Results and FollowUp

Between 1985 and 2003, 69 cases of PH fulfilled the inclusion criteria outlined earlier in this chapter and subsequently underwent partial division of the puborectalis muscle. The day Figure 26.5. Surgical procedure for PH an incision is made while the patient is in the prone jackknife position (PH, puborectalis hypertrophy). Figure 26.5. Surgical procedure for PH an incision is made while the patient is in the prone jackknife position (PH, puborectalis hypertrophy). following the procedure,...

Initial Evaluation of Constipation

Constipation is a common and subjective symptom that can be related to a multitude of factors, including, dietary, psychological, cultural, anatomic, and functional aspects. In addition, constipation is still surrounded by misconceptions and taboos that hamper an objective evaluation and encourage self-medication that is not always innocuous to the patient. The definition of constipation varies tremendously among both patients and physicians. When adults not seeking health care were asked to...

Therapies of the Future

In the not-too-distant future, patients and their physicians may be spared the sometimes tremendously difficult problem of narcotic-induced constipation. To date, the narcotic antagonists have been effective peripherally, but have been unhelpful because they reverse the intended, central effect of the analgesic. Narcotic administration is perhaps the most common cause of iatrogenic constipation. Three types of receptors for opioid peptides have been identified as having effects on human...

Newer Methods

Small-Bowel Magnetic Resonance Imaging A magnetic resonance image (MRI)-based method to determine the small-intestine transit time has been described in the literature in a small number of healthy individuals.25,26 Different contrast agents, gadolinium and perfluorononane, have been used to track the flow of these agents through the gastrointestinal (GI) tract noninvasively. Gadolinium is a highly stable nontoxic aqueous-phase marker, and the safety of the agent following oral administration...

History

To address the broad spectrum of symptoms involving constipation, an extensive questionnaire is recommended. Questioning must be specific and must emphasize the symptom the patient considers most distressing. The main complaint can be infrequent bowel movements, difficult evacuation (straining, hard stools, feeling of incomplete evacuation), symptoms suggesting irritable bowel syndrome (bloating, abdominal pain), or a combination of all these symptoms. When constipation occurs later in life,...

Indications and Patient Evaluation

The lack of knowledge of the mechanism of action makes it difficult to give precise indications for eligible patients, and until now the possibilities of SNM have been evaluated both in patients with colonic slow transit and in patients with difficult evacuation. It is a shared belief that the indication for neuromodulation is severe constipation not amenable to standard drugs or biofeedback therapy or a failed conventional surgical management. The integrity of the nervous supply must be...

Constipation After Rectopexy in Patients Who Have Had No Apparent Constipation Beforehand

The other major consideration in rectal prolapse surgery is the risk of rendering patients constipated after the operation. Factors that seem to increase the risk of constipation for the first time after rectopexy are age under 40, the use of mesh, anterior rectopexy, avoidance of resection, and the use of an open operation as opposed to laparoscopic rectopexy and division of the lateral stalks.22 The problem with postoperative constipation after rectopexy is that it is very difficult to...

Management

As previously mentioned, a large number of patients with symptoms of IBS do not report these symptoms to their physicians. Moreover, some symptomatic patients who visit a physician do not require specific therapy but rather derive a great deal of benefit from explanation of their diagnoses and factors that worsen IBS, including stress and possibly dietary factors. A stepwise approach, beginning with the establishment of a trusting physician-patient relationship is required for effective...

Patients with Concomitant Disease Neurologic Diseases

Constipation occurs commonly among patients with other diseases. In many instances, these conditions are the actual cause of an individual's constipation. For example, hypothyroidism is well known to cause constipation. In other cases the associations may be coincidence or may be the result of shared etiologic risk factors. To investigate this possibility, Johanson et al24 examined the Health Care Financing Administration (HCFA) database comprising 11 million Medicare beneficiaries to assess...

