The Cleveland Clinic Incontinence Score does not include aspects of urgency, but the Vaizey score (Vaizey et al 1999) attempted to address this. Vaizey et al reported that urgency of less than 15 min is not usually a problem; however, when patients are not able to hold for more than 2 min, this has a significant impact on quality of life. A recent study (Cotterill et al 2008) took comments from a panel of seven clinical experts and from patients, and reported five key issues related to anal incontinence. These were unpredictability, toilet locations, coping strategies, embarrassment and restriction of social activities. This group are working on a new instrument to help validate treatments for anal incontinence based around quality of life as well as symptom severity.

Further investigations may be helpful to assess function and structure; they also provide essential evidence in some medicolegal cases.

Anorectal manometry

There are limitations to the reproducibility and reliability of anorectal manometry across institutions. However, a standardized protocol should be used within each institution. Tests are helpful in predicting realistic expectations from surgery and also in explaining the scope of problems to patients.

Anal manometry is not a single test but a series of measurements used to assess anal sphincter function, rectal sensation, rectoanal reflexes and compliance of the rectum (Kourakalis and Andromanakos 2004). The use of pull-through anal manometry allows assessment of the length of the functioning sphincter, resting pressures give a good estimation of internal sphincter function, and squeeze pressures assess external sphincter function. The patient is usually placed in the left lateral position, and manometry can be performed either using stationery pull-through or continuous pull-through techniques. Many catheters have four or eight channels, and these can therefore record different pressures in different parts of the external sphincter and internal sphincter at different levels. Using vector analysis, it is possible to look at the symmetry of the anal canal pressure, and combining this with anal ultrasonography can show whether there is a structural as well as a functional problem in either of the sphincter muscles. The rectoanal inhibitory reflex is usually assessed during the physiology. Absence of this may indicate a longstanding problem such as Hirschsprung’s disease. Rectal distension is assessed by inflating a balloon within the rectum; measurements are taken when the patient first feels the sensation of rectal filling, the feeling when there is maximum fullness, and then the feeling of urgent desire to defaecate. This can be extended to when the volume is unbearable. If the rectal threshold is low, even with a normal anal pressure, continence may be impaired.

Anal skin sensation is usually assessed by some form of electrical stimulation. Pudendal nerve terminal motor latencies are performed by stimulating the pudendal nerve transanally through the lateral wall of the rectum as the nerve transverses the ischial spine, using a St Mark’s electrode on the tip of the examining finger. The normal delay between stimulation and recording is less than 2.2 ms and a longer delay suggests that there has been damage to the pudendal nerve. A lengthening of the pudendal nerve latency is often associated with poorer outcomes after surgery, and may suggest that the patient’s incontinence is associated with nerve damage. An important outcome measure for sphincter repair is whether there is any pudendal neuropathy, as patients with pudendal neuropathy only have a 10% chance of success compared with 80% in patients without pudendal neuropathy (Laurberg et al 1988).

Ultrasound and dynamic imaging

The investigation of choice for structural abnormalities within the anal sphincter is a three-dimensional anal ultrasound. A data set can be captured and then manipulated at a later date to look at structural abnormalities throughout the anal canal (Figure 59.1).

Figure 59.1 Three-dimensional anal ultrasound.

Length of sphincter, damage to internal and external sphincters, and presence of sepsis or abnormalities can all be assessed.

Using the same anal probe transvaginally, it is possible to examine the levator plate and many other anatomical aspects of the pelvic floor. Asymmetry within the levator plate suggests damage during childbirth and often leads to the anus being diverted to the side of the damage (Figure 59.2).

Figure 59.2 Transvaginal scan of pelvic floor.

Dynamic images of the bladder and rectum can be taken using an 8848 transvaginal scanner, looking for perineal descent as well as enteroceles, rectoceles and rectal intussusception.

Further assessment of the pelvic floor often requires some form of proctography. In order to assess the whole pelvic floor using defaecating proctography, patients require not only contrast within the rectum but also in the small bowel, vagina and bladder. Defaecatory magnetic resonance imaging (Figure 59.3) can show all these parts of the pelvic floor. There are very few open magnets where a patient can sit and defaecate; therefore, the majority of these studies are performed with the patient lying prone.

