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Perineal Procedures for Rectal Prolapse

Constipation and rectal prolapse frequently coexist. Estimates of preoperative constipation range from 30 to 67 in prospective studies.1 It is not clear whether constipation results in rectal prolapse, or prolapse results in constipation due to a functional outlet obstruction. Many patients report improvement in bowel function after surgery for rectal prolapse. Conversely, some patients with normal bowel function prior to surgery for rectal prolapse complain of constipation after surgery. Nevertheless, perineal procedures are often performed for patients with constipation and rectal prolapse.

Constipation and Rectal Prolapse

There are many excellent reviews of the surgical treatment of rectal prolapse, but there are few that have specifically addressed the issue of constipation in rectal prolapse patients. It is worth remembering that almost every patient with a rectal prolapse has some abnormality of bowel function. Whether the abnormality of bowel function is the cause of the prolapse or whether the functional bowel abnormality is a consequence of the prolapse is difficult to say.

Investigation in Rectal Prolapse Patients

Investigation in patients who have full-thickness rectal prolapse can be notoriously difficult. Colonic transit marker studies may be performed to assess the presence of colonic inertia, but they should probably be repeated, as a single study may be unreliable. Between 30 and 50 of women with full-thickness rectal prolapse have associated impaired colonic transit14 this incidence may be even higher in men. Videoproctography is remarkably difficult to interpret in patients with rectal prolapse. There is nearly always an intussusception, and a full-thickness rectal prolapse can usually be demonstrated. The presence of the intussusception or the prolapse may mask underlying impaired rectal evacuation. Thus, interpretation of video-proctography as a means of identifying the proportion of prolapse patients who also have impaired rectal emptying may be difficult.15

Laparoscopic Surgery for Rectal Prolapse

Rectal prolapse is regarded as a combined anatomic and functional disorder. This condition is usually accompanied by constipation or incontinence, thus requiring different treatment approaches. Full-thickness rectal prolapse (FTRP) may be approached transabdominally, by rectopexy, by colonic resection, or by a combination of the two, or perineally, either by a Delorme's procedure or a perineal rectosigmoidectomy. Methods described for rectopexy entail a variety of slings, sutures, and even special screws, which are applied in different ways. All of these variations are amenable for the conventional open technique or the minimally invasive approach. The minimally invasive approach offers less postoperative pain, better cosmetic results, and shorter hospital stay, thus making it more appealing.1 It is well recognized that performing laparoscopic colorectal surgery requires training and has a considerable learning curve. The advent of technology and the emergence of surgical robotics...

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 centimeters above the level of the levators. Classically, a funnel-shaped pattern is seen reflecting circular prolapse of the rectal wall. Rectal intussusception previously had been thought to be a common cause of obstructed defecation. However, because operative repair of rectal intussusception has met with little success, current thought suggests that intussusception may be the result of, and not the cause of, obstructed defecation. Figure 3.4. Full-thickness rectal prolapse. Figure 3.4....

Gender Ethnicracial And Life Span Considerations

The elderly are more prone to the condition because of their increased incidence of constipation, hemorrhoids, and diabetes mellitus. Women are more commonly affected by constipation than are men. An anorectal fistula is a rare diagnosis in children, but anorectal abscesses are common in infants and toddlers, particularly those still in diapers. Anal fistulas are complications of anorectal abscesses, which are more common in men than in women. For anatomical reasons, rectovaginal fistulas are found only in women. Ethnicity and race have no known effect on the risk of anorectal fistulas.

Physiological Factors Metabolic

Delayed orocecal transit studies were reported in pregnancy.27 There is an increased incidence of constipation and symptomatic hemorrhoids, especially during the latter phases of pregnancy, either as a result of alterations in hormones or secondary to mechanical compression caused by an enlarging uterus.28

Additional Evaluations

The correlation between psychological factors and constipation is a well-known fact, both in clinical practice and in the literature.57,58,72 Accordingly, the Minnesota Multiphasic Personality Inventory scores for the neurotic triad (hypochondria, depression, and hysteria) are significantly higher in patients with constipation when compared to those with anal incontinence and rectal pain.73 Organic causes of constipation, however, must not be overlooked in psychiatric patients. When a psychiatric disorder is diagnosed in a patient with symptoms of constipa 42. Porter NH. A physiological study of the pelvic floor in rectal prolapse. Ann R Coll Surg 1962 31 379-404.