Infection

The most common infectious cause of constipation is American trypanosomiasis, or Chagas disease. Caused by the parasitic protozoan Trypanosoma cruzi, Chagas disease affects an estimated 17 to 24 million individuals throughout Central and South America and Mexico and leads to 50,000 deaths annually. The disease is endemic in South America, especially in Chile, Brazil, and Argentina. Wild and domesticated mammals harboring T. cruzi and infected redu-viid insects are found in patchy distributions...

Clinical Presentation and Natural History

Constipation may be associated with a number of different diseases or conditions. The known etiologies of constipation include mechanical obstruction, metabolic disturbances, neurologic disorders, and medication side effects. A large proportion of patients with constipation do not have a known cause and suffer from idiopathic constipation. The symptoms of constipation may start at any time, although they typically begin later in life. Constipation usually commences insidiously without any...

Antegrade Colonic Enema

Antegrade irrigation of the colon may be used as an alternative to colectomy or a stoma in patients with severe laxative-resistant constipation.12 Malone et al13 first described the technique of antegrade colonic enema (ACE) in 1990, using the reversed appendix as the conduit with the amputated tip tunneled into the cecum as a continence mechanism. This was a modification of the Mitrofanoff procedure of using the appendix as a nonrefluxing conduit to catheterize the bladder. The ACE technique...

Surface Electromyography Evaluation

The abdominal and pelvic floor,the two channels of sEMG muscle activity, should be monitored simultaneously during the sEMG evaluation and the sEMG biofeedback-assisted pelvic muscle exercise training. Interpretative problems arise when monitoring only pelvic floor muscles without controlling changes in the intraabdominal pressure. The transmission of abdominal artifact to perennial measurements invalidates changes in the pelvic floor muscle measurements and can inadvertently reinforce...

Evolution of Antegrade Colonic Irrigation

Retrograde irrigation has been used successfully in the treatment of constipation for many years, particularly in patients with an inability to effectively evacuate rectal contents.4 However, such methods may not reliably accomplish complete emptying in certain patients, and can lead to complications, including perforation5-8 this significant problem has prompted the search for alternative washout techniques. The observed effectiveness of antegrade cleansing to prepare the bowel for surgery9...

Surgical Treatment of Puborectalis Hypertrophy

Defecation is a complicated procedure in which pelvic floor muscles actively participate in the process. Rectal distention evokes the desire to defecate and induces relaxation of the anal sphincter. Under conducive circumstances, the act of defecation is completed by adoption of a suitable posture, contraction of the diaphragm and abdominal muscles to increase the intraabdominal pressure, and relaxation of the two striated muscle of the puborectalis and external anal sphincter. Puborectalis...

Constipation Caused by Dysfunction of the Pelvic Floor Muscles

It is acknowledged that in a proportion of patients with chronic constipation, the symptoms are due to obstructed defecation caused by dysfunction of the pelvic floor musculature.2 Initially labeled as puborectalis syndrome11 but also often described as anismus,12 it is characterized by the failure of the puborectalis muscle to relax or by its paradoxical contraction during efforts to defecate. In the normal course of events the puborectalis muscle and the external anal sphincter relax,...

Suspected Enterocele or Rectocele Obstructed Defecation

Patients with symptoms of enterocele or recto-cele describe prolonged straining at defecation, with a sensation of partial or complete blockage frequently a closed trapdoor preventing passage of stool . Defecography can demonstrate the presence of a rectocele or enterocele, suggest the presence of a peritoneocele, and clarify contributing disorders such as a nonrelaxing pelvic Table 9.1. Indication for defecography among patients referred to the Minnesota Center for Pelvic Floor Disorders seen...

Diagnosis and Definition

Irritable bowel syndrome IBS is a common chronic intestinal disorder characterized by abdominal discomfort and altered bowel habits. These symptoms occur in the absence of structural or biochemical abnormalities.1 It is estimated that up to 20 of the population of the United States has symptoms suggestive of IBS.2 Multiple comorbidities, the high cost of medical utilization, and diminished productivity and quality of life all may be found in association with IBS.3 Despite extensive research,...