Figure 59.3 Rectocele seen on dynamic magnetic resonance imaging.

It has been shown that magnetic resonance proctography shows increased evidence of other pelvic floor abnormalities over defaecating proctography. However, it underestimates the size of rectoceles and intussusception (Pilkington et al 2009).

Shapes study

By marking and counting the passage of ingested radio-opaque markers on a plain abdominal X-ray, it is possible to make an estimate of segmental and total colonic transit times. In a simplified method, 20 radio-opaque markers are ingested and an X-ray is taken at 60 and 96 h. Transit through the whole colon of more than 67 h is considered abnormal. Transit time is prolonged in 80% of patients suffering from constipation.

It is essential that all of these investigations are taken into consideration along with a full pelvic floor history and diary of bowel habit problems. Discussion at a pelvic floor multidisciplinary team (MDT) meeting allows every compartment to be assessed in equal relevance.

Common Conditions and Treatments

Haemorrhoids

The term ‘haemorrhoids’ (also known as ‘piles’) is generally used to describe enlarged anal cushions which become symptomatic through symptoms of either bleeding or prolapse. However, correlation between symptoms and the treatment of haemorrhoids is poor. Haemorrhoids and associated symptoms are an extremely common problem, presenting in patients at general practitioners’ surgeries and coloproctology clinics. During their lifetime, many patients will present with symptoms of rectal bleeding and many of these will have bleeding secondary to piles. It is most important to ensure that there is no other treatable or more serious problem relating to this bleeding, such as cancer, polyps or inflammatory bowel disease.

Piles often present with a combination of symptoms, including itching, soreness, postdefaecatory leakage and lumps around the anus. It is thought that the sliding anal canal theory proposed by Thompson (1975) is the most likely cause of piles, where Treitz’s muscle is stretched repeatedly resulting in fragmentation of the connective tissue. Haemorrhoids may be small and highly symptomatic, or large and asymptomatic. This is especially so in elderly female patients where normal anal canal pressures are low, and this can result in prolapse but little in the way of symptoms. Several classifications of haemorrhoids have been used over time. Goligher’s classification (Goligher 1976) describes the degree of prolapse and whether these reduce spontaneously (grade 2), require manual reduction (grade 3) or are permanently prolapsed (grade 4). However, although this is good for the description, it does not consider the symptoms of the piles. Work by Lunniss and Mann (2004) has produced a more accurate and useful classification of haemorrhoids, dividing them into non-prolapsing and prolapsing, looking at not only the morphological presentation but also any additional features such as pruritus or pain.

The diagnosis of haemorrhoids relies on a good history, exclusion of other possible causes of these problems and then a thorough clinical assessment. Anal pain may be associated not only with haemorrhoids but also abscesses, fistulae or fissures. Discharge and pruritus may be associated with warts, hypertrophied anal papillae or rectal prolapse. Anal incontinence is usually secondary to internal sphincter dysfunction and a lump or prolapse. Inspection of the perianal area may be done with the patient either lying in the left lateral position or with legs up in a gynaecology chair. The presence of anal skin tags is often suggestive of previous episodes of haemorrhoidal prolapse. If the haemorrhoids are associated with a predominant feature of itching, skin may be macerated or discoloured, and the presence or absence of scars or previous surgery should also be determined.

Second- or third-degree piles may become evident on asking the patient to bear down, and fourth-degree piles should be obvious at the time of examination. Palpation of the rectum is essential in order to exclude any other pathology, although the piles themselves are not easily examined as, by virtue of the nature of the anal canal and the soft tissues, no lumps will usually be felt. However, at the time of digital examination, it is also prudent to examine both the squeeze and the resting pressure associated with the anal canal. A proctoscopy is essential in examining for haemorrhoids, although internal haemorrhoids may be well visualized using an internal flexible sigmoidoscope.

Treatment of haemorrhoids

Estimates of the proportion of the UK population affected with haemorrhoids range from 4.4% to 24.5%. In 2004–2005, approximately 23,000 haemorrhoidal procedures were carried out, and approximately 8000 of these were excision haemorrhoidectomies (National Institute for Health and Clinical Excellence 2007a).

