Stanisław Rządkowski1, 2, Przemysław Ciesielski1, 2, *Małgorzata Kołodziejczak1-3
Rectal and pelvic organ prolapse
Wypadanie odbytnicy i narządu rodnego
1Warsaw Proctology Centre, St. Elizabeth’s Hospital in Warsaw
2Department of General Surgery, District Hospital in Ostrów Mazowiecka
3Department of General and Transplant Surgery Medical University of Warsaw, Infant Jesus Clinical Hospital in Warsaw
Streszczenie
Wypadanie odbytnicy (WO) to schorzenie polegające na przemieszczeniu ściany odbytnicy poza kanał odbytu, często współwystępujące z wypadaniem lub obniżeniem narządów miednicy mniejszej (POP). Patogeneza tych jednostek chorobowych jest zbliżona i obejmuje: osłabienie struktur podporowych dna miednicy, zaburzenia unerwienia oraz przewlekłe zwiększenie ciśnienia śródbrzusznego. Istotny czynnik ryzyka stanowią porody, a zwłaszcza porody instrumentalne i powikłane pęknięciem krocza.
Do objawów wypadania odbytnicy zalicza się: nietrzymanie stolca, zaparcia oraz wyciek treści śluzowej z odbytu. Wypadanie narządów miednicy mniejszej manifestuje się obniżeniem narządu rodnego, dyskomfortem w obrębie krocza oraz ewentualnymi zaburzeniami mikcji i wypróżniania. Diagnostyka obejmuje: badanie kliniczne, kolonoskopię, defekografię oraz – w przypadku współistniejących zaburzeń funkcji dolnych dróg moczowych – badanie urodynamiczne.
Podstawą leczenia współwystępującego wypadania odbytnicy i narządu rodnego jest postępowanie chirurgiczne. U młodszych pacjentek preferuje się dostęp brzuszny, który cechuje się niższym ryzykiem nawrotu. Najczęściej przeprowadzaną procedurę stanowi podwieszenie odbytnicy z użyciem implantu sposobem D’Hoore’a z jednoczasową sakrokolpopeksją. Możliwe jest również przeprowadzenie resekcji esicy i górnej części odbytnicy z rektopeksją szwami oraz podwieszeniem szczytu pochwy do więzadeł krzyżowo-macicznych lub krzyżowo-kolcowych. U starszych chorych z zespołem kruchości zastosowanie znajdują operacje z dostępu kroczowego, takie jak resekcja odbytnicy sposobem Altemeiera lub operacja sposobem Delorme’a uzupełnione o kolpoklezę.
Indywidualizacja postępowania uwzględniająca: wiek, choroby współistniejące i potrzeby pacjentki jest kluczowa dla uzyskania optymalnych wyników leczenia i poprawy jakości życia.
Summary
Rectal prolapse (RP) is a disorder characterised by protrusion of the rectal wall outside the anal canal, often co-occurring with pelvic organ prolapse (POP). The pathogenesis of these clinical conditions is similar and includes weakening of the supporting structures of the pelvic floor, impaired innervation and chronic increase in intraabdominal pressure. Childbirth, especially instrumental deliveries and deliveries complicated by perineal tear, is an important risk factor.
Symptoms of rectal prolapse include faecal incontinence, constipation, and anal discharge of mucous contents. Pelvic organ prolapse manifests as downward movement of pelvic organs, perineal discomfort, and possible voiding and bowel movement disorders. Diagnostic workup includes a clinical examination, colonoscopy, defecography, and a urodynamic assessment in the case of coexisting lower urinary tract dysfunction.
Surgical repair is the primary treatment for concomitant rectal and pelvic organ prolapse. Transabdominal approach, which is characterised by a lower risk of recurrence, is preferred in younger patients. D’Hoore procedure (laparoscopic ventral rectopexy with mesh placement) with simultaneous sacrocolpopexy is the most commonly performed procedure. It is also possible to perform a resection of the sigmoid colon and the upper part of the rectum with suture rectopexy and fixation of the vaginal apex to the sacrouterine or sacrospinous ligaments. Perineal approaches, such as Altemeier rectal resection or Delorme’s procedure supplemented with colpocleisis, are used in older patients with frailty syndrome. Individualisation of treatment, taking into account the patents’ age, comorbidities and needs, is crucial to achieving optimal treatment outcomes and improving the quality of life.
