disorder, characterized mainly by rectal mucosal prolapse. Disorders representing this condition include solitary rectal ulcer syndrome (SRUS), rectal prolapse, proctitis cystica profunda, and inflammatory cap polyps. The gross appearance of rectal MPS can be occasionally misinterpreted as rectal cancer. In contrast, there have been a few reports of colorectal cancer originating from prolapsed mucosa. Herein, we report a case of MPS associated with two independent rectal cancers extending into the submucosal layer. We speculate that long-standing MPS may increase the risk of malignant transformation.     

Pressure and prolapse--the cause of solitary rectal ulceration

The cause of solitary rectal ulceration has been investigated using a method that radiologically visualises rectal voiding whilst simultaneously measuring intrarectal pressure and external anal sphincter electromyographic activity. Control subjects and patients with the solitary rectal ulcer syndrome, both with and without mucosal ulceration, have been studied. A high incidence of rectal prolapse (94%) was present in the patients who voided. Overactivity of the anal sphincter during evacuation contributed to the fact that patients with mucosal ulceration required higher intrarectal pressures to void than the controls and the patients without mucosal ulceration. The results indicate that a combination of rectal prolapse and a high voiding pressure may act to cause the mucosal ulceration in this syndrome by exposing the rectal wall to a high transmural pressure gradient.     

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.     

Solitary rectal ulcer syndrome presenting with rectal prolapse, severe mucorrhea and eroded polypoid hyperplasia: case report and review of the literature.

A case of solitary rectal ulcer syndrome in a 36-year-old woman presenting with severe, persistent mucorrhea and eroded polypoid hyperplasia as the predominant clinical features, who was ultimately noted to have symptoms of rectal prolapse, is presented. Endoscopically, she had multiple (50 to 60) small, whitish polypoid lesions in the rectum that were initially misinterpreted as being a carpeted villous adenoma, juvenile polyposis or atypical proctitis. The lesions were treated with argon plasma coagulation with resolution, but a solitary rectal ulcer developed. The patient then admitted to a history of massive rectal prolapse over the preceding six months and underwent surgical treatment. Severe mucorrhea as the presenting feature and the presence of multiple polypoid lesions consistent with a histological diagnosis of eroded polypoid hyperplasia make the present case unique.     

Soiling: anorectal function and results of treatment

Forty-five patients with soiling but without faecal incontinence were evaluated by means of anorectal function investigations (anal manometry, rectal capacity and saline infusion test). The causes of soiling and the effect of treatment on both soiling and anorectal function were studied. The results were compared with a control group of 161 patients without soiling or incontinence. The diagnoses were haemorrhoids (10), mucosal prolapse (7), rectal prolapse (6), fistulae (5), proctitis (3), faecal impaction (2), rectocele with intussusception (2), scars after fistulectomy (2) and others (8). Simple inspection and proctoscopy were generally sufficient to establish a diagnosis. For two patients the diagnosis rectocele was made after defaecography. Anorectal test results did not differ between the soiling and control group, did not contribute to establish a diagnosis and did not change after treatment. Only patients with a rectal prolapse had abnormal results in anorectal function tests: a low basal sphincter pressure and a limited continence reserve. Appropriate therapy resulted in complete recovery (44%) or improvement of symptoms (29%).     

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.     

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.     

Rectal Hypersensitivity Worsens Stool Frequency, Urgency, and Lifestyle in Patients With Urge Fecal Incontinence

PURPOSE Rectal sensory mechanisms are important in the maintenance of fecal continence. Approximately 50 percent of patients with urge incontinence have lowered rectal sensory threshold volumes (rectal hypersensitivity) on balloon distention. Rectal hypersensitivity may underlie the heightened perception of rectal filling; however, its impact on fecal urgency and incontinence is unknown. This study was designed to investigate the impact of rectal hypersensitivity in patients with urge fecal incontinence.METHODS Prospective and retrospective audit review of all patients (n = 258) with an intact native rectum referred to a tertiary colorectal surgical center for physiologic investigation of urge fecal incontinence during a 7.5-year period. Patients with urge fecal incontinence who had undergone pelvic radiotherapy (n = 9) or rectal prolapse (n = 6) were excluded.RESULTS A total of 108 of 243 patients (44 percent) were found to have rectal hypersensitivity. The incidence of anal sphincter dysfunction was equal (90 percent) among those with or without rectal hypersensitivity. Patients with urge fecal incontinence and rectal hypersensitivity had increased stool frequency (P < 0.0001), reported greater use of pads (P = 0.003), and lifestyle restrictions (P = 0.0007) compared with those with normal rectal sensation, but had similar frequencies of incontinent episodes.CONCLUSIONS Urge fecal incontinence relates primarily to external anal sphincter dysfunction, but in patients with urge fecal incontinence, rectal hypersensitivity exacerbates fecal urgency, and this should be considered in the management and surgical decision in patients who present with fecal incontinence.Christopher L. H. Chan, F.R.C.S., is supported by a MRC Clinical Training Fellowship.     