Treatment of haemorrhoids can be divided into internal haemorrhoids (i.e. those above the dentate line) and external haemorrhoids (i.e. those below the dentate line and therefore covered with sensate epithelium).

Medical treatment for haemorrhoids

Patients with symptomatic but small internal haemorrhoids are best treated with dietary management; increasing the intake of fluid and fibre is the mainstay of this treatment. The typical symptoms of internal haemorrhoids are rectal bleeding and, sometimes, prolapse; avoiding straining by these dietary methods usually improves the symptoms. Dietary manipulation also improves rectal bleeding alone from grade 1 and grade 2 haemorrhoids, and this has been proven in three randomized controlled trials (Cataldo et al 2005).

Patients with persistent symptoms from grade 1, 2 or 3 haemorrhoids may benefit from an outpatient procedure. The most common procedure used and probably the most effective is haemorrhoidal banding. Other procedures that may be offered include sclerotherapy, infrared coagulation and cryotherapy. All of these treatments are aimed at decreasing the haemorrhoidal tissue volume and fixing the anal cushion back to the rectal wall. A meta-analysis of outpatient treatment suggested that rubber band ligation was the most effective of all outpatient procedures and was associated with a lower recurrence rate (MacRae and McLeod 1995). It is, however, relatively painful and the pain associated with the procedure increases with the number of rubber bands that are used to treat these piles. It is essential that the bands are placed well above the dentate line, or the immediate pain felt from the sensate epithelium is excruciating and patients will need to have these bands removed. Rubber band ligation is associated with a success rate of 65–85%, but follow-up at 5 years shows a relatively high recurrence rate. Following outpatient procedures for haemorrhoids, approximately 2% of patients report pain and less than 1% report urinary retention. Major complications include significant haemorrhage, which may take place immediately or as a secondary haemorrhage between postoperative days 7 and 10.

Thrombosed external haemorrhoids

Thrombosed external haemorrhoids are extremely painful and the thrombosis will settle; however, patients sometimes need intervention prior to spontaneous resolution of symptoms. External haemorrhoids do thrombose spontaneously and the exact aetiology remains unclear. Patients may be treated conservatively, especially if they present more than 3 days after the thrombosis occurred; actulose, analgesia and ice packs on the perineum will often resolve the symptoms more quickly than a surgical procedure.

Operative procedures for haemorrhoids

Haemorrhoidectomy of any sort should only be offered to patients with large external haemorrhoids or significant prolapse, or those who have been resistant to outpatient procedures. Open haemorrhoidectomy is effective; however, it is associated with pain, infection and other complications, such as incontinence and stenosis of the anal canal. More recently, patients have been able to undertake a less painful form of surgical procedure called a ‘stapled haemorrhoidopexy’. The evidence for this has been reviewed by the National Institute for Health and Clinical Excellence (NICE) (2007a). A stapled haemorrhoidopexy is an intrarectal procedure that aims to reduce the prolapse of haemorrhoidal tissue by excising a band of the prolapse anal mucosal membrane above the dentate line using a specific circular stapling device (PPH03 Ethicon). The procedure is thought to interrupt the blood supply to the haemorrhoids and reduce the potential continuing prolapse of mucosa. The NICE review studied 27 randomized controlled trials of stapled haemorrhoidopexy and found that the procedure was associated with less pain up to 14 days following surgery, shorter wound healing times and significantly less postoperative bleeding. On the basis of the evidence in the literature, it was felt that a stapled haemorrhoidopexy offered benefits over a conventional haemorrhoidectomy in the reduction of short- and medium-term postoperative pain. However, although stapled haemorrhoidopexy is associated with a higher rate of recurrent prolapse, the committee concluded that ‘a stapled haemorrhoidopexy should be recommended as a treatment option for people in whom surgical intervention is considered appropriate for the treatment of prolapsed internal haemorrhoids’.

Surgical haemorrhoidectomy can be performed open (Milligan-Morgan) or closed (Ferguson). During an open procedure, the haemorrhoid is dissected and the pedicle is either ligated or cauterized with diathermy; the wounds are left to heal by secondary intention. This may result in extreme discomfort and postoperative morbidity. The closed technique involves greater dissection but the wound is closed with a running suture.