Słowa kluczowe: wypadanie odbytnicy, wypadanie narządu rodnego, rektopeksja, sakrokolpopeksja
Introduction
Rectal prolapse (RP) is defined as a full-thickness protrusion of the rectal wall through the anal canal and anus. According to most studies, it occurs in about 0.5% of the population, with a 9:1 female predominance (1). In patients presenting with rectal prolapse (RP), the concurrent rate of pelvic organ prolapse (POP) is between 21 and 34% (2). This high percentage can be explained by common risk factors, which will be discussed later in this paper. Despite its benign nature, concomitant rectal and pelvic organ prolapse significantly worsens the quality of life, leading to social isolation and frequent depressive disorders.
Over the years, many surgical techniques for rectal and pelvic organ prolapse have been developed using perineal and transabdominal approaches. Perineal surgeries are primarily used in older patients with frailty syndrome (3), while transabdominal surgeries, which have a lower recurrence rate, are the treatment of choice in younger patients (4).
Aetiology
Although various RP risk factors have been identified, the exact cause of the disorder remains unknown. In some cases, it is not clear whether a given factor is a cause or a consequence of the disease. Risk factors for rectal prolapse include (5):
– female gender,
– multiple pregnancies (although about 1/3 of patients with RP have never given birth),
– instrumental delivery, obstetric perineal tear,
– older age (the peak incidence in women is in their seventh decade). Interestingly, the age at onset in men is usually ≤ 40 years. The higher incidence of autism or comorbid mental disorders is a striking feature of younger patients (both men and women),
– anorexia,
– physical work,
– chronic constipation,
– chronic diarrhoea,
– deep pouch of Douglas,
– long sigmoid colon,
– spinal cord injury,
– connective tissue diseases.
The accompanying POP, defined as downward movement of one or more parts of the vagina and uterus, is due to the weakening of the pelvic floor muscles, which is caused by similar factors (6). As in the theory of a hernia, attention is paid to collagen dysfunction, which is the basis of the disorder (7). According to the Bump and Norton model, mechanical damage to the myofascial structures of the pelvis (e.g. during childbirth and as a result of gynaecological surgeries) and the aging process are considered to be factors initiating POP (8).
Cervical or vaginal stump descent following hysterectomy is referred to as an apical defect (DeLancey level 1 support). DeLancey level 2 prolapse, on the other hand, involves the vesicovaginal fascia, manifesting as cystocele (bulging of the anterior vaginal wall) or the rectovaginal fascia, manifesting as rectocele (bulging of the posterior vaginal wall) (9). An isolated lesion at one of the DeLancey levels is rare, and current evidence suggests that apical defect repair is crucial to reduce the risk of POP (10).
Symptoms
Rectal prolapse initially occurs during bowel movements and other activities that increase intra-abdominal pressure (e.g. coughing, sneezing, lifting). However, it may occur spontaneously in advanced cases.
Faecal incontinence and constipation occur in 50-75% and 25-50% of cases, respectively (11).
Faecal incontinence in RP can be explained by chronic stretching of the sphincter muscles by the prolapsed rectum and continuous stimulation of the rectoanal inhibitory reflex (RAIR) by the invaginating tissue (12).
Obstruction of the anal canal by the invaginating rectum is the main causative factor of constipation. Concomitant pelvic floor dyssynergia or colonic motility disorders may also contribute to impaired bowel movement (13).
Typical symptoms of RP further include discharge of mucous and bloody secretions, a feeling of incomplete bowel movement, and perianal pruritus due to impaired faecal continence.
A feeling perineal fullness and the presence of bulging of one or both vaginal walls are common symptoms of all forms of POP. Additionally, patients often experience an urge to urinate and/or defecate, frequent voiding and the need for manual prolapse reduction (so-called splinting) to facilitate bowel movement (in the case of rectocele) or urination (in the case of cystocele) (14). It should be noted that there is only a minor correlation between the grade of prolapse and subjective symptoms (15).
Medical history and diagnosis
Medical history should include risk factors and symptoms discussed earlier in the paper. Below, we summarise aspects important for planning further treatment, along with the diagnostic tools we commonly use:
– childbirths:
• number,
• instrumental delivery,
• obstetric anal sphincter injuries (OASIS), grades 3 and 4 in particular,
– gynaecological surgeries,
– stage of pelvic organ prolapse (POP-Q),
– coexisting urinary incontinence or the need for splinting,
– coexisting constipation (Cleveland Clinic Constipation Score – CCCS) and faecal incontinence (Wexner scale),
– manual work,
– age, quality of life, self-care.
