Authors: Varut Lohsiriwat

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.

Topics: Abscess; Adult; Anorectal Malformations; Digital Rectal Examination; Emergencies; Endoscopy; Fissure in Ano; Foreign Bodies; Fournier Gangrene; Gastrointestinal Hemorrhage; Hemorrhoids; Hirschsprung Disease; Humans; Infant, Newborn; Intestinal Obstruction; Perineum; Rectal Diseases; Rectal Neoplasms; Rectal Prolapse; Rectum; Sexually Transmitted Diseases; Thrombosis; Varicose Veins

PubMed: 27468181
DOI: 10.3748/wjg.v22.i26.5867

Review

Authors: Kenneth C Loh, Konstantin Umanskiy

Rectal prolapse is a debilitating condition that often results in impaired quality of life. Posterior compartment defects including rectal prolapse and rectal intussusception are often associated with middle and anterior compartment prolapse and require a multicompartment approach to treatment. In recent years, ventral rectopexy, with or without sacrocolpopexy for combined middle compartment prolapse, has emerged as a safe and effective method of treatment for rectal prolapse. In this article, we aim to review the etiology of rectal prolapse and intussusception, describe the indications and workup for surgery, discuss technical aspects of ventral rectopexy alone and in combination with sacrocolpopexy, review potential surgical complications, and describe the reported outcomes of the surgery.

PubMed: 33536851
DOI: 10.1055/s-0040-1714288

Review

Authors: Rebecca M Rentea, Shawn D St Peter

Rectal prolapse is a common and self-limiting condition in infancy and early childhood. Most cases respond to conservative management. Patients younger than 4 years with an associated condition have a better prognosis. Patients older than 4 years require surgery more often than younger children. Multiple operative and procedural approaches to rectal prolapse exist with variable recurrence rates and without a clearly superior operation. These include sclerotherapy, Thiersch's anal cerclage, Ekehorn's rectopexy, laparoscopic suture rectopexy, and posterior sagittal rectopexy.

PubMed: 29487493
DOI: 10.1055/s-0037-1609025

Review

Authors: Naveen Kumar, Devinder Kumar

Topics: Adult; Aged; Fecal Incontinence; Female; Humans; Male; Middle Aged; Pregnancy; Rectal Prolapse

PubMed: 32002830
DOI: 10.1007/s12664-020-01014-1

Review

Authors: Yukihiro Hamahata, Kazunari Akagi, Takahumi Maeda...

Pelvic organ prolapse (POP) is a condition wherein one or more of the organs in the pelvis slip down from their original position and protrude into the vagina. Pelvic organ prolapse surgery has increased in the urogynecological field due to higher aging society. POP patients often suffer from bowel dysfunction, such as difficulty of bowel movements and the need to strain or push on the vagina to have a bowel movement. Rectocele is often treated with the same method used for POP, but sometimes it is treated transanally. In the transabdominal approach, the vagina is divided from the rectum, and the mesh is fixed between the vagina and rectum. On the other hand, rectal prolapse is a condition wherein the rectum slips down from its original position and protrudes from the anus. Like POP surgery, rectal prolapse has been treated laparoscopically. Even though the protruding position is different, both are pelvic conditions, and the concept of treatment is similar. Recently, POP and rectal prolapse have been diagnosed at the same time, and sometimes these diseases have been treated together. In the higher aging society, incidences of POP and rectal prolapse will increase, and both will have greater chance to be treated. Although POP is a urogynecological disease, coloproctologists need to know the bowel dysfunction in order to treat POP.

PubMed: 35572489
DOI: 10.23922/jarc.2020-007

Review

Authors: Jamie A Cannon

Full-thickness rectal prolapse, or procidentia, is the passage of the full-thickness wall of the rectum beyond the anal sphincters. This condition results in pain and fecal incontinence which greatly impairs the quality of life of those afflicted. It is associated with several anatomic abnormalities, including decreased anal sphincter tone, levator muscle diastasis, and a deep anterior cul-de-sac. The diagnosis of rectal prolapse is made based on physical examination, although several other modalities are used to provide additional information about the patients' condition. While medical management of rectal prolapse can be effective in some cases, the mainstay of management of rectal prolapse is surgical correction.