Anal fissures

Patients with pelvic floor straining and post childbirth often present with anal pain associated with an anal fissure. An anal fissure is a tear running longitudinally in the epithelium of the anal canal, the majority of which lie posteriorly in the midline. Acute fissures are usually superficial, whereas chronic fissures may be associated with secondary changes including a sentinel tag or hypertrophied anal papilla. As with all acute and chronic anal conditions, efforts should be made to identify any precipitating causes or associated diseases (Crohn’s disease or anal carcinoma). A recent consensus statement from the Association of Coloproctology of Great Britain and Ireland covers aspects of diagnosis and treatment (Cross et al 2008). The most common presenting features are pain during defaecation which may last for several hours afterwards, as well as rectal bleeding. The most consistent finding on examination is spasm of the anal canal, and it is uncertain whether this is the result of or due to ischaemia. Many of the management options have been based around reducing the internal anal spasm, but as with many benign anal conditions, one of the most important measures is to increase dietary fibre and adequate fluid intake. The majority of fissures, especially posterior fissures, are associated with a high resting pressure and a low blood flow to the anoderm resulting from this spasm. However, postpartum fissures are usually anterior and may be associated with a rectocele. The scar formation may be associated with ischaemia; however, the resting pressures in these patients are usually low. If there are multiple fissures or the fissures are not in the midline, a differential diagnosis of Crohn’s disease, ulcerative colitis, human immunodeficiency virus and associated infections as well as neoplasia should be considered. An anal fissure may occur at any time in life but is most common between the second and fourth decades, with an equal distribution between men and women and a lifetime incidence of just over 11%. Inspection of the anus will usually reveal the fissure, and it is not usually possible to carry out any further examination due to the pain associated with the fissure.

Botulinum toxin

Botulinum toxin works by binding irreversibly to the presynaptic nerve terminals preventing acetylcholine release and resulting in hypotonia and a reduced resting anal pressure. The effects last for 2–3 months until the acetylcholine has reaccumulated in the nerve terminals (Jones et al 2003). The majority of people use 20 units of botulinum toxin, although the dosages reported in the literature vary between 10 and 100 units; healing rates of 40–100% have been reported. Botulinum toxin is given in two doses into the internal sphincter, and 75% of patients will be healed using this treatment.

Surgery

If these conservative and medical treatments have failed, patients may require surgery. Surgical options include lateral sphincterotomy which permanently divides the internal sphincter, fissurectomy and advancement procedures. Lateral sphincterotomy has a reported cure rate of approximately 85%; however, the downside of this procedure is a significant incontinence problem, with up to 30% of patients having difficulty in controlling wind and at least 3–5% of people suffering from overt incontinence (Garcia-Aguilar et al 1996). If a sphincterotomy is performed, it should be limited to the length of the fissure as this almost certainly reduces the incontinence problems. If the patient has a short anus or has had previous anorectal surgery, extreme caution is advised.

Fissurectomy

Excising the fissure and the fibrotic edge may improve healing rates and can be used in association with botulinum toxin.

Anal advancement flap

In patients in whom the fissure is associated with a low pressure, any medical or surgical aims to reduce anal pressure are unlikely to cause healing. Therefore, these patients should usually have some form of V–Y advancement flap or rotational flap, and although the results can be good, there may be problems with infection and wound healing at the donor site.

Faecal incontinence

Faecal incontinence is a debilitating symptom or sign which occurs in 1–10% of adults. It is largely a hidden problem due to embarrassment, and may be a result of many contributing factors. Recent NICE guidelines recognized that the treatment of this problem should be patient centred, and will vary considerably between patients according to their lifestyle and culture (National Institute for Health and Clinical Excellence 2007b). One of the recommendations is that people who are reported to have faecal incontinence should be offered care which is managed by appropriate healthcare professionals, and these people should have relevant skills, training and experience. They should also work within an integrated continence service. Groups who are at very high risk of faecal incontinence include frail, older people; people with loose stools from any cause; women following childbirth, especially after a third- or fourth-degree tear; and patients with pelvic organ prolapse or rectal prolapse. Other groups include patients with cognitive impairment or learning difficulties, and those who have undergone pelvic radiotherapy. It is essential to be aware that faecal incontinence is a symptom, not a disease, and there are many contributing factors; there is not usually a primary diagnosis.