Clinical evaluation

Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms.

System Reconstructive Procedures

Patients with a rectocele have a history of constipation, hemorrhoids, pressure sensations, low back pain, difficulty with intravaginal intercourse, and difficulty controlling and evacuating the bowel. Symptoms may be worse when standing and lifting and are relieved somewhat when lying down. Obstetric history often reveals a forceps delivery. Some report that they are able to

Discharge And Home Healthcare Guidelines

Review use of any pain medication prescribed, as well as non-pharmacologic comfort measures for episiotomy, lacerations, and hemorrhoid care. Instruct the patient to report any increase in perineal or uterine pain, foul odor, fever or flulike symptoms, or vaginal bleeding that is heavier than a menstrual period. Sadness or mood swings that persist beyond 4 weeks should be reported to the physician.

Lower Gastrointestinal Bleeding

Risk factors that may have contributed to the bleeding include and nonsteroidal anti-inflammatory drugs, anticoagulants, colonic diverticulitis, renal failure, coagulopathy, colonic polyps, and hemorrhoids. Patients may have a prior history of hemorrhoids, diverticulosis, inflammatory bowel disease, peptic ulcer, gastritis, cirrhosis, or esophageal varices. D. Hematochezia. Bright red or maroon output per rectum suggests a lower GI source however 12 to 20 of patients with an upper GI bleed may have hematochezia as a result of rapid blood loss. 2. Painless massive bleeding suggests vascular bleeding from diverticula, angiodysplasia, or hemorrhoids. 4. Bleeding with rectal pain is seen with anal fissures, hemorrhoids, and rectal ulcers. 5. Chronic constipation suggests hemorrhoidal bleeding. New onset of constipation or thin stools suggests a left sided colonic malignancy. 6. Blood on the toilet paper or dripping into the toilet water suggests a perianal source of bleeding, such as...

Chamomile German chamomile Matricaria recutita syn M chamomilla Asteraceae

Chamomile is one of the most important medicinal plants of Europe, and has been in use for more than 2,000 years. It is used internally for gastrointestinal and respiratory complaints, as well as topically for inflammatory skin conditions (eczema, wounds, haemorrhoids). Hippocrates called it euanthemos (the real or good flower), Dioscorides called it anthemis and anthyllis, and Galen called it anthemis and chamaimelon (apple growing on the ground). It continues to be an important medicine in academic as well as popular medicine. The species has been exported to many areas and is today an essential element of medical systems all over the world. Chamaemelum nobile, or Roman chamomile, has very similar uses, especially as a (bitter) tonic and a gastrointestinal remedy, but it is chemically rather different. Historically it has been an important medicinal plant in England, France, and Italy.

Background Information

Intestinal bacteria play an important role in the pathogenesis of disease as intestinal inflammation failed to develop in CD45RBhigh CD4+ cell-restored immunodeficient mice raised under germ-free conditions (Aranda et al., 1997 Powrie et al., 1998). It is not known whether T cells are activated as a result of recognition of antigenic bacterial peptides or whether bacterial products act as mitogens or superantigens leading to polyclonal T cell expansion. Evidence to date suggests that IBD develops as a result of an abnormal immune response to commensal bacteria however, recent studies have highlighted the effect that pathogenic bacteria can have on the disease process. Experimental infection of C.B-17 SCID mice with Helicobacter hepaticus leads to development of colitis in recipients even in the absence of T cells. By far the most severe disease, often including rectal prolapse, was obtained in the presence of both CD45RBhigh CD4+ cells and H. hepaticus infection, indicating that an...

Surgical Treatment of Rectocele Colorectal Approaches

Rectocele Measurement Defecography

Anterior rectocele is a frequent finding in females, with an incidence ranging from 39 to 72 .6 Furthermore, rectocele may coexist with other anal or perineal pathologies such as sig-moidocele, enterocele, hysterocele, cystocele, rectal prolapse, hemorrhoids, and anal fissure. Olsen et al7 noted that 76 of woman with documented pelvic organ prolapse had concomitant rectocele. Moreover, Freimanis et al8 and Shorvon et al9 found a 60 and 76 incidence of rectoceles, respectively, in dynamic proctography of asymptomatic females.

