The value of posterior levator repair in the treatment of anorectal incontinence due to rectal prolapse – a clinical and manometric study

Abstract.

Background: When treating a complete rectal prolapse, the most important objective is elimination of the prolapse. In addition, restoration of sufficient anorectal continence is extremely important for the patients. We examined the value of posterior levator repair with respect to stabilization of the pelvic floor and to improvement in anorectal incontinence. Methods: In patients with disabling anorectal incontinence, a posterior levatorplasty can be concomitantly performed during operative removal of the prolapse. To facilitate evaluation of the operative results, we implemented a scoring system to judge the patients' subjective symptoms of incontinence; in addition, we performed manometric measurements of resting and squeezing pressures of the anal sphincter to objectify the anorectal incontinence. Results: From 1991 to 1997, 84 patients (mean age 65±10 years, 38–91 years; 79 women, 5 men) with complete rectal prolapse and severe incontinence were operatively treated; corresponding follow-ups were done. The following procedures were performed: Frykmann-Goldberg, 28 patients; Wells, 18 patients; Ripstein, 22 patients; and perineal proctectomy, 16 patients. Incontinence for liquid and solid stools was present in all of these patients. Posterior levatorplasty was implemented in 38 patients, and in this group we found significantly better postoperative results, both clinically and in the manometric measurements. Continence was improved by 84% in the group with levatorplasty, but improvement was only 67% in the other group (P<0.05). The incontinence score decreased significantly in the group with levatorplasty (preoperative 16.4±3.1, postoperative 9.3±4.5, P<0.05, vs the other group with preoperative 15.6±4.2, postoperative 11.5±5.1). Manometric observations in the group with levatorplasty demonstrated 55% improvement in resting pressure (preoperative 29±17 cm H2O, postoperative 45±21 cm H2O, P<0.05) and 40% improvement in squeezing pressure (preoperative 61±25 cm H2O, postoperative 85±31 cm H2O, P<0.05). In the group without levatorplasty, resting and squeezing pressure improved only by 20% (resting pressure: preoperative 32±16 cm H2O, postoperative 38±18 cm H2O; squeezing pressure: preoperative 64±29 cm H2O, postoperative 75±26 cm H2O). Conclusions: Posterior levatorplasty is an easy and efficient operative procedure which facilitates an improvement in anorectal continence. There are no apparent disadvantages. For this reason, levatorplasty can be part of operative procedures implemented in the treatment of a complete rectal prolapse accompanied by disabling anorectal incontinence.