Assessment

The baseline assessment of these patients should include a relevant medical history, examination and anorectal examination. Once again, the focus should be on warning signs for a lower gastrointestinal cancer, prolapse, acute disc prolapse or cauda equina syndrome (which would be associated with anal sensation loss), and potentially treatable causes of diarrhoea. The long-term management of patients with incontinence should include a 6-monthly review of symptoms, and giving patients contact details of all relevant support groups as well as advice about continence products, skin care and how to communicate with their friends and families. It is of utmost importance to preserve dignity and offer emotional support as well as psychological support, as appropriate.

The history should focus on differentiation between urge, passive and postdefaecatory leakage. A full assessment of obstetric history, trauma and surgery to the perineum, previous pelvic surgery, back problems/surgery and medical conditions (diabetes and neurological conditions) is essential. Examination should focus on an abdominal examination and a full pelvic floor examination, including anterior and posterior compartment. Sigmoidoscopy and proctoscopy is essential to examine for rectal and anal pathology.

Investigations specific to incontinence include anorectal physiology, anal and perineal ultrasound, and sometimes magnetic resonance proctogram.

Initial management

It is important to explain to patients that there is no ‘quick fix’ for incontinence, and a range of treatments and interventions may be necessary. The mainstay of initial treatment is alteration of stool consistency in order to try to reduce wind and avoid soft bowel motions. Patients should still be encouraged to drink at least 1.5 l of fluid per day unless contraindicated, and one of the best routes for reducing bowel frequency is to limit wheat fibre or insoluble fibre intake, as well as reducing the intake of caffeine and fizzy drinks. It is often useful to get the patient to diary their problem (i.e. stool consistency, number and types of leakage or urge incontinence episodes), and to encourage them to alter one part of their diet or management at a time. It is then possible to decide whether this alteration has been appropriate or helped their incontinence problem. Patients who have urge incontinence with soft stools or even normal stools often do very well with a very low dose of loperamide hydrochloride. This comes in a syrup, which allows patients to closely titrate the amount of loperamide (2 teaspoons = 1 tablet). Occasionally, patients develop abdominal pain with this; these patients should be offered codeine phosphate or co-phenotrope instead. Patients should not be offered loperamide if they have an acute flare of ulcerative colitis, hard or infrequent stools, or diarrhoea without a diagnosed cause. It is usually beneficial to start the loperamide at 1 teaspoon or less, and to advise patients to use the loperamide to manipulate their bowel movements and consistency, rather than allowing their bowel movements to control their lifestyle.

Many of these patients who are post childbirth have poor pelvic floor muscles and a reduced rectoanal angle which contributes to their incontinence. These patients should be referred for physiotherapy, electrical stimulation and management within the continence advisory service. This gives them access to a group of professionals who are readily available to help manage their needs for pads and anal plugs, and who can then provide a link back into secondary health care when appropriate.

Patients who continue to have episodes of faecal incontinence after this initial management may need to be referred to a specialist continence service where they can undertake pelvic floor retraining, bowel retraining, biofeedback, electrical stimulation and rectal irrigation. Rectal irrigation is particularly beneficial for those who have poor emptying as well as incontinence, and two types of pumps are readily available: the Braun irrimatic pump and the Peristeen pump (Coloplast). In order for these systems to be useful, patients need to have the ability to insert a tube into the rectum and manage the irrigation system.

Further treatment

All patients with faecal incontinence who are being considered for surgery should be referred to a specialist colorectal surgeon, who can offer the surgical and non-surgical options and discuss the realistic and likely outcome of any surgical intervention. Patients with a full-length external anal sphincter defect (which can be assessed on three-dimensional ultrasound) which is 90° or greater may be considered for an overlapping sphincter repair. This is done through a transperineal incision (Figure 59.4), and good long-term results at 5 years of 70% improvement should be expected. However, results deteriorate with time (Table 59.2). Patients with a Cleveland Clinic Incontinence Score below 9 should not be offered this as there is also a 15–20% risk that these patients will remain the same or be made worse. If patients have an incomplete internal sphincter defect, pudendal neuropathy, loose stools or irritable bowel, these are likely to decrease the effectiveness of a sphincter repair.