PubMed: 28144208
DOI: 10.1055/s-0036-1593431

Review

Authors: Jean-Luc Faucheron, Bertrand Trilling, Edouard Girard...

AIM

To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.

METHODS

MEDLINE, PubMed, EMBASE, and other relevant database were searched to identify studies. Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.

RESULTS

Twelve non-randomized case series studies with 574 patients were included in the review. No surgical mortality was described. Conversion was needed in 17 cases (2.9%), most often due to difficult adhesiolysis. Twenty eight patients (4.8%) presented with major complications. Seven (1.2%) mesh-related complications were reported. Most frequent complications were urinary tract infection and urinary retention. Mean recurrence rate was 4.7% with a median follow-up of 23 mo. Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%. Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages. Evaluation of functional score was disparate between studies.

CONCLUSION

Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.

Topics: Constipation; Digestive System Surgical Procedures; Fecal Incontinence; Humans; Laparoscopy; Postoperative Complications; Recovery of Function; Rectal Prolapse; Recurrence; Risk Factors; Time Factors; Treatment Outcome

PubMed: 25945021
DOI: 10.3748/wjg.v21.i16.5049

Authors: Autumn D Pak, Tien T Nguyen, Mathew Bogoyas...

Psychosis is a constellation of symptoms that present with a disconnect from reality. The duration, severity, and presentation of symptoms can present on a wide spectrum, and etiologies can vary from patient to patient. Psychosis is also associated with self-injurious thinking, behavior, and suicidality. Long-term treatment of psychosis with antipsychotics can often result in side effects like constipation, sedation, dry mouth, and metabolic syndrome. Though rectal prolapse is uncommon in adolescent patients, there was a noted correlation with rectal prolapse in adult patients that were treated for chronic psychiatric disease. We report a case of a 17-year-old female with psychosis and rectal prolapse, who was admitted for inpatient treatment.

PubMed: 36059365
DOI: 10.7759/cureus.27615

Authors: Carol Bugge, Elisabeth J Adams, Deepa Gopinath...

BACKGROUND

Pelvic organ prolapse is a common problem in women. About 40% of women will experience prolapse in their lifetime, with the proportion expected to rise in line with an ageing population. Women experience a variety of troublesome symptoms as a consequence of prolapse, including a feeling of 'something coming down' into the vagina, pain, urinary symptoms, bowel symptoms and sexual difficulties. Treatment for prolapse includes surgery, pelvic floor muscle training (PFMT) and vaginal pessaries. Vaginal pessaries are passive mechanical devices designed to support the vagina and hold the prolapsed organs back in the anatomically correct position. The most commonly used pessaries are made from polyvinyl-chloride, polythene, silicone or latex. Pessaries are frequently used by clinicians with high numbers of clinicians offering a pessary as first-line treatment for prolapse.  This is an update of a Cochrane Review first published in 2003 and last published in 2013.

OBJECTIVES

To assess the effects of pessaries (mechanical devices) for managing pelvic organ prolapse in women; and summarise the principal findings of relevant economic evaluations of this intervention.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 January 2020). We searched the reference lists of relevant articles and contacted the authors of included studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in at least one arm of the study.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts, extracted data, assessed risk of bias and carried out GRADE assessments with arbitration from a third review author if necessary.

