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Hemorrhoid No More Summary


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Contents: 150 Page Ebook
Author: Jessica Wright
Official Website: www.hemorrhoidnomore.com
Price: $37.00

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Gender Ethnicracial And Life Span Considerations

The elderly are more prone to the condition because of their increased incidence of constipation, hemorrhoids, and diabetes mellitus. Women are more commonly affected by constipation than are men. An anorectal fistula is a rare diagnosis in children, but anorectal abscesses are common in infants and toddlers, particularly those still in diapers. Anal fistulas are complications of anorectal abscesses, which are more common in men than in women. For anatomical reasons, rectovaginal fistulas are found only in women. Ethnicity and race have no known effect on the risk of anorectal fistulas.

System Reconstructive Procedures

Patients with a rectocele have a history of constipation, hemorrhoids, pressure sensations, low back pain, difficulty with intravaginal intercourse, and difficulty controlling and evacuating the bowel. Symptoms may be worse when standing and lifting and are relieved somewhat when lying down. Obstetric history often reveals a forceps delivery. Some report that they are able to

Normal Anatomy and Morphology with Anal Ultrasound

The submucosal layer has a mixed echogenic aspect and is partly collapsed by pressure of the endo-probe 25 . Submucosal thickness increases slightly with age 26 . This has also been found to a larger extent in internal haemorrhoids 33 and might be caused by physiological distal displacement or enlargement of the anal cushions 34 . The mucosa cannot be identified separately with the frequencies used.

Clinical Presentation

Carcinoid tumor presentation depends largely on the anatomical site in which the neoplasm originates. Bronchopulmonary carcinoids frequently manifest with cough, hemoptysis, or recurrent respiratory infections (7). Gastric carcinoids can produce abdominal pain or rarely GI bleeding, whereas small intestine tumors may present with signs and symptoms of obstruction owing to the desmoplastic reaction caused by carcinoid tumors (8). Colonic tumors are usually right-sided, and present with obstructive symptoms or manifestations of disseminated disease. Rectal carcinoids are nearly always found incidentally on routine rectal examination, or on endoscopic exam for unrelated reasons. Rarely, rectal pain or bleeding will result in a diagnosis of a carcinoid tumor.

Operative Intervention

Operative treatment is usually indicated for full-thickness rectal prolapse if the primary problem is not one of excessive straining. More than 100 different procedures have been described to treat the condition 30 but can be broadly divided into those that are abdominal (open or laparoscopic) or perineal in approach. The latter are often favoured for the frail and the infirm and in young males to minimise operative trauma and the risk of nerve damage. Continence restoration rates are similar between the two Table 1. Large studies ( 50 patients) involving open abdominal repair of full-thickness rectal prolapse Table 1. Large studies ( 50 patients) involving open abdominal repair of full-thickness rectal prolapse Table 2. Large studies ( 50 patients) involving perineal repair of full-thickness rectal prolapse Table 2. Large studies ( 50 patients) involving perineal repair of full-thickness rectal prolapse

Fecal Occult Blood Tests 321 Guaiac Based Stool Tests

Elektolit Batrai

The American College of Physicians has published comprehensive guidelines for fecal occult blood testing (FOBT) and interpretation with review of the data (7,8). FOBT has been estimated to detect around 90 of cancers with repeated testing over several years (9). However, a one-time FOBT (three samples) has an estimated sensitivity for advanced neo-plasia of only 23.9 (10). FOBT is most commonly performed using a guaiac-based test for peroxidase activity. Therefore, it is important that patients avoid other substances with peroxidase or pseudoperoxidase activity, such as rare red meat and some fruits and vegetables (e.g., turnips and horseradish). False-positive results can also occur as a result of other sources of gastrointestinal bleeding (e.g., hemorrhoids, peptic ulcer, and gum disease). False-negatives can result from tumors,

Surgical Treatment Sphincter Repair

Excision was later implicated in the failure of the apposition technique 37 . More recently, in a study of 40 patients with sphincter trauma over a 15-year period, an end-to-end apposition was performed with excellent results 95 . The technique involves minimizing dissection of the injured muscle to preserve vascularity and the preservation of scar tissue to help anchor the overlapped muscle. The authors advocate the apposition repair because of its simplicity and effectiveness. Plication or reefing can be performed anteriorly (vaginal mobilization, external sphincter division, levator ani plication followed by puborectal-is and external sphincter repair, or posterior plication of the external sphincter and levators) 96 . In 1975, Parks described the postanal repair for incontinence associated with rectal prolapse and idiopathic incontinence 97 . The postanal repair involves posterior plication of the puborectalis muscle to restore the normal anorectal angle. The postanal repair is...

