Rectal Intussusception: Medical management and timing of the decision to operate.

Elsevier

Available online 11 December 2022, 100940

Seminars in Colon and Rectal SurgeryAuthor links open overlay panelAbstract

Rectal Intussusception (RI) occurs when the rectal wall telescopes distally without prolapse past the anal verge during defecation and occurs as the result of abnormal rectal wall biomechanics. Symptoms are variable though ¾ of patients with high grade intussusception report straining, incomplete emptying and the need for manual assistance during evacuation. The diagnosis of RI requires a comprehensive clinical history, physical exam and dynamic imaging of evacuation with MR or fluoroscopic defecography. Phenotypic grading is important as low-grade, non-obstructing RI may not significantly contribute to symptoms and outcomes following surgery in this group is poor. Initial management should focus on improving stool form and evacuatory dynamics in conjunction with biofeedback if there associated dyssynergia. Surgery should only be considered in those patients with high-grade intussusception and symptoms resistant to medical therapies after appropriate counselling regarding the risks and benefits of intervention.

Section snippetsBackground

Rectal intussusception (RI), also known as internal rectal prolapse, is characterized by intraluminal invagination of the rectum without extrusion past the anal verge during defecation1. The apex of the intussusception originates anteriorly and progressive involvement of the posterior rectal wall leads to circumferential telescoping of all layers of the rectum particularly during pushing to evacuate. This results in a reduction in the luminal diameter of the rectum causing mechanical

Pathoetiology

Cross-sectional studies suggest that a structurally significant RI may be found during proctographic testing in 32% patients presenting with constipation alone and 27% of patients with co-existent constipation and fecal incontinence2. However, intussusception in all its forms is not always associated with symptoms as studies demonstrate that degrees of RI may be found in up to 50% of asymptomatic volunteers3.

The pathoetiology of RI has been inadequately studied, however it is generally accepted

Presenting symptoms

Symptoms of straining, a sensation of incomplete evacuation and the need for manual assistance during defecation are reported in more than 3/4 of patients with high-grade RI9. Toilet revisiting, anal pain and the sensation of prolapse are also predictive of this defecographic finding1. Abdominal pain, hard stools and bloating may also be reported2 however, these symptoms are not correlated with the degree of obstructive defecation on imaging10 and are commonly associated with other functional

Clinical examination

Although the diagnosis of RI requires functional imaging, a thorough clinical exam is pertinent to assessment as it allows (a) exclusion of serious pathology such as rectal carcinoma or inflammatory bowel disease, (b) demonstration of other pelvic floor / proctological conditions such as rectocele, sphincter hypotonia, haemorrhoids or anal fissure and (c) assessment of pelvic floor dynamics. All of the above can mimic / exacerbate / better explain symptoms found in patients with RI.

Particular

Symptom assessment

Excluding those patients with a secondary solitary rectal ulcer, management of patients with RI is aimed purely at reducing symptom burden15. For this reason, documentation of symptom severity with standardized scores is often beneficial during triage to therapy and assessment of response to treatment. Symptoms of both incontinence and constipation should be assessed, particularly as the co-existence of these symptoms is often underreported by patients and underappreciated by clinicians2. The

Diagnosis and work up

Detailed characterization of symptom etiology in patients with RI is essential to facilitate planning of optimal treatment. Full assessment not only includes identification and characterization of the intussusception itself, but also involves interrogation of pelvic floor dynamics, anorectal co-ordination, anal sphincter function, rectal sensation and the anterior / middle compartment structures20.

The gold standard for diagnosis of RI is evacuation proctography which involves fluoroscopy in the

Management goals

The aims of treatment for RI are essentially to reduce symptom burden to improve quality of life. While surgical interventions often deem appropriate for patients with advanced stages of RI and rectal prolapse the role of surgery in low grade RI is less clear. Nevertheless, low-grade RI symptoms are nonspecific and often due to the primary underlying pathology as compared to the prolapsing tissue itself. Therefore, the management approach should focus on identifying the etiology of symptoms and

Habit training

Education of patients about lifestyle interventions to tackle constipation (also known as habit training) has been shown to be as clinically effective and more cost-effective than biofeedback in treatment naïve patients with constipation24. Such training is usually nurse led and includes information on basic GI anatomy and function, the causes of constipation, impact of psychological and lifestyle stressors, education about optimization of eating patterns to maximize the gastro-colic response,

Stool form optimization

Inconsistent bowel habits with constipation is commonly reported in patients with RI and adjusting the stool consistency could be challenging11. Fiber is often the first to go trial for the management of stool consistency. Water soluble fiber as compared to insoluble dietary fiber such as bran, is more effective in improving constipation symptoms25. Probiotics have been popularized in management of irritable bowel syndrome and constipation through the modulation of gut microbiome, however the

Transanal irrigation

There is an increasing amount of evidence to support the use of transanal irrigation (TAI) in the treatment of bowel dysfunction with studies showing symptom improvement in patients with neurogenic bowel disease, fecal incontinence, low anterior resection syndrome and chronic idiopathic constipation27. Treatment may be delivered using a number of commercially available devices, though randomized studies suggest that high volume irrigation is more effective and preferred over low volume

Biofeedback

As discussed elsewhere biofeedback therapy plays a key role in treatment of patients with RI. Biofeedback protocols should aim on correcting 1) dyssynergia to achieve a coordinated and complete evacuation, 2) facilitating normal evacuation by simulated defecation training using balloons, and 3) improve rectal sensory thresholds in patients with impaired rectal sensation32. In a cohort of patients with large intussusception, rectum extending into the anal canal, biofeedback therapy improved both

Multidisciplinary care

Integrated multidisciplinary care is recommended in the management of patients with pelvic floor dysfunction35. Multidisciplinary care has been shown to be superior to medical management in improving functional symptoms, quality of life, and cost of care for the treatment of functional gastrointestinal disorders36.

Dietary and behavioral therapies are important aspects of management of patients with constipation and fecal incontinence15. Addressing the psychological comorbid conditions that are

Timing of surgery and patient selection

The triage of patients to surgical consult should be carefully considered in a multidisciplinary setting and not made before behavioural and medical therapies and adjuncts have been exhausted as anatomical correction may not result in symptom relief39. The proposed approach algorithm is shown in Figure 1.

Surgical approaches

As reviewed elsewhere in this book, a number of approaches have been described for the management of RI. Historically, a posterior rectopexy was the technique of choice, however the extensive posterior mobilisation required can result in autonomic denervation of the rectum and worsening constipation in nearly half of patients40. Alternatives include a combined rectopexy and sigmoid resection (a Frykman-Goldberg procedure) however this procedure by its nature has a risk of anastomotic leak. More

Summary

Approach to patients with RI should be tailored to the bothersome symptoms, anorectal coordination and function and burden of the anatomical pathologies. Medical management with stool form optimization, habit training, and biofeedback therapy should be considered for all patients with symptoms related to obstructive defecation. Surgery should be reserved for patients with high grades of RI who remain symptomatic after exhausting all medical and conservative therapies.

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