Anal sensitivity test: What does it measure and do we need it?

PURPOSE: This study was undertaken to determine the anal sensitivity in controls and in different patient groups and to establish factors that determine anal sensitivity. METHODS: Anorectal function tests were performed in 387 patients with different anorectal diseases. Anal sensitivity was measured in 36 controls. Anal sensitivity was measured by means of mucosal electrosensitivity (MES) using a catheter with two electrodes placed in the anal canal. A constant current (square wave stimuli 100 μsec, pulses per second) was increased stepwise from 1 to 20 mAmp until the threshold sensation was reached. Other tests used were anal manometry (maximum basal pressure, maximum squeeze pressure, rectal compliance (maximum rectal volume and pressure), endosonography (submucosal thickness), defects and thickness of internal and external sphincter), electromyography (maximum contraction pattern, Grade 1 (solitary contractions) to Grade 4 (interference pattern)), and pudendal nerve terminal motor latency. Multiple regression analysis was performed. It was postulated that age, local conditions (anal scars, anal fissures, hemorrhoids, mucosal prolapse, proctitis, sphincter thickness and defects, and submucosal thickness), and neurologic factors could influence anal sensitivity. RESULTS: Controls had an MES of 3.4±1.7. MES was significantly increased compared with controls in patients with fecal incontinence, soiling, hemorrhoids, mucosal prolapse, constipation, anal scars, anal surgery, and sphincter defects; patients with fecal incontinence had the highest MES (6.7±4.3;P <0.0001). Patients with anal fissures and proctitis showed no differences compared with controls. MES correlated significantly with age (R =0.29), maximum basal pressure (R =?0.29), maximum squeeze pressure (R =?0.32), submucosal thickness (R =0.19), maximum contraction pattern (R =?0.39), single-fiber electromyography (R =0.39), and maximum rectal volume and pressure (0.14). Multiple regression analysis showed that age, internal sphincter defects, and submucosal thickness significantly influenced anal sensitivity, but explained only 10 percent of the variance. CONCLUSION: Anal sensitivity is diminished in all patients with anorectal diseases except for anal fissures and proctitis. There are correlations with other anorectal function tests. Anal sensitivity is determined for 10 percent by age, internal sphincter defects, and thickness of the submucosa. Anal sensitivity measurement, therefore, has limited clinical value and should be used in conjunction with other tests in a research setting.     

Inflammatory cloacogenic polyp mimicking anorectal malignancy

Inflammatory cloacogenic polyp is a rare condition arising from the transitional zone of the anorectal junction. It is benign but may macroscopically resemble anorectal malignancy. Inflammatory cloacogenic polyp was diagnosed in two patients with rectal bleeding and polypoid growths at the anorectal junction. The lesions were best visualized with an endoscope retroflexed in the rectum. Accurate diagnosis was dependent on histological examination. The histological similarities to solitary rectal ulcer syndrome and other mucosal prolapse conditions are discussed, and the literature on inflammatory cloacogenic polyp and its management reviewed.     

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.     

Solitary lesions of the rectum caused by suppositories combining acetylsalicylic acid and paracetamol

The reports of 8 female patients who, because of recurrent headache, were using analgesic suppositories containing acetylsalicylic acid and paracetamol (Perdolan) for more than two years are analyzed. Symptoms were nonspecific: anal pain, rectal tenesmus or bleeding. The lesions were located within 8 cm from the anal verge and consisted of superficial ulcerations, fibrotic scar tissue and rectal stenosis. Biopsies showed non-specific inflammation, limited to the rectum. Rectal prolapse or intussusception was not associated. By discontinuing the use of suppositories, symptoms usually resolved; rectal stenoses required anorectal dilatations and in 2 cases surgical resection. When solitary rectal lesions are observed in the absence of rectal prolapse, chemical aggression of the rectal mucosa by use of suppositories containing acetylsalicylic acid should be considered.     

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.     

Clinical and manometric assessment of gracilis muscle transplant for fecal incontinence

Six cases of gracilis muscle transplant for fecal incontinence are reported. The causes of fecal incontinence included previous anal operation, idiopathic incontinence, and rectal prolapse. All patients had had a previous operation for fecal incontinence. Postoperative sepsis developed at the operative site in five patients despite a defunctioning colostomy in two. Functional results of the operation were poor in all patients and a colostomy has now been raised in all cases. The operation was not associated with any objective improvement in resting or voluntary component pressure.