Preoperative Assessment

Operative intervention is undertaken in patients in whom appropriate assessment has been performed. This includes a careful history, clinical examination, endoanal ultrasound and anal manometry. Further tests that may be useful are a defecating proctogram, pudendal nerve terminal motor latency (PNTML) and needle electromyelogram (EMG). If these investigations identify a defect in the external sphincter, then the patient should undergo a sphincter repair rather than a postanal repair. Rectal prolapse should be excluded by careful history and examination and if necessary, a defecating proctogram.

Proctological Procedures General Introduction

Anal Sphincter Ultrasound

Anal dilatation has been a mainstay of treatment of many colorectal diseases and was popularised for treating haemorrhoids by Lord 3 . Techniques have been variable. Watts et al. used four fingers in the anal canal to provide lateral distraction with considerable force and reported occasionally some bleeding from the mucocutaneous junction 4 . Others have tried to standardise the procedure, using a Parks' retractor opened to a set distance 5 . There have been many reports of incontinence after manual anal dilatation. This appears to be related to internal anal sphincter fragmentation. A study from St. Mark's Hospital in the UK of 12 men with incontinence after manual anal dilatation found that resting anal pressures were low. Eleven of the men had a disrupted internal anal sphincter, with fragmentation in ten of these cases (Figs. 1 and 2). Three patients also had external anal sphincter fragmentation 6 . A further study 7 examined 32 consecutive patients who had undergone manual...

Doxium For Varicose Veins

The relation between plasma endothelin-1 levels and metabolic control, risk factors, treatment modalities, and diabetic microangiopathy in patients with Type 2 diabetes mellitus. Journal of diabetes and its complications, Vol. 15, No. 3, (May-June 2001), pp. (150-157), ISSN 1056-8727 Allain, H., Ramelet, A. A., Polard, E. & Bentue-Ferrer, D. (2004). Safety of calcium dobesilate in chronic venous disease, diabetic retinopathy and haemorrhoids. Drug Safety, Vol. 27, No. 9, (August 2004), pp. (649-660), ISSN 0114-5916 Almarsson, O., Bourghol Hickey, M., Peterson, M. L., Zaworotko, M. J., Moulton, B. &

Internal Anal Sphincter Abnormalities

The majority of lesions of the IAS are due to iatro-genic and obstetric injuries, often in combination with injuries to the EAS, leading to faecal incontinence. Smaller lesions leading to minor faecal incontinence or soiling are due to hemorrhoidectomy or mucosal prolapsectomy. Manual anal dilatation 65 or lateral internal sphincterotomy 66-68 are notorious and have been associated with faecal incontinence in 27 and 50 of patients, respectively. Fistula surgery can cause faecal incontinence in up to 60 of cases 69 . Fortunately, not all traumatic sphincter defects lead to faecal incontinence or soiling. In a study of 50 patients after haemorrhoidecto-my (24), fistulectomy (18), and internal sphincterotomy (8), 23 (46 ) had a defect of the anal sphincter (13 IAS, one EAS, nine combined defect) three after hemorrhoidectomy, 13 after fistulectomy, and seven after internal sphincterotomy. Seven patients (30 ) had symptoms, and they all had a sphincter defect. In the other 16 (70 ), the...

