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 com- monly 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 exacer- bates 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 intussuscep- tion, which subsequently forms into a full- thickness rectal prolapse.
Schultz and colleagues
1compared the results of Marlex rectopexy in 46 patients with a full- thickness rectal prolapse to 29 with an intussus- ception. A much higher proportion of patients with intussusception developed deteriorating constipation compared with the prolaspe group (Table 21.1).
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.
2–8Often 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 There are many excellent reviews of the surgical
treatment of rectal prolapse, but there are few that have specifically addressed the issue of con- stipation in rectal prolapse patients.
It is worth remembering that almost every patient with a rectal prolapse has some abnor- mality of bowel function. Whether the abnor- mality of bowel function is the cause of the prolapse or whether the functional bowel abnor- mality is a consequence of the prolapse is difficult to say.
Constipation in Rectal Prolapse
Etiology
Rectal prolapse is considered by most authori- ties to be a true intussusception of the rectum through the pelvic floor and sphincters. Video- proctographic studies clearly demonstrate the apex of a rectal prolapse descending through the ampulla of the rectum and through the pub- orectalis swing to appear inside the anal canal and subsequently on the perineum as a rectal prolapse.
Intussusception
It is unknown whether an intussusception sub- sequently 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.
Intussusception is commonly associated with chronic straining due to a feeling of incomplete
21
Constipation and Rectal Prolapse
Michael R.B. Keighley
201
incontinence, with urgency, imperfect control of flatus, soiling, and poor bowel control, particu- larly if there is associated straining.
4,9–13Investigation in Rectal Prolapse Patients
Investigation in patients who have full-thickness rectal prolapse can be notoriously difficult.
Colonic transit marker studies may be per- formed 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 transit
14; 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 demon- strated. 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.
15History
A good clinical history is probably the most important single investigation. Patients will tell you whether or not they have to strain to eva- cuate. Patients will also be able to identify if they have infrequent evacuation with relatively normal emptying. If a patient has a history of chronic laxative use with difficulty evacuating, concomitant colectomy may be seriously consid- ered.
16In patients with laxative dependence, constipation is often worsened following abdominal rectopexy.
13Thus, if colonic inertia is identified, a subtotal colectomy with ileoproc- tostomy may be indicated. Similarly, finding a
symptomatic third-degree sigmoidocele with otherwise normal colonic transit may warrant a synchronous sigmoid colectomy.
A word of warning is needed with respect to resection rectopexy. Fixation of the prolapse and coexisting resection of the sigmoid may control the prolapse and normalize constipation, but if an excessively long left-sided colonic resection is performed, there may be a risk of precipitating incontinence. Most rectal prolapse patients have a patulous anus associated with low resting and squeeze pressures.
4There is a fine line between postoperative continence with some constipa- tion and incontinence but control of the prolapse with elimination of constipation. Thus, resection rectopexy should be reserved for patients with a clear history of preoperative constipation where there have been no factors that may have weak- ened the sphincter. Moreover, clinical examina- tion, anal manometry, and anal ultrasonography should all reveal satisfactory findings.
Thus, the thrust of preoperative investigations in rectal prolapse patients is not only to deter- mine colonic transit and impaired rectal evacua- tion, but also to assess whether the sphincters are strong enough to withstand the consequences of a colonic resection.Although this is an important warning note, the data seemed to indicate that resection rectopexy has no deleterious effect on either resting or squeeze anal canal pressure compared with rectopexy alone. Furthermore, the incidence of persistent incontinence is no greater after resection rectopexy compared with resection rectopexy alone (Table 21.2). In fact, the incidence of postoperative constipation is supe- rior after resection rectopexy as compared to rec- topexy alone.
17,18Two prospective randomized studies revealed superior function after resec- tion rectopexy as compared to rectopexy alone. Specifically, Luukkonen and coworkers
17prospectively randomized 30 patients between abdominal rectopexy and sigmoid resection versus rectopexy alone. While constipation
Table 21.1. Functional results of rectopexy: comparing prolapse with incomplete intussusception1
Rectal prolapse Incomplete
(n= 46) intussusception (n= 29) Rectal emptying
Improved 17 4
Unchanged 21 12
Deteriorated 8 13
Bowel incontinence
Improved 20 7
Unchanged 16 8
Deteriorated 10 4
Table 21.2. Functional outcome: rectopexy versus resection rectopexy13
Constipation Incontinence Preop Postop Preop Postop Rectopexy (n= 129) 47 (36) 42 (33) 48 (37) 25 (19) Resection rectopexy 12 (67) 2 (11) 5 (28) 3 (17)
(n= 18)
Values in parentheses are percentages.