Sacral Nerve Stimulation

Pelvic causes of abnormal evacuation include rectal aganglionosis, rectal intussusception or complete rectal prolapse, and anterior rectal wall hernia (rectocele), and they may sometimes be cured with surgery. Many patients with rectal constipation lack coordination of the rectum and the anal sphincters (outlet constipation),which is not amenable to simple surgical treatments. While biofeedback, stool softeners, and laxatives help some patients, these agents are often not a satisfactory long-term solution. Moreover some patients with colonic inertia are unresponsive to medical therapy, and the results of a subtotal colectomy are not always predictable.

Anal Encirclement Procedure

In 1891, Thiersch initially described encirclement of the anus with silver wire for treatment of incontinence and rectal prolapse.5'6 It was hoped that the wire would produce an area of fibrosis around the anus that would act as a passive support for the pelvic floor (Fig. 20.1). Unfortunately, not only did the wire fail to provoke the desired fibrosis, but it also produced unwanted complications, including ulceration, erosion, breakage, and fecal impaction. Figure 20.1. Anal encirclement. Also known as the Thiersch procedure, this operation has been performed with the use of many types of material. Note that the ring is placed in the subcutaneous (perianal) tissue and offers no support to the levators. (From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier.) Figure 20.1. Anal encirclement. Also known as the Thiersch procedure, this operation has been performed with the use of many types of material. Note that the ring...

Perineal Rectosigmoidectomy

Perineal rectosigmoidectomy. With the rectum prolapsed,the outer rectal tube is incised circularly (a) and unfolded (b).The mesorec-tum is serially ligated and divided (c). When all redundancy has been removed,the inner tube is divided, which completes the resection (d). From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier. Figure 20.3. Perineal rectosigmoidectomy. With the rectum prolapsed,the outer rectal tube is incised circularly (a) and unfolded (b).The mesorec-tum is serially ligated and divided (c). When all redundancy has been removed,the inner tube is divided, which completes the resection (d). From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier. RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier. RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from...

Mucosal Sleeve Procedure

Resection of mucosal sleeve and plication of the rectal wall (Delorme procedure). This operation involves a total mucosal stripping of the prolapsed segment and its plication in an accordion-like fashion by a series of stitches. From Karulf RE,Madoff RD,Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier. Figure 20.5. Resection of mucosal sleeve and plication of the rectal wall (Delorme procedure). This operation involves a total mucosal stripping of the prolapsed segment and its plication in an accordion-like fashion by a series of stitches. From Karulf RE,Madoff RD,Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier. The main advantage of the Delorme procedure is its minimal physiologic impact. The lack of an abdominal incision and avoidance of the peritoneal cavity are key factors. It can be performed under local anesthesia, if needed, on even the highest risk patients. It is ideal for a...

Associated Constipation

A careful history in patients with rectal prolapse indicates that between 30 and 45 of women suffering from full-thickness rectal prolapse have constipation.2-8 Often there is a history of incomplete rectal evacuation. It is more common, however, to elicit a history of fecal incontinence in patients with rectal prolapse, as approximately 70 of women with a full-thickness rectal prolapse suffer bowel Rectal prolapse

Treatment Implications Warning About Risk

Division of the lateral stalks will reduce the incidence of postoperative recurrence at the expense of increasing the incidence of postoperative constipation. A prospective randomized study was undertaken including 26 patients with full-thickness rectal prolapse.26 Fourteen patients had rectopexy with and 12 without division of the lateral ligaments. Incontinence improved in both groups of patients however, the authors note that division of the lateral ligaments statistically significantly increased the number of patient with postoperative constipation. While three patients had preoperative constipation, 10 patients suffered postoperative constipation in this latter group. Although mean anal canal pressures were higher after surgery in all patients in the study, sensory thresholds significantly increased in those in whom the ligaments had been divided but not in those in whom they had been preserved. However, these benefits of preservation of the lateral...

Preoperative Investigations and Management

Preoperative investigations are important to ensure that patients receive the appropriate treatment or procedure. Flexible sigmoidoscopy or colonoscopy is necessary to exclude any possibility of a malignant or benign lesion that may act as a lead point for intussusception. In addition, other conditions such as solitary rectal ulcer, suggestive of internal rectal prolapse, should be excluded. Prolonged constipation prior to rectal prolapse is suggestive of colonic inertia, thus mandating a combined approach of resection with rectopexy.3-5 In patients with suspected incontinence, anal ultrasonography, manometry, and pudendal nerve latency tests should be performed prior to the procedure. It is suggested that these patients would benefit mostly from a suture rectopexy without the addition of bowel resection.6 These tests may be of some predictive value and serve as a point of reference in monitoring postoperative improvement. Also, they may dictate the preference of one method over the...