Small Bowel And Colonic Lymphomas

Patients present with various symptoms depending on the location of the disease and include abdominal pain, diarrhea, hematochezia, weight loss, and fatigue. Endoscopic evaluation should be tailored to the patient's complaints. At colonoscopy, the typical polyps can be seen in the colon or terminal ileum, and appear as fleshy nodular or polypoid tumors that range in

Physiological Investigations

Loose Pelvic Floor Rectal Prolapse Gifs

Skin excoriation infection Perianal perineal scars Patulous anus Perineal soiling Anal ectropion Hemorrhoidal prolapse Rectal prolapse Sphincter deficit Loss of perineal body Perineal descent Fistula Hemorrhoids Anal rectal tumors Inflammatory bowel disease Solitary rectal ulcer Alterations of PNTML are identified in relation to patient's age, being more frequent in older subjects. In a large number of patients with FI (with or without urinary incontinence) and rectal prolapse, the PNTML is abnormally prolonged. PNTML levels are thought to have a predicting value in patients undergoing treatment, but this assumption remains controversial.

University of North Carolina Clinical Experience

Ing continence in 22 25 patients (88 ), significant morbidity was observed. Two patients required permanent colostomy for refractory incontinence. In terms of donor-site complications, 16 25 patients (64 ) developed a combination of posterior thigh numbness (7), dysesthesias (5), cellulitis (5), irregular contour (3), abscess (2), severe chronic pain (2), and hematoma (1), but there was no altered gait or hip dysfunction. Regarding perirectal complications, 14 25 patients (56 ) had sinus tract formation (3), flap dehiscence requiring reoperation (2), perirectal abscess requiring temporary fecal diversion (2), chronic pelvic pain (2), vaginal perforation with delayed healing (1), recurrent fistula (1), and rectal prolapse (1). Six patients required readmission for wound care, intravenous antibiotics, or operative intervention.

Macrolactam indole alkaloid

Ipomoea obscura (L.) Ker-Gawl., or obscure morning glory, is a slender climber common on fences. It is native to tropical East Africa, the Mascarene Islands, tropical Asia, throughout the Malay Archipelago, to northern Australia and Fiji. The leaves are cordate to 5 cm long and the flowers are infundibuliform and creamy white (Fig. 35). In Indonesia, a paste of leaves is applied on sores, ulcers, hemorrhoids, and swellings. The seeds of Ipomoea obscura (L.) Ker-Gawl are known to contain unusual indole alkaloids including ipobscurines B-D, being unique structural types characterized as serotonin hydroxycinnamic acid amide-type conjugates with a second phenylpropanoid moiety forming an ether with the 5-OH position of the indole nucleus (10). It would be interesting to know whether or not these alkaloids hold some potential as promoters of serotoninergic neurotransmission.

Multimodal Rehabilitation

The clinical outcome of multimodal rehabilitation is encouraging. Eighty-nine percent of patients show a significant improvement in incontinence score and 38 become symptom free. The worst results are obtained in patients affected by rectal prolapse and those with sphincter-saving operations. Long-term evaluation as well as prospective studies could confirm the promising results of the multimodal rehabilitation model.

Medicinal Hamamelidaceae

The family Hamamelidaceae consists of 26 genera and about 100 species of shrubs or tress known to contain tannins and iridoids. The leaves are alternate, simple, and often palmately lobed. The flowers are small and appear in spikes. The fruits are woody, capsular, and scepticidal. In Western medicine, the dried leaves of Hamamelis virginiana (hamamelis, British Pharmaceutical Codex, 1963), yielding not less that 20 of alcohol (45 )-soluble extractive, have been used as astringents for the treatment of hemorrhoids. Hamamelis water (British Pharmaceutical Codex, 1969) made from the stems has been used as a cooling application to sprains and bruises and as a styptic remedy. It is also used in cosmetics and as active ingredient of eye lotions.

Discharge And Home Healthcare Guidelines

Review use of any pain medication prescribed, as well as non-pharmacologic comfort measures for episiotomy, lacerations, and hemorrhoid care. Instruct the patient to report any increase in perineal or uterine pain, foul odor, fever or flulike symptoms, or vaginal bleeding that is heavier than a menstrual period. Sadness or mood swings that persist beyond 4 weeks should be reported to the physician.