Physical Examination

Physical examination must be thorough and complement the history in order to exclude systemic etiology. Evidence of systemic illness, including neurologic or muscular deterioration, and endocrine or metabolic disorders, should be sought. In addition, special attention should be directed to the abdominal and anorectal regions. The abdominal examination may detect excessive stool or gaseous distention and the presence of surgical scars that are evidence of neoplasic or inflammatory bowel...

Soave Procedure

Modified Duhamel Operation Hirschsprung

Franco Soave,10 an Italian surgeon, created this ingenious and appealing operation, with the specific theoretical purpose of avoiding the consequences of nerve damage provoked by an imprecise Swenson dissection. The aganglionic rectosigmoid is resected by an endorectal dissection, theoretically minimizing the risk of pelvic injury Fig. 24.3A,B . The normoganglionic colon is passed through the rectal muscular cuff left after the endorectal dissection Fig. 24.3C,D . There is no aganglionic...

Extracolonic Causes of Constipation

Szarka In clinical practice, it is commonly accepted that fiber therapy and stool-bulking agents are the main therapeutic agents of choice in the initial management of primary constipation.1 Several clinical trials have been performed on the effects of fiber therapy and constipation. Meta-analyses of these trials have had discordant conclusions. In one study, a total of seven double-blind, placebo-controlled trials were analyzed five of the studies resulted in...

Recurrent Constipation

The incidence of recurrent constipation varies quite considerably in the literature. This measure is an important end point for success after colec-tomy. The definition of constipation used after colectomy is variable and may contribute to the wide range reported the definition of Drossman et al,27 most commonly used elsewhere in the literature two or fewer stools per week and or straining at stool more than 25 of the time is often not followed after colectomy. Knowles and colleagues24 reported...

Posterior Colporrhaphy Technique

Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address a rectocele or relaxed perineum and widened genital hiatus. Preoperatively, the severity of the rectocele is assessed, and the desired final vaginal caliber is determined. Allis clamps are placed on the hymen remnants bilaterally and approximated in the midline such that the resultant vagina should loosely admit two to three fingers. The skin is infiltrated with a dilute epi-nephrine solution. A...

Medical Treatment of Constipation

Sandler, Benjamin Person, and Ramu Raju Constipation is commonly defined as the paucity of bowel movements. However, patients may have constipation regardless of the number of bowel movements in a unit of time. The inability to satisfactorily evacuate one's colon and rectum can be manifested by different degrees of abdominal discomfort associated with normal bowel habits, infrequent stools, or even overflow diarrhea. In addition, many other abdominal complaints are related to...

Sacral Nerve Stimulation

Ezio Ganio, Luc Alberto Realis, Giuseppe Clerico, and Mario Trompetto Although most physicians consider two or fewer evacuations per week as constipation, many patients consider the subjective feeling of incomplete or difficult defecation and include symptoms such as hard feces or the need for dig-itation, enema suppositories, or the symptoms of tenesmus as part of constipation. Pelvic causes of abnormal evacuation include rectal aganglionosis, rectal intussusception or complete rectal...

Pathophysiology

Since its description more than 150 years ago, clinicians and scientists have been puzzled over the cause s of IBS. Current basic and clinical research studies have suggested that this syndrome is a disorder associated with physiologic alterations of several organ systems including the gut, spinal cord, and brain 14 altered signaling among these systems fuels and perpetuates the condition. Just as the gastrointestinal tract sends signals to the brain in response to a variety of local stimuli,...

Surgical Treatment of Rectocele Colorectal Approaches

Rectocele Measurement Defecography

Lumi The rectum and the vagina have a common embryologic origin with close anatomic affinity. They originate from the cloaca that is divided by the urorectal septum into a ventral urogenital and a dorsal rectal portion. From an anatomic point of view, a layer of strong connective-type tissue has been identified between the rectum and vagina known as the rectovaginal septum or the rectovaginal fascia. This layer, located immediately beneath the vaginal mucosa,...

