Clinical, endoscopic and radiological assessment of patients with obstructed defecation: findings and management at a District General Hospital

Background: The aim of the study was to determine the diagnostic value of clinical, endoscopic and proctographic assessment as well as clinical outcomes in patients with obstructed defaecation (OD). The study also examined correlation between clinical/endoscopic findings and proctogram in the diagnosis of rectocele and intra-rectal intussusception (IRI).Methods: Patients presenting with symptoms of OD between January-December 2018 were assessed with manual examination, endoscopy and defecation proctogram. Patients were followed for 2-3 years for clinical outcomes.Results: There were 65 female (97.01%) and 2 male patients (2.98%), with an average age of 57.77 (34-88) years. Main indications were OD, altered bowels, faecal urgency and rectal bleeding. A total of 67 X-ray defecating proctograms and 77 endoscopies were performed. Main findings on clinico-endoscopic examination were IRI (44), rectocele (36) and haemorrhoids (21). Main findings on proctogram were rectocele (59), IRI (56) and enterocele (13). Endoscopic assessment showed sensitivity: 55.93%, specificity: 62.50% and accuracy: 56.72% in diagnosing rectocele when compared with the diagnostic confirmation on proctogram. Combining manual assessment with endoscopic findings improved sensitivity (76.27%) and accuracy (68.66%). Similar improvement was also noted in the sensitivity (61.40 to 66.67%), specificity (47 to 58%), and accuracy (53.73 to 58.21%) in diagnosing IRI when compared with the diagnostic confirmation on proctogram. Majority of the patients improved with conservative measures; however, surgical intervention was required in 13 patients.Conclusions: Although manual examination enhances endoscopic assessment in diagnosing rectocele and IRI, proctogram is still required for objective assessment. Management of OD remains mainly conservative, with surgical intervention required in some patients.

Barium Defecating Proctography and Dynamic Magnetic Resonance Proctography: Their Role and Patient’s Perception

Objectives: The objectives of the study were to compare the imaging findings and patient’s perception of barium defecating proctography and dynamic magnetic resonance (MR) proctography in patients with pelvic floor disorders. Material and Methods: This is a prospective study conducted on patients with pelvic floor disorders who consented to undergo both barium proctography and dynamic MR proctography. Imaging findings of both the procedures were compared. Inter-observer agreement (IOA) for key imaging features was assessed. Patient’s perception of these procedures was assessed using a short questionnaire and a visual analog scale. Results: Forty patients (M: F =19:21) with a mean age of 43.65 years and range of 21–75 years were included for final analysis. Mean patient experience score was significantly better for MR imaging (MRI) (p < 0.001). However, patients perceived significantly higher difficulty in rectal evacuation during MRI studies (p = 0.003). While significantly higher number of rectoceles (p = 0.014) were diagnosed on MRI, a greater number of pelvic floor descent (p = 0.02) and intra-rectal intussusception (p = 0.011) were diagnosed on barium proctography. The IOA for barium proctography was substantial for identifying rectoceles, rectal prolapse and for determining M line, p < 0.001. There was excellent IOA for MRI interpretation of cystoceles, peritoneoceles, and uterine prolapse and substantial to excellent IOA for determining anal canal length and anorectal angle, p < 0.001. The mean study time for the barium and MRI study was 12 minutes and 15 minutes, respectively. Conclusion: Barium proctography was more sensitive than MRI for detecting pelvic floor descent and intrarectal intussusception. Although patients perceived better rectal emptying with barium proctography, the overall patient experience was better for dynamic MRI proctography.

Sigmoid carcinoma with sigmoid-rectal intussusception presenting as rectal prolapse and large bowel obstruction in the ED

Background Intestinal obstruction is a surgical emergency with most cases being small bowel obstruction. Large bowel obstruction is comparatively uncommon and colonic malignancies are a usual cause. Such lesions cause intestinal obstruction by luminal narrowing or rarely serve as lead point of intussusception. Case presentation Herein, we describe an unusual case of sigmoid carcinoma causing sigmoid-rectal intussusception, rectal prolapse, and eventually large bowel obstruction. Conclusion Pre-operative CT should be done in all adult large bowel obstruction to look for possible site and cause of obstruction and to rule out malignancy as a cause of obstruction. Conversely, every case of rectal prolapse should be diligently evaluated to rule out intussusception, which if present in an adult indicates a high likelihood of underlying malignancy.

Ventral Rectopexy

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.

Outcomes of a modified Bresler procedure for the treatment of rectocele with rectal intussusception

Background Obstructed defecation syndrome (ODS) is a condition that is frequently caused by rectocele and rectal intussusception. This study aimed to evaluate the effectiveness of a modified Bresler procedure for the treatment of ODS. The outcomes of this modified procedure were compared with the stapled transanal rectal resection (STARR) procedure. Methods We performed a retrospective analysis of the clinical data from 76 female patients who presented with ODS between June 2014 and June 2016. The patients were divided into two treatment groups, namely Modified and STARR. Patients in the Modified group (n = 36) underwent the modified Bresler procedure, which involved posterior rectal-wall resection using a circular tubular stapler with multilevel purse-string sutures. Patients in the STARR group (n = 40) underwent the standard STARR procedure. We analysed post-operative complications, Wexner constipation scores (WCS), rectocele depths, and four-point post-operative satisfaction scales. Results Patients in the Modified group exhibited shorter operative times and fewer post-operative complications (both P &lt; 0.05). At 12 months post-operatively, both the Modified and STARR groups displayed a significant improvement in the Wexner constipation score and the depth of rectocele. The post-operative WCS for the Modified group were significantly improved compared to those for the STARR group (P &lt; 0.05), while there was no significant difference in the rectocele depth between the two groups (P &gt; 0.05). Post-operative interviews at post-operative 12 months showed that patients in the Modified group had a better satisfaction (P = 0.05). Conclusions Our modified procedure may be an effective treatment strategy for patients experiencing ODS caused by rectocele and rectal intussusception, with fewer complications and effective relief of symptoms.

RETRACTED ARTICLE: Evaluation of obstructed defecation syndrome (ODS) using magnetic resonance defecography (MRD)

Background Obstructed defecation syndrome is associated with varying combinations of a host of ano-rectal abnormalities, and no physical examination can demonstrate these abnormalities. The present study was aimed to evaluate the spectrum of various pelvic floor abnormalities in obstructed defecation syndrome (ODS). Results Of the total 302 patients imaged with age range of 18–72 years (mean age 54 years), 218 were females, and 84 were males. Ano-rectal junction descent was the commonest abnormality observed in 273 (90.3%) patients followed by rectocele (232) (76.8%), rectal intussusception (93) (30.7%), and cystocele (92) (30.4%). Cervical descent was observed in 78 (35.7%) of female patients. Spastic perineum was seen in 27 (8.9%) patients. Conclusion MRD serves as single stop shop for demonstrating and grading a gamut of pelvic organ abnormalities underpinning ODS which in turn helps in choosing the best treatment plan for the patient.