Primary Nursing Diagnosis

The pain and itching from vaginitis may be quite intense until the medication is effective. Some women find that by applying wet compresses and then using a hair dryer on a cool setting several times a day provides some relief of itching. Other women find that a cool sitz bath provides comfort. For yeast infections, tepid sodium bicarbonate baths and applying cornstarch to dry the area may increase comfort during treatment. Be informed about which sexually transmitted diseases need to be reported to the local health department.

Incontinence with Anorectal Sphincteric Abnormalities

The remaining ambulatory elderly patients with fecal incontinence will exhibit one or a combination of abnormalities of continence mechanisms. Most can be ascertained when a directed physical examination is performed by a skilled and experienced examiner 14, 18 . For example, the tone of the internal anal sphincter and the contractile strength of the external anal sphincter can be assessed by digital examination of the anal canal at rest (largely reflecting internal anal sphincter function) and when the patient tightens the anal canal (external anal sphincter function). Deeper insertion of the finger allows assessment of puborectalis muscle contraction strength. Having the patient bear down, especially in a squatting or dorsal lithotomy position, allows optimal assessment for rectal prolapse or excessive descent of the perineum, suggesting weakness of the pelvic floor muscles. Only impaired rectal sensation cannot be assessed by conventional physical examination however, this rarely...

Surgical Results Outcomes of Primary Repair

The presence of a colorectal surgeon at the time of delivery is potentially disruptive to both the staff and to the needs of the mother and newborn baby and may not be feasible within the organization of a delivery ward. However, there is widespread agreement that interdisciplinary cooperation and integrated follow-up is necessary. Counseling by a continence advisor and offering consultation with a col-orectal surgeon 51 , sphincter repair workshops 48 , clinical evaluation by a proctologist every 6 months to determine if a repair should be repeated 47 , and the use of anorectal physiology to plan future deliveries 52 have all been suggested. Follow-up of all women with sphincter tears will identify symptomatic women early enough to allow them to be treated and to advise them regarding future deliveries 53 .

Direct Health Care Costs

Patients presenting with fecal incontinence are often not hospitalized for instance, in Italy in 2003, the number of hospitalizations with a diagnosis of fecal incontinence on discharge amounted to 222 7 . To place this figure in its proper perspective, it should be compared with the number of hospitaliza-tions for two very common disorders with a heavy clinical and social impact, namely, hemorrhoids and urinary incontinence, which accounted for 36,073 and 2,274 hospitalizations, respectively, in 2003 7 .

Indications and Contraindications for the ABS

In cases of neurogenic or neurologic fecal incontinence, it is essential to take into account possible associated dyschezia and excessive perineal descent. The ABS creates an obstacle to rectal evacuation, which can sometimes cause considerable evacuation difficulties. Continence restoration should not be achieved to the detriment of evacuation capacities. However, an objective assessment of the state of pre-operative transit is not always easy. Patients have often modified their diet to avoid difficulties or have had recourse to antidiarrheic treatments. Rectal prolapse or a history of surgical cure for prolapse should be carefully considered before implantation of an ABS insofar as these conditions are indicative of disturbances in the defecation process.

Clinical Assessment

Inspection of the perineum and digital examination of the anorectum are essential and should be performed in all patients with faecal incontinence before enemas or laxatives are given. With the patient lying in the left lateral position, he she should be asked to bear down. Normally, the perineum descends no more than a centimetre. Bearing down may also reveal the existence of rectal prolapse, which is frequently associated with sphincter weakness and is a frequent cause of seepage. The presence of obvious external haemorrhoids is also a common cause of anal seepage of mucus. Digital examination of the rectum is a useful and simple means of assessing resting anal tone and the strength of the conscious contraction. Proctoscopy and or sigmoidoscopy (with or without biopsy) should be performed to exclude not only haemorrhoids, fistulas, and fissures, but also solitary rectal ulcers, proctitis, inflammatory bowel disease, and tumours. The remaining colon should be evaluated, usually by...