The diagnosis is based on physical examination at rest and during Valsalva’s manoeuvre, most often performed in the Sims or lithotomy position (16). Its goal is to asses the length of the prolapsed rectum, as well as passive and active sphincter tone. Gynaecological examination using a speculum is also performed to assess the bulge of the vaginal walls. It is worth performing a combined examination through the rectum and vagina, which allows for the assessment of any potential thinning and stretching of the rectovaginal septum that may give rise to rectocele.
Each patient should undergo colonoscopy to exclude polyps and tumours at the front of the invaginating rectum. Solitary rectal ulcer (SRU), affecting 10-15% of patients, the clinical picture of which is diverse and may resemble rectal cancer, is common pathology associated with RP (17). If SRU is suspected, biopsy of the lesion should be performed. Histologically, the lesion is characterized by mucosal thickening with disturbed architecture of the intestinal crypts, with obliterated mucosal lamina propria, partially replaced by a hypertrophied muscularis (18).
Defecography, which is a functional test assessing the process of bowel movement and allowing for the visualization of rectal prolapse and rectocele, is also useful.
Magnetic resonance imaging (MRI) allows for assessing pathologies within pelvic structures that do not directly participate in bowel movement (cystocele, apical defect, or enterocele).
Defecography is also the gold standard for diagnosing internal rectal intussusception (i.e. without extrusion of the rectum outside the anal canal). Obstructed defecation syndrome (ODS) is the main clinical manifestation of internal rectal intussusception. It should be emphasised that asymptomatic internal rectal intussusception (occurring in up to 20-50% of the population as reported by some authors) is not an indication for surgery (19). Patients experiencing severe pain during bowel movement and severe tenesmus are an exception. In such cases, surgery may contribute to symptom resolution.
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
- Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
- Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
- Aby kupić kod proszę skorzystać z jednej z poniższych opcji.
Opcja #1
29 zł
Wybieram
- dostęp do tego artykułu
- dostęp na 7 dni
uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony
Opcja #2
69 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 30 dni
- najpopularniejsza opcja
Opcja #3
129 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 90 dni
- oszczędzasz 78 zł
Piśmiennictwo
1. Gourgiotis S, Baratsis S: Rectal prolapse. Int J Colorectal Dis 2007; 22: 231-243.
2. Altman D, Zetterstrom J, Schultz I: Pelvic organ prolapse and urinary incontinence in women with surgically managed rectal prolapse: a population-based case-control study. Dis Colon Rectum 2006; 49(1): 28-35.
3. Daniel VT, Davids JS, Sturrock PR et al.: Getting to the bottom of treatment of rectal prolapse in the elderly: analysis of the National Surgical Quality Improvement Program (NSQIP). Am J Surg 2019; 218(2): 288-292.
4. Jallad K, Gurland B: Multidisciplinary approach to the treatment of concomitant rectal and vaginal prolapse. Clin Colon Rectal Surg 2016; 29(2): 101-105.
5. Bordeianou L, Paquette I, Johnson E et al.: Clinical practice guidelines for the treatment of rectal prolapse. Dis Colon Rectum 2017; 60(11): 1121-1131.
6. Raju R, Linder BJ: Evaluation and management of pelvic organ prolapse. Mayo Clin Proc 2021; 96(12): 3122-3129.
7. Reid RI, You H, Luo K: Site-specific prolapse surgery. I. Reliability and durability of native tissue paravaginal repair. Int Urogynecol J 2011; 22(5): 591-599.
8. Bump RC, Norton PA: Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998; 25: 723-746.
9. DeLancey JOL: What’s new in the functional anatomy of pelvic organ prolapse? Curr Opin Obstet Gynecol 2016; 28(5): 420-429.
10. Cvach K, Dwyer P: Surgical management of pelvic organ prolapse: abdominal and vaginal approaches. World J Urol 2012; 30(4): 471-477.
11. Kim DS, Tsang CB, Wong WD et al.: Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42: 460-466.
12. Hawkins AT, Olariu AG, Savitt LR et al.: Impact of rising grades of internal rectal intussusception on fecal continence and symptoms of constipation. Dis Colon Rectum 2016; 59: 54-61.
13. Schultz I, Mellgren A, Dolk A et al.: Long-term results and functional outcome after Ripstein rectopexy. Dis Colon Rectum 2000; 43: 35-43.
14. Jelovsek JE, Maher C, Barber MD: Pelvic organ prolapse. Lancet 2007; 369(9566): 1027-1038.
15. Burrows LJ, Meyn LA, Walters MD, Weber AM: Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 2004; 104: 982-988.
16. Cannon JA: Evaluation, diagnosis, and medical management of rectal prolapse. Clin Colon Rectal Surg 2017; 30(1): 16-21.