Laparoscopic Rectopexy and Sigmoid Resection

The combined procedure follows the principle of providing remedial surgical treatment for each of the disorders malfunctions in the proposed mechanism of full-thickness rectal prolapse. This procedure entails full mobilization of the rectum without division of the lateral stalks and followed by a posterior rectopexy, fixing the rectum to the sacral promontory.

Postoperative Outcome

Evaluation of the postoperative outcome of surgical treatment for rectal prolapse is based not only on morbidity and recurrence rates but also on functional outcome.12 There are a large variety of surgical solutions for this disorder, suggesting that no single solution can provide 100 of success.

Necrotizing Enterocolitis NEC

Necrotizing enterocolitis is most commonly seen in premature infants and presents as intolerance of feeds which progresses to distension and bloody stools. It may be associated with ischemia, malnutrition, and use of synthetic formulas. Radiographic findings may include pneumatosis intestinalis which is caused by gas forming bacteria. Initial treatment is to stop the tube feeds, place an NG for decompression, and start TPN and antibiotic therapy. Surgery involves resection of the affected bowel with ostomy and is performed on those infants with free air, refractory acido-sis, peritoneal signs, or gas within the portal vein among other findings. If laparo-tomy reveals massive gangrene necrosis, only the bowel which is clearly necrotic is

Postoperative Course FollowUp

The immediate postoperative recovery was uneventful. After leaving the hospital, the patient suffered constant rectal pain requiring readmission to hospital. Examination under anesthesia, 5 weeks after the operation, revealed a large necrotic ulcer of the posterior wall of the rectum and upper anal canal 70 mm in length. There was florid granulation tissue present, partly covered by fibrin and slough. Biopsies showed no evidence of carcinoma. There were occasional bizarre cells consistent with radiotherapy effect. The rectal pain continued over a period of 11 months. Healing of the ulcer occurred without specific treatment in 12 months. The referring gastroenterologist in a distant rural area performed further supervision. The patient succumbed to liver metastases 18 months after the local excision. There was no clinical evidence of local recurrence.

Primary Nursing Diagnosis

Careful postoperative management is essential for providing comfort and reducing surgical mortality. Observe vital signs, prothrombin times, drainage from drains, and wounds for signs of infection, hemorrhage, or fistula formation. Report immediately any evidence of increasing abdominal distension shock hematemesis, bloody stools or bloody, gastric, or bile-colored drainage from incision sites. Vitamin K injections and blood components may be needed.

Motility

The slow waves are the most frequent, from nine to 20 cycles per minute. The intermediate waves have frequencies varying from four to eight cycles per minute and has been noted in patients with neurogenic incontinence and after ileal pouch-anal anastomosis. The ultraslow waves are the second most frequent, with frequencies varying from five to 15 cycles per minute and were associated with the presence of hemorrhoid disease and anal fissures. In addition, the ultraslow waves have been seen in patients with high resting pressures related to chronic constipation (Fig. 8.12).

Pain with Defecation

Ill-defined low pelvic pain and painful straining at defecation (tenesmus) are frequently difficult to explain and even more difficult to treat. After evaluating for obvious sources, such as fissure, hemorrhoids, or ulcer, defecography may help to establish or exclude an anatomic etiology. For example, paradoxical contraction of pelvic muscles may explain anismus and cramping or spastic pain. Extensive perineal descent may result in stretching of the pudendal nerve that can cause a dull, aching sensation after defecation.

Reproducibility

Variation in the reproducibility of specific defeco-graphy measurements remains an unresolved issue. To determine interobserver variation, four independent observers, two blinded to the patient's history, reviewed randomly sequenced videodefecographies performed in constipated patients. Two weeks after the initial assessment, intraobserver variation was determined by a repeat blinded review of unlabeled randomly sequenced studies. The results of interobserver accuracy for sigmoidocele, rectal sigmoidocele, intussusception, rectal prolapse, rectal empyting, opening of the anal canal, puborectalis contraction, and straightening of the anorectal angle and rectal empyting were 89.5 , 46 , 87.5 , 97.5 , 86.5 , 88.5 , 83 , and 80 , respectively. The intraobserver variations for these same variables