Etiology of Fecal Incontinence

Other causes of anatomical disruption include iatrogenic factors such as anorectal surgery for hemorrhoids, fistulae, or fissures and proctitis after radiotherapy for prostate cancer. Postoperative fecal incontinence may affect up to 45 of patients after lateral internal sphincterotomy 6 , 8 , and 1 reported incontinence to flatus, minor fecal soiling, and loss of solid stool, respectively, 5 years later 23 . Incontinence following lateral internal sphincteroto-my does not appear to recover in the long term and appears to be an independent cause of fecal incontinence 24 . Similarly, the risk of fecal incontinence after fistulotomy ranges from 18 to 52 25 . The internal anal sphincter is occasionally and inadvertently damaged during hemorrhoidectomy 26 . The risk of developing fecal incontinence is about 28.3 in patients receiving closed hemorrhoidectomy by Ferguson technique 27 , which is now considered a gold standard for hemorrhoidectomy. Pelvic radiotherapy results in chronic...

Invited Commentary

Other traumatic causes of fecal incontinence include consequences of surgery to address other anorectal disease. Fistulotomy and hemorrhoidecto-my can leave various degrees of defects in the muscle or anal topography that lead to leakage. Sometimes these problems can be surgically improved by smoothing the scar ridge or reapproximating the muscle ends. However, internal anal sphincter disruption from stretching or hemorrhoid excisional surgery that includes some muscle fibers may not respond to conventional muscle reapproximation and necessitate consideration of one of the novel approaches to improve fecal leakage. Once again, the ability to detect defects in specific sphincter components and the size and configuration is mandatory.

Classification of Incontinence

It has been established that rectocele may be associated with anal incontinence for many reasons, including complete rectal prolapse and rec-toanal intussusception 21 . But it is important to note that the association between rectocele and anal incontinence is more evident in the subgroup with urge FI 8 .

Invertebrate Phyla Other Than Arthropods

The phylum Platyhelminthes comprises the flatworms and flukes. There are four classes, of which we will describe three. The turbellarians include the small aquatic flat-worm Planaria (Figure 8.1), found on the bottom of rocks in streams. The trematodes include the blood fluke Schistosomona (also called Bilharzia), which causes the important waterborne parasitic infection schistosomiasis (or bilharziasis). This disease is common in warm climates. The schistosomes are discharged from the intestines of infected people in their feces. If the fecal contamination reaches a stream, the fluke can infect a specific kind of snail, where it develops. Released back to the water, the schistosomes can reinfect humans through the bare skin. It then travels via the bloodstream to infection sites in the liver and digestive system. Symptoms in humans include extreme diarrhea and bloody stool or urine. It can be controlled by proper sanitation and by control of conditions favorable to the snail host.

Techniques for Bulking Agent Injection

The ideal track of the injection needle is also unresolved. There are two main options. The first is to use a method similar to that for injecting oily phenol into piles, where the product is injected via a proctoscope into the submucosa above the dentate line. The second method is trans-sphincterically through a long tract to avoid product back leakage. Under local or general anaesthesia, a longer needle is used to pass through the skin and both sphincter muscles, the tip of the needle being directed to the submucosa above the dentate line. Performed through a proctoscope

Which Tests in Which Condition

Concerning physiological assessment, AREP should play a crucial role, although its use is rather limited because specific experience in electrophysiology is required. EMG performed to map sphincter lesions is no longer frequently used, but it could be of interest to visualize denervation or reinnervation patterns in many clinical conditions (i.e., sphincter atrophy, neuropathies, elderly patients). AREP allows assessment of both anal and rectal threshold sensations, which should be mandatory when investigating FI due to rectal prolapse, after rectal resection or irradiation, in neuropathy and metabolic diseases, and in elderly patients. PNTML assessment could reveal a pudendal neuropathy and, then, be useful in a number of FI cases in both obstetric and iatrogenic sphincter lesions, being suggested of importance in choosing some therapeutic approach (i.e., sphincteroplasty) in sphincter atrophy in rectal prolapse or resection in irradiated patients in central peripheral neuropathies...