MAIN RESULTS

We included four studies involving a total of 478 women with various stages of prolapse, all of which took place in high-income countries. In one trial, only six of the 113 recruited women consented to random assignment to an intervention and no data are available for those six women. We could not perform any meta-analysis because each of the trials addressed a different comparison. None of the trials reported data about perceived resolution of prolapse symptoms or about psychological outcome measures. All studies reported data about perceived improvement of prolapse symptoms. Generally, the trials were at high risk of performance bias, due to lack of blinding, and low risk of selection bias. We downgraded the certainty of evidence for imprecision resulting from the low numbers of women participating in the trials. Pessary versus no treatment: at 12 months' follow-up, we are uncertain about the effect of pessaries compared with no treatment on perceived improvement of prolapse symptoms (mean difference (MD) in questionnaire scores -0.03, 95% confidence interval (CI) -0.61 to 0.55; 27 women; 1 study; very low-certainty evidence), and cure or improvement of sexual problems (MD -0.29, 95% CI -1.67 to 1.09; 27 women; 1 study; very low-certainty evidence). In this comparison we did not find any evidence relating to prolapse-specific quality of life or to the number of women experiencing adverse events (abnormal vaginal bleeding or de novo voiding difficulty). Pessary versus pelvic floor muscle training (PFMT): at 12 months' follow-up, we are uncertain if there is a difference between pessaries and PFMT in terms of women's perceived improvement in prolapse symptoms (MD -9.60, 95% CI -22.53 to 3.33; 137 women; low-certainty evidence), prolapse-specific quality of life (MD -3.30, 95% CI -8.70 to 15.30; 1 study; 116 women; low-certainty evidence), or cure or improvement of sexual problems (MD -2.30, 95% -5.20 to 0.60; 1 study; 48 women; low-certainty evidence). Pessaries may result in a large increase in risk of adverse events compared with PFMT (RR 75.25, 95% CI 4.70 to 1205.45; 1 study; 97 women; low-certainty evidence). Adverse events included increased vaginal discharge, and/or increased urinary incontinence and/or erosion or irritation of the vaginal walls. Pessary plus PFMT versus PFMT alone: at 12 months' follow-up, pessary plus PFMT probably leads to more women perceiving improvement in their prolapse symptoms compared with PFMT alone (RR 2.15, 95% CI 1.58 to 2.94; 1 study; 260 women; moderate-certainty evidence). At 12 months' follow-up, pessary plus PFMT probably improves women's prolapse-specific quality of life compared with PFMT alone (median (interquartile range (IQR)) POPIQ score: pessary plus PFMT 0.3 (0 to 22.2); 132 women; PFMT only 8.9 (0 to 64.9); 128 women; P = 0.02; moderate-certainty evidence). Pessary plus PFMT may slightly increase the risk of abnormal vaginal bleeding compared with PFMT alone (RR 2.18, 95% CI 0.69 to 6.91; 1 study; 260 women; low-certainty evidence). The evidence is uncertain if pessary plus PFMT has any effect on the risk of de novo voiding difficulty compared with PFMT alone (RR 1.32, 95% CI 0.54 to 3.19; 1 study; 189 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain if pessaries improve pelvic organ prolapse symptoms for women compared with no treatment or PFMT but pessaries in addition to PFMT probably improve women's pelvic organ prolapse symptoms and prolapse-specific quality of life. However, there may be an increased risk of adverse events with pessaries compared to PFMT. Future trials should recruit adequate numbers of women and measure clinically important outcomes such as prolapse specific quality of life and resolution of prolapse symptoms.   The review found two relevant economic evaluations. Of these, one assessed the cost-effectiveness of pessary treatment, expectant management and surgical procedures, and the other compared pessary treatment to PFMT.

Topics: Bias; Female; Humans; Muscle Strength; Pelvic Floor; Pelvic Organ Prolapse; Pessaries; Randomized Controlled Trials as Topic; Rectal Prolapse; Urethral Diseases; Urinary Bladder Diseases; Uterine Prolapse

PubMed: 33207004
DOI: 10.1002/14651858.CD004010.pub4

Review

Authors: L Cariou de Vergie, A Venara, E Duchalais...

Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.

Topics: Constipation; Defecography; Fecal Incontinence; Humans; Laparoscopy; Magnetic Resonance Imaging; Quality of Life; Rectal Prolapse; Severity of Illness Index; Surgical Stapling; Treatment Outcome

PubMed: 27865742
DOI: 10.1016/j.jviscsurg.2016.10.004