Barium Enema

Dolichocolon

Barium enema is generally not useful in the diagnosis of chronic constipation48 and has been replaced by colonoscopy for the screening and evaluation of many diseases, including divertic-ular disease and colorectal cancer. However, it does have the advantage of providing a permanent record for future evaluation regarding the size, length, and anatomic abnormalities of the colon. In this sense, barium enema is probably superior to colonoscopy. High-quality double-contrast technique and inclusion...

Central Nervous System

A variety of colorectal dysfunction can be attributed to lesions of the central nervous system. Those disorders that are seen most commonly in clinical practice will be discussed, namely cere-brovascular accidents, spinal cord injury, multiple sclerosis, Parkinson's disease, and spina bifida. The impact of gastrointestinal GI complications after an episode of cerebrovascular accident is determined by the extent of the functional impairment related to the event. Initially after the event of a...

Disease Definition

A description of the epidemiology of constipation is clearly dependent on how the disorder is defined. Attempts to provide an objective definition of constipation date back to the 1960s. In a commonly cited study, Connell and col leagues2 surveyed the bowel frequency of factory workers in England and found that more than 99 had bowel frequencies ranging between three per day and three per week. These data provided an easily measurable and reproducible definition that did not rely on an...

Beyond Kegels

The Beyond Kegel, a complete rehabilitation program for pelvic muscle dysfunction developed by Hulme, is based on the principle that the support system for the pelvic organs includes more than just the pelvic floor muscles. This support system, which is called the pelvic muscle force field PMFF , includes the obturator inter-nus, pelvic diaphragm levator ani , urogenital diaphragm, and adductor muscles. In summary, these muscles function as an interdigitated and interrelated synergistic unit,...

Colonic Scintigraphy

More recently, radioscintigraphy has been used to provide a more detailed assessment of overall and regional colonic transit with an acceptable radiation exposure. Two approaches have been used. To avoid dispersion of radiolabel during its passage through the stomach and small bowel, orocecal intubation was utilized to instill liquid radioisotopes, such as mIn-DTPA, directly into the large bowel.42 This method has been adapted by simply following an mIn-liquid meal emptied from the stomach.43...

Fluid Filled and Air Filled Balloon Systems

Rectoanal Inhibitory Reflex

One of the most common methods of measuring anorectal pressure utilizes a closed balloon system. The pressure result obtained with balloon recording is an average of all pressures acting into the balloon radial asymmetry cannot be detected. However, larger balloons are unphysiologic as the probe itself may cause reflex contractions but the results obtained are more representative of a greater area of the sphincter. It is of tremendous importance to understand that a compliance hysteresis...

Segmental Colonic Resection

If a particular segment of the colon could be reliably identified as the cause of constipation, then segmental colectomy could offer some advantage by preventing severe diarrhea or incontinence that occurs in a small number of cases after subtotal colectomy and ileorectal anastomosis. Another potential advantage of a limited colonic resection is a reduction in the de-peritonealized area that may reduce the risk of postoperative adhesions. In general, the published functional results of...

Treatment of Combined Colonic Inertia and Obstructed Defecation

Transit studies and anorectal physiology tests can subdivide severely constipated patients into three groups colonic inertia causing slow transit, obstructed defecation, and a combination of both. Patients with obstructed defecation may have mechanical outlet obstruction related to the presence of anatomic abnormalities such as a rectocele, or functional outlet obstruction. The principles of treating slow-transit constipation or obstructed defecation alone are generally agreed upon. The optimal...

References

A descriptive study of the management of pain and pain-related side effects in a cancer center and a hospice. Hosp J 1995 10 89-108. 2. Sandler RS, Drossman DA. Bowel habits in young adults not seeking health care. Dig Dis Sci 1987 32 841. 3. Huizinga JD, Daniel EE. Motor functions of the colon. In Philips SF, Pemberton JH, Shorter RG, eds. The Large Intestine Physiology, Pathophysiology, and Disease. New York Raven Press, 1991 93-114. 4. Kellow JE, Borody TJ, Phillips...