Sacral Nerve Stimulation

Sacral nerve stimulation may be considered at this stage and has the advantages of having a peripheral nerve evaluation phase to evaluate whether a permanent implant is likely to be successful. It is also a minimally invasive procedure and may be carried out under local anaesthetic. Four female patients with persisting faecal incontinence following full-thickness rectal prolapse repair have shown improvement in incontinent episodes from 14 to two per week 52 . Two other papers 53,54 studying sacral nerve stimulation in a more general population included three patients with ongoing resistant faecal incontinence Table 3. Large studies ( 50 patients) involving laparoscopic abdominal repair of full-thickness rectal prolapse Table 3. Large studies ( 50 patients) involving laparoscopic abdominal repair of full-thickness rectal prolapse following rectal prolapse surgery. All three were reported as showing improvement. It appears to be an effective therapy in this subgroup of patients,...


Campylobacteriosis is the leading cause of foodborne illness worldwide. The clinical manifestations of the disease are very diverse, ranging from mild, noninflammatory watery diarrhea to more severe inflammatory diarrhea with abdominal cramps. The incubation time can be 1-7 days, and although severe illness can last more than a week, the disease is generally self-limiting and complications are rare. Antibiotics may be used in such clinical circumstances as high fever, bloody stools, prolonged illness with symptoms lasting more than a week, pregnancy, infection with human immunodeficiency virus (HIV), and other immunocompromised states, although they are not generally required. Erythromycin is the drug of choice, and resistance to it remains relatively low following decades of use. 4 It is estimated that about 1 in 1000 cases of campylobacteriosis results in the neurological disorder Guillain-Barre syndrome. 5 Another related neurological disorder, Miller-Fisher syndrome, is also...

Role Of Endoscopy

As previously mentioned, carcinoid tumors of the stomach, duodenum, rectum, colon, appendix, and terminal ileum may be found incidentally when other conditions are being investigated via endoscopy. Infrequently, a carcinoid tumor will produce symptoms such as abdominal or rectal pain, blood per rectum, bowel obstruction, or mass felt on rectal exam, necessitating a diagnostic endoscopy. Simple biopsy of a luminal mass may be adequate to diagnose a carcinoid tumor. However, the submucosal location of most tumors sometimes results in nondiagnostic biopsies. In these cases, endoscopic ultrasound (EUS) may provide images of the internal structure of the GI wall, determine the depth of mucosal carcinoid tumors (153) as well as provide fine-needle aspiration or ESMR to obtain diagnostic tissue (Fig. 2). One group has advocated endoscopic resection of gastric carcinoids less than 2 cm if EUS can confirm that the tumor is confined to the submucosa without local adenopathy (154).

Meadow Saxifrage

Dyer. 1889 suggested that the granulated roots of this species provided another signature. Presumably he had in mind the similar roots of plants like Lesser Celandine, though in the latter case it was haemorrhoids it was supposed to cure, and there seems to be no record that Meadow Saxifrage was used in a similar way.

Symptoms and Signs

Typically, patients complain of prolapse, mucus discharge, bleeding and either incontinence or constipation. The diagnosis of full-thickness rectal prolapse, although suggested by the history, needs to be confirmed on examination to rule out partial-thickness rectal prolapse, prolapsing haemorrhoids and the like. Ideally, the patient should be placed on a toilet or commode and encouraged to bear down in order to demonstrate the prolapse, as embarrassment and fear of soiling often prevents demonstration of the prolapse in the consultation room. Incontinence should be specified, as mucus or minor soiling from the surface of the prolapsing rectum is often reported as faecal incontinence.


When diabetic diarrhoea is complicated by faecal incontinence, the first priority is to bring the diarrhoea under control and, subsequently, ascertain whether the patient has a treatable cause for incontinence. Certain conditions that occur with increased frequency in patients with diabetes, including coeliac disease, pancreatic insufficiency, and bacterial overgrowth of the small intestine, must be excluded. Coeliac disease in particular is easily overlooked and can be excluded by taking jejunal biopsies. Pancreatic insufficiency must be considered and should be excluded by measurement of faecal fat and appropriate pancreatic function tests, or by a trial of oral pancreatic enzyme therapy. Bacterial overgrowth can be diagnosed by a hydrogen breath test or suspected by improvement of the diarrhoea by a short course of broad-spectrum antibiotics (ampicillin, tetracycline). Other causes of diarrhoea that must be excluded are irritable bowel syndrome, laxative abuse, rectal prolapse, and...