Evaluation

The importance of preoperative evaluation prior to embarking of any form of surgical intervention for rectal prolapse cannot be overemphasized. Three specific areas are assessed before perineal surgery for patients with constipation and rectal prolapse. First, many of the patients specifically referred for perineal procedures for rectal prolapse are sent because of their high risk for abdominal surgery. A careful evaluation of the patient's medical history and risk factors for surgery must be performed. Second, because patients with prolapse can manifest a wide range of dysfunction from incontinence to constipation, the understanding of the pelvic floor physiology of each individual is essential. A common battery of tests may include electromyography, anal manometry, and defecography. Paradoxical puborectalis contraction is often found during preoperative evaluation with defecography. In one series, 12 of 61 patients (20 ) with rectal prolapse had non-relaxing puborectalis prior to...

Perineal Rectopexy

Through a posterior perineal incision, the rectum is widely mobilized. A patch of Mersilene mesh is sewn to the sacrum. The sides of the rectum will then be sutured to its edges. From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier. Figure 20.6. Perineal rectopexy. Through a posterior perineal incision, the rectum is widely mobilized. A patch of Mersilene mesh is sewn to the sacrum. The sides of the rectum will then be sutured to its edges. From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001 38 771-832, with permission from Elsevier.

Abnormal Motility

In a review, 12 patients complaining of constipation after Orr-Loygue rectopexy were compared with 12 patients with full-thickness rectal prolapse and 10 healthy volunteers.29 The rectopexy group was similar to the other two groups in terms of demographics and preoperative function. However, the rectopexy group had lower weekly stool frequency and a higher prevalence of abdominal pain. The authors also reported prolonged global, right, and left colonic transit times in the rectopexy group, but similar rectosigmoid transit times and manometric parameters of the anal sphincter in all three groups. They suggested that the obstruction was

Intussusception

It is unknown whether an intussusception subsequently develops into a full-thickness rectal prolapse. Studies on the long-term natural history of intussusception indicate that some patients do ultimately develop full-thickness rectal prolapse. evacuation of the rectum, causing straining and in time possibly the development of a full-thickness rectal prolapse. There is no doubt that intussusception is commonly associated with obstructed defecation, purely on the basis of mechanics. Thus, the intussusception fills the lumen of the rectum and prevents normal evacuation. It is quite likely that there are some patients who have a primary problem of colonic inertia and impaired rectal emptying who, as a result of straining, develop an incomplete intussusception, which exacerbates the constipation. Hence, it is likely that a small proportion of patients with rectal prolapse have a primary abnormality of colonic transit and rectal emptying, leading to an intussusception, which subsequently...

Physical Examination

Two Finger Cul Sac

Both the lateral decubitus and prone jackknife positions are adquate for routine anorectal examination. Although the prone position allegedly provides wider exposure, the left lateral decubitus is a good alternative and better accepted by patients, particularly the elderly or those otherwise incapacitated. Occasionally, however, in order to reveal a rectal prolapse, it may be necessary to place the patient in a squatting position. The anorectal examination should begin by inspection of the patient's undergarment and perineal skin for evidence of fecal soiling. Soiling may result from overflow incontinence associated with fecal impaction (overflow or paradoxical fecal incontinence), especially in elderly patients. This situation must be differentiated from true incontinence due to sphincter dysfunction and humid anus or pseudoincontinence, which is caused by hemorrhoidal prolapse, pruritus ani, perianal fistula, rectal mucosal prolapse, and anorectal venereal diseases, and should be...

Biofeedback Sessions

With dyssynergia, voiding dysfunction, and pelvic pain. Jacobson's progressive muscle relaxation strategy indicated that after a muscle tenses, it automatically relaxes more deeply when released.21 This strategy is used to assist with hypertonia, placing emphasis on awareness of decreased muscle activity viewed on the screen as the PFM becomes more relaxed. This repetitive contract-relax sequence of isolated pelvic muscle contractions also facilitates discrimination between muscle tension and muscle relaxation. Some patients, usually women, have a greater PFM descent with straining during defecation associated with difficulty in rectal expulsion. Pelvic floor weakness may result in intrarectal mucosal intussusception or rectal prolapse, which contributes to symptoms of constipation. Furthermore, the PFM may not have the ability to provide the resistance necessary for extrusion of solid stool through the anal canal.16

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