Thus, young people with a rectal prolapse should be thoroughly investigated. In this group, not only should there be an assessment of colonic transit, but it would be wise to assess small-bowel transit and even gastric emptying as well, as some of these patients have a panen- teric myopathy or neuropathy. These are a group of patients in whom electromyography (EMG) assessment of puborectalis activity during straining might identify patients with anismus in whom results are likely to be poor. Panenteric inertia may preclude any resection and pelvic outlet obstruction may be amenable to biofeed- back or botulinum toxin injection.
Other risk factors for postoperative constipa- tion are (1) patients with gross perineal descent, (2) patients who admit to a history of straining, and (3) patients with a coexisting solitary rectal ulcer.
Advice Regarding Primary Treatment for Prolapse in Patients with a
History of Constipation or Impaired Evacuation Without Colonic Inertia or Megacolon
Resection rectopexy may be strongly recom- mended in most of these patients. All the evi- dence points to the fact that resection rectopexy has a lower incidence of postoperative constipa- tion compared with rectopexy alone.
The literature suggests that the rectopexy should be sutured and that a foreign material should be avoided. The incidence of constipation is much higher if Marlex or Ivalon or other foreign materials are used for fixation of the rectum (Table 21.3).
disappeared in three patients after resection rec- topexy and in two other patients after rectopexy alone, it became considerably worse in five addi- tional patients who had rectopexy alone, one of whom required a colectomy. The authors noted that although surgery did not significantly change colonic transit times and did seem to increase operative morbidity, sigmoid colectomy did diminish postoperative constipation spe- cifically, causing less obstruction.
In a similar study, McKee and associates
18prospectively randomized 18 patients with full- thickness rectal prolapse to rectopexy with or without sigmoid colectomy. Using postoperative colonic transit studies, the authors noted that after rectopexy alone there was a statistically significantly higher number of patients who developed postoperative marker delay as com- pared to patients after sigmoid colectomy with rectopexy. Anorectal physiologic investigation may have helped provide some answers to this difference, in that patients following rectopexy alone had a significantly higher rectal compli- ance than did patients after resection rectopexy.
The authors have hypothesized that the redun- dant sigmoid colon may have delayed passage of the intestinal contents and caused kinking at the junction of the sigmoid and rectum.
Risk Factors for Constipation
The principal risk factor for constipation after rectopexy for rectal prolapse is young age.
19Young patients have a high rate of recurrence, and the majority have been constipated for most of their lives. In the majority of these young people rectal prolapse is secondary to a long history of chronic straining.
Table 21.3. Continence and constipation after rectopexy and alternative procedures
Reference Operation Same Improved Worse New Onset
Kimm et al (1999) (n= 44)6 Resection rectopexy 45 52 NS NS
Aitola et al (1999) (n= 50)7 Rectopexy 16 8 6 22
Sayfan et al (1990) (n= 57)5 Rectopexy 40 24 NS 24
Lechaux et al (2001) (n= 35)8 Resection rectopexy 6 47 3 0
Holmstrom et al (1986) (n= 108)9 Ripstein 27 (foreign material) NS NS 43 NS
Klaaborg et al (1985) (n= 23)11 Roscoe Graham (suture) 27 NS NS 30
Watts et al (1985) (n= 138)2 Ivalon rectopexy + sigmoid colectomy 35 56 9 0
Mann and Hoffman 1988 (n= 66)3 Ivalon rectopexy alone 29 NS NS 47
Yoshioka et al (1989) (n= 135)4 Ivalon rectopexy alone 24 0 22 18
Sayfan et al (1990) (n= 13)5 Sutured and sigmoid colectomy 8 31 0 0
NS, not stated.