17. Felt-Bersma RJF, Tiersma ES, Cuesta MA: Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am 2008; 37(3): 645-668.
18. Chiang JM, Changchien CR, Chen JR: Solitary rectal ulcer syndrome: an endoscopic and histological presentation and literature review. Int J Colorectal Dis 2006; 21(4): 348-356.
19. Palit S, Bhan C, Lunniss PJ et al.: Evacuation proctography: a reappraisal of normal variability. Colorectal Dis 2014; 16(7): 538-546.
20. Chaikin DC, Groutz A, Blaivas JG: Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse. J Urol 2000; 163(2): 531-534.
21. Bergman A, Koonings PP, Ballard CA: Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988; 158(5): 1171-1175.
22. Brubaker L, Cundiff GW, Fine P et al.: Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006; 354: 1557-1566.
23. Tou S, Brown SR, Malik AI, Nelson RL: Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 2008; (4): CD001758.
24. Hagen S, Stark D, Maher C, Adams E: Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2006; (4): CD003882.
25. Wu V, Farrell SA, Baskett TF, Flowerdew G: A simplified protocol for pessary management. Obstet Gynecol 1997; 90: 990-994.
26. Dvorkin LS, Chan CLH, Knowles CH et al.: Anal sphincter morphology in patients with full-thickness rectal prolapse. Dis Colon Rectum 2004; 47(2): 198-203.
27. Cunin D, Siproudhis L, Desfourneaux V et al.: No surgery for full-thickness rectal prolapse: what happens with continence? World J Surg 2013; 37: 1297-1302.
28. Fu CW, Stevenson AR: Risk factors for recurrence after laparoscopic ventral rectopexy. Dis Colon Rectum 2017; 60: 178-186.
29. Maher C, Feiner B, Baessler K et al.: Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev 2016; 10(10): CD012376.
30. Zaburzenia statyki narządów płciowych i wysiłkowego nietrzymania moczu u pacjentek. Rekomendacje PTGIN 2009.
31. Wallace SL, Syan R, Lee K, Sokol ER: Vaginal hysteropexy compared with vaginal hysterectomy with apical suspension for the treatment of pelvic organ prolapse: A 5-year cost-effectiveness Markov model. Obstet Gynecol 2024; 131(3): 362-371.
32. Carlin GL, Lange S, Ziegler C et al.: Sacrospinous Hysteropexy Versus Prolapse Hysterectomy with Apical Fixation: A Retrospective Comparison over an 18 Year Period. J Clin Med 2023; 12(6): 2176.
33. Schulten SFM, Detollenaere RJ, Stekelenburg J: Sacrospinous Hysteropexy vs Vaginal Hysterectomy with Uterosacral Ligament Suspension in Women with Uterine Prolapse Stage 2 or Higher: Observational Follow-up of a Multicentre Randomised Trial. BMJ 2019; 366.
34. Daniel VT, Davids JS, Sturrock PR et al.: Getting to the bottom of treatment of rectal prolapse in the elderly: analysis of the National Surgical Quality Improvement Program (NSQIP). Am J Surg 2019; 218(02): 288-292.
35. Suskind AM, Jin C, Walter LC, Finlayson E: Frailty and the role of obliterative versus reconstructive surgery for pelvic organ prolapse: a national study. J Urol 2017; 197(06): 1502-1506.
36. Novell JR, Osborne MJ, Winslet MC, Lewis AA: Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg 1994; 81: 904-906.
37. Cundiff GW, Varner E, Visco AG et al.; Pelvic Floor Disorders Network: Risk factors for mesh/suture erosion following sacral colpopexy. Am J Obstet Gynecol 2008; 199(6): 688.e1-5.
38. Koimtzis G, Stefanopoulos L, Geropoulos G et al.: Is There a Gold Standard Method: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13(5): 1363.
39. Geltzeiler CB, Birnbaum EH, Silviera ML: Combined rectopexy and sacrocolpopexy is safe for correction of pelvic organ prolapse. Int J Colorectal Dis 2018; 33(10): 1453-1459.
40. Weinberg D, Qeadan F, McKee R et al.: Safety of laparoscopic sacrocolpopexy with concurrent rectopexy: peri-operative morbidity in a nationwide cohort. Int Urogynecol J 2019; 30(3): 385-392.
41. Wallace S, Gurland B: Approaching combined rectal and vaginal prolapse. Clin Colon Rectal Surg 2022; 34(5): 302-310.