Pudendal Nerve Terminal Motor Latency

Mark Electrode Pudendal

Pudendal nerve terminal motor latency PNTML is a measurement of time, or latency, from stimulation of the pudendal nerve at the level of the ischial spine to the muscle response in the external anal sphincter.5,23 A disposable electrode is placed on the examiner's gloved index finger Fig. 11.4 and inserted into the anal canal Fig. 11.5 . The stimulation is transrectally performed with the electrode located at the ischial spine while the response is recorded at the base of the examiner's finger....

Enterocele Peritoneocele

Enterocele Defecography

A peritoneocele is a caudal invagination of the peritoneum, between the posterior vaginal wall Figure 9.3. Rectal intussusception or internal prolapse, increasingly pronounced with straining. Note the initial appearance of an anterior rectocele,fol-lowed by the teacup appearance of the middle image. Figure 9.3. Rectal intussusception or internal prolapse, increasingly pronounced with straining. Note the initial appearance of an anterior rectocele,fol-lowed by the teacup appearance of the middle...

Diaphragmatic Breathing Physiological Quieting

The breathing cycle is intimately connected to both sympathetic and parasympathetic action of the autonomic nervous system.19 Bowel and bladder function is also mediated by the autonomic nervous system.10 Conscious deep diaphragmatic breathing is one of the best ways to quiet the autonomic nervous system. This breathing effectively initiates a cascade of visceral relaxation responses. The aim of this exercise is to make the shift from thoracic breathing to abdominal breathing.19 Patients are...

Bulking Agents

Fiber supplementation should be foundational therapy for most if not all constipated patients.7 A constipated patient should be started at a relatively low dose and slowly increased to a typical daily dose over several days to 1 week. Starting low will help to decrease bloating. After 2 to 4 weeks on therapy, if the patient is still having symptoms, the dose should be doubled in a split dose. Many patients have relief with fiber alone. Continued problems thereafter can be treated with...

Rectal Prolapse

Markedly Redundant Colon

Internal rectal intussusception is an early stage of rectal prolapse, where the proximal rectum has prolapsed into the ampulla but has not progressed through the anal canal. Symptoms include constipation and an incomplete sense of evacuation. Less commonly reported are incontinence, pain, and soiling. Endoscopy may reveal a solitary rectal ulcer on the anterior rectal wall 8 to 10 cm above the anal verge. Defecography is the diagnostic test of choice and shows the rectum intussuscepting several...

Rectocele

Rectocele Repair

A rectocele may be an important cause of obstructive defecation that presents as constipation. A rectocele is a herniation of the anterior wall of the rectum into the lumen of the vagina. A rectovaginal septum weakened by multiple childbirths and the aging process may enable stool to become trapped in this herniation, leading to a sense of incomplete evacuation. Continued straining may further weaken the rectovaginal septum and lead to progressive enlargement of the herniation. Because patients...

Sigmoidocele

Sigmoidocele

The existence and clinical implications of sig-moidocele are controversial. We have demonstrated that a deep rectovaginal pouch may contain small bowel at one time and sigmoid at another time, in the same patient. Jorge et al19 maintain that, as opposed to the small bowel, the herniated sigmoid is more prone to stasis, owing to its larger diameter and more solid contents. Jorge et al19 undertook a study to assess the incidence and clinical significance of sigmoi- Figure 9.5. Deep rectovaginal...

Conclusion

The epidemiology of constipation demonstrates a consistent pattern with several key points. No true population-based incidence or natural history studies have been published to date. The prevalence of constipation ranges from 3 to 27 , averaging approximately 15 , the variance resulting from differing case definitions of constipation and the effects of varying ascertainment methods. Constipation increases progressively with age, and this increase is particularly marked after the age of 65...

Descending Perineum Syndrome

Weakness of pelvic floor support may result in the descending perineum syndrome. This muscular weakness is reportedly related to injury of the sacral nerves or pudendal nerves or due to damage to the musculature itself during childbirth or chronic straining while defecating. Obstruction to defecation may occur through widening of the anorectal angle, weakening of the perineal body, and a more vertical orientation of the rectum, which are all results of pelvic floor weakness.14 A perineal...