Anal Dilatation

Although first described almost two centuries ago, anal dilatation became the primary treatment for anal hypertonia associated with chronic fissure-in-ano and haemorrhoids after the introduction of the now-infamous Lord's procedure originally an eight-finger ( ) anal stretch in 1968 186 . The concept was that forceful dilatation would loosen the sphincter muscle and increase blood flow to the anoderm 187 . Despite reported success rates with respect to pain relief of 55-80 188-190 , it is now well documented that this procedure is frequently associated with compromised continence. Furthermore, symptom recurrence may be high over the long term 189, 191 .


Medical Anus

Pected, suggesting a sphincter gap, occult rectal prolapse, or neuropathy (Fig. 1). Anal deformities, such as key-hole anus, frequently caused after posterior sphincterotomy or fistulotomy, prevent the anus from closing properly and can explain the leak of feces and mucus. The patient should be asked to squeeze so the symmetry and quality of closure can be assessed. Asymmetric collapse of the sphincter ring may reveal a unilateral gap in the sphincter as well as bilateral defects in a different area. The anus and the perineal area should also be evaluated under the Valsalva maneuver. Under these conditions, rectal prolapse with concentric folds will differ from mucosa prolapse that shows radial folds and is rarely responsible for severe incontinence, although it can explain minor mucus leak. This is also the time to look for third- and fourth-degree hemorrhoids, as well as perineal descent, which is clear when the perineum descends below the level of the ischial tuberosities line....

Patient Selection

Sphincter Operation

Only major contraindications to the sphincter replacement procedures are very severe chronic bowel diseases causing intractable defecation dysfunctions (severe diarrhea as well as severe constipation) and coexistence of rectal prolapse, intussusception, rectocele, or enterocele. has rapidly expanded, and step by step, acceptable indications have been suggested. Initial applications concerned patients with dysfunctions of nonlesioned striated anal muscles, then with a prevalent neuro-genic etiology 58-64 . Thereafter, as clinical use and understanding of action mechanisms made progress, SNS expanded to other indications, including idio-pathic sphincter degeneration, iatrogenic internal sphincter damage, partial spinal cord injury, sclero-derma, limited lesions of internal or external anal sphincters, rectal prolapse repair, and low anterior resection of the rectum 65-78 . Actually, alterations of the sacrum or skin in the implantation area, very wide sphincter tears, pregnancy, and...


In terms of structures contributing to continence, the sphincter muscles alone cannot entirely close the anal lumen 213 , and approximately 15 of the basal anal canal resting tone is generated by the expansile vascular anal cushions 214 , which, along with secondary anal mucosal folds 215 , provide a hermetic seal. The importance of these structures becomes evident in patients with prolapsing haemorrhoids, where the mucocutaneous junction, which provides a barrier against mucus and liquid faecal leakage, may be displaced beyond the anal verge 216 . Faecal soiling is not uncommon in such patients 217 and may indeed be cured by haemorrhoidectomy 218, 219 . Contrarily, however, in continent patients with symptomatic haemorrhoids, surgery is now clearly recognised as carrying a risk for the development of incontinence.


15 , but it is not contraindicated for DGP because a new, well-innervated muscle is introduced. Defecog-raphy can help exclude other reasons for fecal incontinence and other diagnoses that contraindicate a DGP, for instance, intussusception, rectocele, entero-cele, or rectal prolapse.

Maternal responses

Hyperemesis gravidarum is more likely and severe cases may respond to steroid therapy or odansetron. All the minor complications of pregnancy such as backache, oedema, varicose veins, reflux, haemorrhoids etc. are also increased, both as a result of the physical effects of greater uterine size and also of greater placental hormone production. Gestational diabetes is increased in most studies.