Anterior rectopexy (Ripstein procedure) would also be contraindicated in patients with a history of constipation. The incidence of consti- pation after anterior rectopexy, even without stenosis, is very high, and there is a risk of mechanical stricturing as well.
A randomized controlled trial comparing Ivalon rectopexy with sutured rectopexy re- ported a lower incidence of constipation when the foreign body was avoided (Table 21.4).
20Perhaps the most difficult question to answer is how much colon to remove. Usually in resec- tion rectopexy the sigmoid is removed so that the large bowel is straight between the descend- ing colon and the rectum, with some bowstring- ing as a consequence of the rectopexy. Some data would support a subtotal colectomy in a patient with colonic inertia where anal sphinc- ter anatomy and function are satisfactory and where there is no history of incontinence.
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 consti- pated after the operation.
Factors that seem to increase the risk of con- stipation 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.
22The problem with postoperative constipation after rectopexy is that it is very difficult to predict who will become constipated and thus in whom concomitant resection would be justified.
To help avoid disappointed patients, it is cru- cially important to warn patients that rectopexy might conceivably precipitate or exacerbate con- stipation. Similarly, they should have these same expectations about new or preexisting fecal incontinence.
Laparoscopic Rectopexy
All the evidence suggests that open rectopexy, particularly with mesh, has a 20% to 40% risk of causing constipation. Recent data suggest that the incidence of constipation is probably reduced by laparoscopic rectopexy, even without a resection, and that the number who develop constipation for the first time is also small (Table 21.5).
21–25Treatment Implications
Warning About Risk
The key messages are that patients having a rec- topexy, even if they do not suffer from any pre- operative constipation, should be warned about the risks of postoperative constipation. Further- more, the majority of these patients should be offered a resection rectopexy on the grounds that this does not in any way increase the risk of incontinence while reducing the incidence
Table 21.4. Randomized trial of sponge versus sutured rectopexy (no resections)20
Ivalon sponge Sutured alone (n= 31) (n= 32) Hospital stay (days) 14 (8–52) 14 (8–50)
Mortality 0 0
Complications 6 (19%) 3 (9%)
Recurrent prolapse 1 (3%) 1 (3%) Late postoperative incontinence 6/10 2/10 Postop constipation 15 (48%) 10 (31%)
Table 21.5. Laparoscopic rectopexy
Constipation
No. Mortality Recurrence Hospital stay (days) Resection Before After New onset
Bruch et al (1999)22 72* 0 0 15 (6–47) 40 37 8 4
Stevenson et al (1998)21 34 1 0 5 (3–66) 30 14 5 2
Boccasanta et al (1999)25 10 0 1 7 (5–12) 0 1 1 0
Heah et al (2000)23 25 0 0 7 (3–23) 0 9 9 2
Solomon et al (2002)24 20 0 0 4 (3–6) 0 Visual analogue
scale only
* 22% rendered incontinent or incontinence worse after operation.
versely, sigmoid colectomy alone is unlikely to resolve the problems of persistent constipation, and a high proportion of these individuals require a subtotal colectomy and ileorectal anas- tomosis. Thus, the majority of patients with con- stipation after a previous rectopexy, after appropriate counseling and investigation, are likely to be offered some form of subtotal colec- tomy, provided that their sphincter anatomy and function are satisfactory and provided that the preoperative tests do not indicate a high risk of incontinence.
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A prospective randomized study was under- taken including 26 patients with full-thickness rectal prolapse.
26Fourteen patients had rec- topexy 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 pa- tients 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 preserva- tion of the lateral stalk were at the expense of an increased rate of recurrence, as prolapse recurred in six patients in whom the stalks were not divided, but did not recur in any of the 12 patients in whom the ligaments were divided.
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Laparoscopic Procedures
To date, the results of laparoscopic rectopexy and resection rectopexy seem to be associated with less constipation than open rectopexy alone.
Thus, laparoscopic treatment should be encour- aged, provided the recurrence rates remain low.
All patients who develop postoperative con- stipation should be investigated by colonic transit studies and probably also by small-bowel transit studies, videoproctography, and anal manometry and contrast enema. These studies should help identify both physiologic and anatomic causes of constipation.
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