Figure 59.4 Overlapping sphincter repair. (A) Prone jack-knife position. (B) Curvilinear perineal incision to access ends of anal sphincter. (C) Sphincter muscle and scar tissue identified. (D) Overlapping repair with two layers of PDS (polydioxanone suture).

Table 59.2 Long-term results

Patients in whom sphincter surgery is deemed inappropriate (i.e. those who have an intact anal sphincter, those in whom sphincter disruption is small, or where there is an absence of much in the way of voluntary contraction) may be referred for sacral nerve stimulation.

Sacral nerve stimulation

Sacral nerve stimulators have revolutionized the treatment of anal incontinence, and probably work through stimulation of both the external sphincter and the pelvic floor. Patients with significant anal incontinence are asked to keep a 2-week diary (Figure 59.5) about their episodes of incontinence. They have a test or trial of a percutaneous nerve stimulator, placed through S3 (or S2 or S4), and are asked to rediary their bowel movements during the 2 weeks of stimulation.

Figure 59.5 Medtronic diary card for assessment of results from sacral nerve stimulation.

Results suggest that 70–80% of incontinent patients (urge and passive) will benefit from sacral nerve stimulation. If the trial is successful, these patients should be offered a permanent sacral nerve stimulator. This process involves implantation of a battery connected to a tyned wire which is inserted through the sacral foramen under X-ray guidance. The wire is tunnelled back to the battery, which is placed in the buttock or, occasionally, on the abdominal wall. Between 90% and 95% of patients who have at least a 50% improvement in symptoms with a temporary wire have a benefit with the permanent sacral nerve stimulator. There is a risk of infection, lead displacement and non-functioning of the permanent wire. NICE guidelines (National Institute for Health and Clinical Excellence 2004) looked at the results in 266 patients who had a sacral nerve stimulator; complete continence was achieved in 41–75%, and 75–100% of patients experienced a decrease of 50% or more in the number of incontinence episodes. As well as the incontinence, there is an ability to defer defaecation, which was absent previously, and an improvement in general quality of life. Adverse events in the fitting of the permanent implant are low (13%), mostly involving infection (three out of 149), lead migration (seven out of 149) and pain (six out of 149) (National Institute for Health and Clinical Excellence 2004).

Graciloplasty and artificial bowel sphincter

If sphincter repair and sacral nerve stimulation have failed after full maximization of medical treatment, alternatives include a stimulated graciloplasty or an artificial bowel sphincter. Stimulated graciloplasty involves making a new anal sphincter using the gracilis muscle, which is transposed after dissecting it off its attachments on the medial aspects of the tibia. The muscle is then wrapped around the anus and reattached on to the ischial tuberosity. Electrodes are implanted into the transposed muscle and stimulated continuously in order to change the muscle fibres from type 2 to type 1 (smooth muscle).

In 2006, NICE looked at a systematic review of 37 studies of graciloplasty and found that 42–85% of patients are continent after the procedure (National Institute for Health and Clinical Excellence 2006). One case series reported a successful outcome in 72% of patients at 5-year follow-up. One of the most common complications of this procedure is wound infection (overall rate of 28%, with 15% requiring hospitalization). Electrical or technical problems also occur in 48% of patients; one of the side-effects of the procedure is problems with evacuation resulting in obstructive defaecation. The procedure is recommended but only if performed in specialist units and in carefully selected patients in whom other treatments have failed.

Artificial anal sphincters were adapted from approved urinary sphincters. They have been associated with high levels of infection and mechanical failure. Recently, in an attempt to avoid these septic complications, Finlay et al (2004) developed a transabdominal artificial bowel sphincter with a control balloon reservoir in the abdominal space. An inflatable cuff keeps the anal canal closed, and the patient presses a control pump in the abdominal wall which deflates the cuff in order to evacuate the bowel. Repressing the button closes the sphincter again by allowing the fluid to return into the cuff. In a series of 12 patients with follow-up of 59 months, 75% of patients had a functioning implant and the continence scores were improved from 16 to 3 after surgery. Three out of 12 patients had to have the device removed because of complications, and it is recommended that this procedure should only be performed under strict audit and clinical governance conditions and in units with specialist interest in faecal incontinence (National Institute for Health and Clinical Excellence 2008a). However, it may be a promising route for patients with severe faecal incontinence.