The majority of patients with full-thickness rectal prolapse experience faecal incontinence 4, 5, 60 . Once the prolapse has been dealt with surgically, approximately one third of these patients continue to suffer from faecal incontinence 4-7 . Treatment is largely conservative in what is often an elderly group of patients. Minimally invasive procedures, such as sacral nerve stimulation, and other more invasive procedures, including stoma formation, should be reserved for the carefully selected minority or patients with ongoing symptoms significantly affecting their quality of life.

Future Directions

A broad spectrum of patients is today successfully selected by the current pragmatic approach. Recently, some small case series and individual case reports have investigated the effect of SNS in groups of patients presenting with distinct conditions or well-defined anorectal physiologic findings, e.g., muscular dystrophy 39 , a history of rectal resection and neoadjuvant chemoradiation 40 , a sphincteric gap requiring surgical repair 41 , neurologic dysfunction 42 , rectal prolapse repair 43 , and rectal resection for cancer 44 . Initial results are promising but need to be confirmed in large prospective trials. This approach hopes to pinpoint clinical predictors of responders, potentially obviating test stimulation also, by focusing on a distinct pathophysiologic condition, it may be helpful to our understanding of how SNS works.

Anal Manometry

Anal manometry is not routinely carried out in all patients with rectal prolapse. However, in patients with associated faecal incontinence, it has some predictive value in identifying patients who are likely to remain incontinent following rectal prolapse repair 22 . Patients with rectal prolapse have a reduced resting anal canal pressure 4, 5, 23, 24 . Those with rectal prolapse and incontinence have both reduced resting and squeeze pressures, which improve significantly following operation. Patients who remain incontinent after surgery have a significantly lower preoperative resting anal pressure and maximum voluntary contraction pressure than do patients who improve or regain continence. Preoperative resting anal pressure below 10 mmHg and maximum voluntary contraction pressure below 50-60 mmHg are associated with persisting incontinence after surgery 25, 26 .


A thorough physical examination is performed, the key portions of which are the perianal and rectal examination. The perianal area is inspected for soiling, evidence of infectious diseases, skin excoriation, or poor hygiene. Presence of a patulous anus, skin tag, episiotomy scars, spontaneous hemorrhoidal prolapse, drainage, fistulas, or fissures are noted. The patient is asked to strain so that prolapse or perineal descent can be evaluated, and anal sensation is tested. External palpation excludes fissure, masses, abscesses, or fistulas. Digital rectal examination evaluates for masses or tenderness and assesses resting sphincter tone. The patient is asked to squeeze, and the examiner feels for concentric contraction of the sphincter muscle and estimates squeeze pressure. Upon relaxation, contraction of the puborectalis muscle is assessed for paradox. Anoscopy enables visualization of the mucosa and provides further assessment of hemorrhoids. A bidigital exam assesses the thickness of...

Physical Exam

Patient should be examined lying in the left lateral position, with good illumination. The exam begins with an inspection to look for the presence of fecal matter, prolapsed hemorrhoids, dermatitis, scars, skin excoriation, absence of perianal creases, or the presence of a gaping anus. Excessive perianal descent or rectal prolapse can be demonstrated by asking the patient to attempt defecation. An outward bulge that exceeds 3 cm is usually defined as excessive perineal descent 52 .

Seasonal Variability

In a study from the USA, norovirus was associated to exacerbation of both UC and CD in pedi-atric patients, in all cases associated with bloody diarrhea, and with demand for hospitalization. This was in contrast to diarrhea without hematochezia when the infection occurs in the absence of IBD 118 .

Endoanal Ultrasound

Endoanal ultrasound often reveals an early thickened internal anal sphincter and submucosa 27 and, with long-standing prolapse, a torn or even fragmented internal anal sphincter and or external sphincter 28, 29 . The feeling is that the internal sphincter thickens initially in response to the prolapse in order to try to contain it but eventually fails from traumatic disruption. In the incontinent patient, baseline endoanal ultrasound and physiological measurements are useful to ascertain the likelihood of ongoing problems of faecal incontinence following rectal prolapse fixation.

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