Abstract
Background
Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty.
Patients and methods
Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression.
Results
Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05).
Conclusions
Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Karlbom U, Pahlman L, Nilsson S, Graf W (1995) Relationships between defecographic findings, rectal emptying and colonic transit time in constipated patients. Gut 26:907–912
Pomerri F, Zuliani M, Mazza C, Villarejo F, Scopece A (2001) Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects. Am J Roentgenol 176:641–645
Sun WM, Read NW, Donnelly TC, Bannister JJ, Shorthouse AJ (1989) A common pathophysiology for full thickness rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer. Br J Surg 76:290–295
Pescatori M, Quondamcarlo C (1999) A new grading of rectal internal mucosal prolapse (RIMP) and its correlation with diagnosis and treatment. Int J Colorectal Dis 14:245–249
Sarles JC, Arnaud A, Selezneff I, Olivier S (1989) Endo-rectal repair of rectocele. Int J Colorectal Dis 4:167–171
Pescatori M, Favetta V, Dedola S, Orsini S (1997) Transanal stapled excision of rectal mucosal prolapse. Tech Coloproctol 1:96–98
Tsunoda A, Yatsuda N, Yokoyama N, Kamiyama G, Kusano M (2003) Delorme’s procedure for rectal prolapse: clinical and physiological analysis. Dis Colon Rectum 46:1260–1265
Zbar AP, Lienemann A, Fritsch H, Beer-Gabel M, Pescatori M (2003) Rectocele: pathogenesis and surgical management. Int J Colorectal Dis 18:369–384
Devroede G, Girard G, Bouchoucha M et al (1989) Idiopathic constipation by colonic dysfunction: relationship with personality and anxiety. Dig Dis Sci 34:1428–1433
Renzi C, Pescatori M (2002) Family drawing in the clinical approach to patients with chronic constipation: preliminary data. Neurogastroenterology 2:54–57
Spielberg CD (1996) STAI, state-trait anxiety inventory. Mindgarden, Redwood City CA, OS Organizzazioni Speciali, Firenze
Chen HH, Ioratulam A, Alabaz O, Weiss EG, Nogueras JJ, Wexner SD (2001) Associations of defecography and physiologic findings in male patients with rectocele. Tech Coloproctol 5:157–161
D’Hoore A, Penninckx F (2003) Obstructed defecation. Colorectal Dis 5:280–287
Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD (1996) A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 29:681–685
Pescatori M, Anastasio G, Bottini C, Mentasti A (1992) A new grading and score of anal incontinence: evaluation of 335 patients. Dis Colon Rectum 35:482–487
Tsiaoussis J, Chrysos E, Glynos M, Vasiliakis JS, Xynos E (1998) Pathophysiology and treatment of anterior mucosal prolapse syndrome. Br J Surg 85:1699–1702
Mellgren A, Schultz I, Johansson C, Dolk A (1997) Internal rectal intussusception seldom develops into total rectal prolapse. Dis Colon Rectum 40:817–820
Allen-Mersh TG, Henry MM, Nicholls RJ (1987) Natural history of anterior mucosal prolapse. Br J Surg 74:679–682
Altomare DF, Rinaldi M, Sallustio PL, Martuo P, DeFazio M, Memeo V (2001) Long-term effects of stapled haemorrhoidectomy on internal anal sphincter function and sensitivity. Br J Surg 88:1487–1491
Araki Y, Ishibashi N, Kishimoto Y et al (2001) Circular stapling procedure for mucosal prolapse of the rectum and with outlet obstruction. Kurume Med J 48:201–204
Renzi C, Pescatori M (2000) Psychological aspects in proctalgia. Dis Colon Rectum 43:35–39
Devroede G, Bouchoucha M, Girard G (1989) Constipation, anxiety and personality: what comes first? In: Bueno L, Collins S, Junior JL (eds) Stress and digestive motility. John Libbey, London, pp 55–60
Leroi AM, Bernier C, Watier A et al (1995) Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract. Int J Colorectal Dis 10:200–206
Garvey M, Noyes R, Yates W (1990) Frequency of constipation in major depression: relationship to other clinical variables. Psychosomatics 31:204–206
Nehra V, Bruce BK, Rath-Harvey DM, Pemberton JH, Camilleri M (2000) Psychological disorders in patients with evacuation disorders and constipation in a tertiary practice. Am J Gastroenterol 95:1755–1758
Wald A, Hinds JP, Caruana BJ (1989) Psychological and physiological characteristics of patients with severe idiopathic constipation. Gastroenterology 97:932–937
Mason HJ, Serrano-Ikkos E, Kamm MA (2002) Psychological state and quality of life in patients having behavioural treatment (biofeedback) for intractable constipation. Am J Gastroenterol 97:3154–3159
Tjandra JJ, Ooi BS, Tang CL, Dwyer P, Carey M (1999) Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus. Dis Colon Rectum 42:1544–1550
Sielezneff I, Malouf A, Cesari J, Bresset C, Sarles JC, Sastre B (1999) Selection criteria for internal rectal prolapse repair by Delorme’s transrectal excision. Dis Colon Rectum 42:367–373
Acknowledgements
The authors wish to thank Stella Ayabaca for her helpful cooperation.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Pescatori, M., Boffi, F., Russo, A. et al. Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation. Int J Colorectal Dis 21, 160–165 (2006). https://doi.org/10.1007/s00384-005-0758-x
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-005-0758-x