Injectable bulking agents

Few long-term data are available for the use of bulking agents in passive leakage or incontinence. Injections of a variety of bulking agents (collagen, carbon beads and silicon particles) have been used. They are usually injected submucosally in three or four places, just above the dentate line (where the anal canal is less sensate and therefore less painful), in order to try and reproduce the anal cushions and stop passive leakage. The largest case series has shown that 82 patients had significant continence score improvement in 6–12 months (Tjandra et al 2004). The largest case series showed that the most common complications are pain, minor ulceration and, occasionally, infection, as well as leakage of the substance from the anus. NICE guidance suggests that the evidence is not adequate for bulking agents to be used without special arrangements for consent, audit and research, and these procedures should only be performed in units specializing in faecal incontinence that have the ability to audit these results and inform patients of the potential lack of evidence (National Institute for Health and Clinical Excellence 2007c).

Stoma

Patients who fail all of the above procedures may require a stoma, and in many circumstances, colostomies can improve quality of life and decrease the amount of time organizing bowel care. Nowadays, An end colostomy can be performed laparoscopically. Although it is a relatively simple procedure, there are complication rates of between 25% and 75%. Often, patients experience problems with skin irritation, retraction and bleeding from the stoma, as well as problems with the bag sticking. However, the most common problems in the long term are parastomal hernias, stenosis and prolapse.

Rectal prolapse surgery for full-thickness rectal prolapse

A full-thickness rectal prolapse is an extremely distressing and uncomfortable condition. It occurs most frequently in elderly ladies, and the quality of life of these patients can be severely compromised. Occasionally, there are complications such as gangrene and perforation, but the majority of patients have symptoms of a heavy feeling, mucus leakage, bleeding and recurrent prolapse through the anus. This may be associated with other pelvic floor prolapses such as uterine prolapse. In younger age groups, full-thickness rectal prolapse may be associated with previous eating disorders, and although the cause is not known, it is suspected that this may be due to a problem of collagen formation. The only possible curative treatment for a full-thickness rectal prolapse is surgery, but if a patient is relatively asymptomatic, surgery can be avoided and patients can have their constipation treated with a stool softener. Surgical interventions are based on either ‘chopping off the prolapse’ or ‘hitching it up’. When hitching it up (rectopexy), a resection of the sigmoid may also be undertaken if there is associated constipation. A recent Cochrane analysis (Tou et al 2008) looked at a series of five different types of intervention, with the outcome measures being morbidity, length of stay and mortality. Unfortunately, the number of studies available was extremely small, and most of the randomized controlled trials included few patients. Twelve studies were included in this work with a total of 380 participants. Patients who are fit should be offered a laparoscopic or open rectopexy; these are associated with lower recurrence than a perineal procedure. Frail and unfit patients should have a perineal procedure (i.e. Altemeier operation or Delorme’s procedure), the results of which suggest a recurrence rate of 25–40%. However, the morbidity and mortality associated with perineal procedures is low, and since many of these patients are over 80 years of age, this may make the recurrence rates relatively acceptable. If any form of prolapse is associated with a gynaecological prolapse, a combined procedure should be undertaken.

Altemeier operation

The design of this operation is to resect any prolapsing or redundant bowel and to attempt to recreate the pelvic floor by plicating the levators and reconnecting the sigmoid colon back to the anus with a coloanal anastomosis. However, there is no fixation of the rectum back up to the sacrum. The recurrence rate is approximately 16%, in comparison with 5% or less for an abdominal procedure (Tou et al 2008).

Delorme’s procedure

The alternative perineal procedure is the Delorme’s procedure, where the mucosa is resected off the bowel muscle tube. The bowel wall is then plicated and the mucosa of the anal canal is reanastomosed to the musosa high up within the anal canal. It is associated with a relatively high recurrence rate (up to 37%) (Tou et al 2008).

Rectopexy

The rectopexy has a much lower recurrence rate (<10%), and although mucosal prolapse is a relatively common form of recurrence, full thickness rarely occurs. The rectum is dissected down to the pelvic floor and then fixed up to the presacral fascia. Nowadays, this is mainly done laparoscopically and with sutures, but meshes and sponges were used for this fixation in the past.

In summary, healthy patients or patients with low comorbidity should probably have an abdominal or laparoscopic approach to treat their rectal prolapse with some sort of fixation. If there is any evidence of constipation, sigmoid resection with proctopexy is the preferred choice. However, there is a risk of an anastomosis and potential leak. In high-risk patients, a perineal approach should be offered and this varies culturally between an Altmeier’s operation (often performed in the USA) and a Delorme’s procedure (tends to be favoured in the UK).

Solitary rectal ulcer syndrome

This is a rare syndrome associated with rectal straining, resulting in an ischaemic, ulcerated wall of the rectum. This usually occurs anteriorly. The symptoms which then develop include further straining, a feeling of incomplete emptying, rectal bleeding and the passage of mucus as well as pain. On clinical examination, there is often a single or occasionally multiple ulcers, which are shallow. Occasionally, this may present as a polypoid lesion, which can be confused with the gross appearance of a carcinoma or a large polyp. A biopsy will confirm the diagnosis. Treatment is aimed at preventing straining and further chronic damage. Internal intussusception is found in a large number of these patients, but it is difficult to know whether this is related to solitary rectal ulcer formation or a result of the long-term straining. The mainstay of treatment is biofeedback aimed at reducing the length of time on the toilet. Straining patients are told how and where to sit and are given psychological support. They may require repeated courses of biofeedback as the results tend to fade after 2–3 years. Many people have tried a variety of surgical treatments for these ulcers, including local excision, rectopexy, stoma and even anterior resection. However, it has been found that resection is unlikely to improve the problem, and the majority of the surgical procedures result in less than 50% of the patients being cured. Even formation of a stoma may not relieve the symptoms. The patient will still have tenesmus and feel the need to defaecate continually.

Chronic constipation

Constipation in adults is extremely common and may be associated with a variety of abdominal symptoms as well as perineal discomfort.

Rome criteria for constipation

Constipation is defined as the presence of two or more of the following symptoms:

• Straining during at least 25% of defaecation.

• Lumpy or hard stools in at least 25% of defaecation.

• Sensation of incomplete emptying for at least 25% of defaecation.

• Sensation of anorectal obstruction blockage for at least 25% of defaecation.

• Manual manoeuvres to facilitate at least 25% of defaecation (such as digital evacuation support of the pelvic floor).

• Fewer than three bowel movements a week.

• Loose stools are rarely present without the use of laxatives.

Criteria have to have been met for the previous 3 months with the onset of symptoms 6 months prior to diagnosis.

Constipation occurs in up to 30% of the population (Garrigues et al 2004), and females have a higher incidence than males. Physical exercise and a high fibre diet are protective against constipation. Constipation can be divided into slow transit constipation, obstructive defaecation syndrome and irritable bowel syndrome (IBS).

Simple causes of constipation include a low fibre diet, dementia, depression and eating disorders. There are metabolic causes such as hypothyroidism, hypokalaemia, hypercalcaemia and diabetes mellitus (McCallum et al 2009). Neurological problems can include multiple sclerosis and Parkinson’s disease, and there are a variety of drug-related causes for constipation. Patients with painful anorectal conditions such as fissures, haemorrhoids, fistulas etc. may develop constipation secondary to their painful anus. The majority of cases of constipation can be treated with basic dietary advice. Patients should sit on the toilet with their feet raised so that they sit in a semi-squatting position; this opens up the anorectal junction and allows them to defaecate more effectively. The use of abdominal massage and exercises which can be provided through a specialist nurse practitioner can help with the process of defaecation. Patients should ensure that they are well hydrated and take adequate amounts of fluid as well as exercise. Fibre may be beneficial, although patients with constipation related to IBS may find that their abdominal pain is increased with their intake of fibre. Preferred laxatives include movicol and magnesium hydroxide which do not rely on gut stimulation. However, stimulant laxatives are sometimes of use in patients who have poor colonic motility, especially secondary to opiates (McCallum et al 2009).