Annals of Coloproctology

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Anorectal physiology & pelvic floor disorder

Laparoscopic ventral mesh rectopexy with and without transverse perineal support using biological mesh for rectal prolapse and perineal descent: postoperative course and functional outcomes: Maria Clelia Gervasi, Giorgio Brancato, Lorenzo Crepaz, Ahmad Tfaily, Alberto Di Leo; Ann Coloproctol. 2025;41(5):453-461. Published online October 28, 2025; DOI: https://doi.org/10.3393/ac.2025.00080.0011

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Purpose
Laparoscopic ventral mesh rectopexy (LVMR) is effective for the treatment of rectal prolapse. However, descending perineal syndrome may impair the outcomes of LVMR. The aim of this study was to assess the safety and functional outcomes of LVMR performed with and without transverse perineal support (TPS).
Methods
This was a retrospective study of 143 consecutive female patients treated with LVMR with or without TPS between 2018 and 2022. Patients with rectal prolapse and perineal descent who underwent surgery were included. Obstructed defecation syndrome and fecal incontinence were evaluated using the Cleveland Constipation Score (Wexner score) and St. Mark’s Incontinence Score, respectively. Perineal descent was defined using defecography. Biological meshes were utilized in all cases.
Results
No significant differences were recorded between with- and without-TPS groups at baseline. TPS was performed in 110 patients (76.9%). Surgical morbidity was higher in the with-TPS group (12.7% vs. 0%, P=0.047), primarily due to seroma formation. Almost all complications were mild (Clavien-Dindo grades I–II). In both groups, digital aid for defecation (P<0.001), prolonged straining (P=0.004), and hematochezia (P<0.001) nearly disappeared postoperatively, though constipation and laxative/enema use persisted in 22.4%. Fecal incontinence significantly decreased from 43.4% to 11.2% (P<0.001). TPS appears to have a potentially favorable effect in reducing the constipation score. Both constipation and incontinence scores remained low up to 24 months after surgery. Operative time was significantly longer in the LVMR with-TPS group (P<0.001).
Conclusion
LVMR with TPS appears safe and feasible. TPS may provide better surgical outcomes compared to LVMR alone for patients with symptomatic rectoceles and descending perineum syndrome.

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Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm for obstructed defecation syndrome
Michele Schiano di Visconte, Sonia Sarnari
World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef

Anorectal physiology & pelvic floor disorder

Transverse perineal support improves long-term outcomes in patients undergoing stapled transanal rectal resection for obstructed defecation syndrome: a multicenter observational case-control study: Adolfo Renzi, Luigi Marano, Pasquale Talento, Luigi Brusciano, Angela Pezzolla, Domenico Izzo, Carmine Antropoli, Francesco D’Aniello, Giandomenico Di Sarno, Gianluca Minieri, Grazia Cantore, Gianmattia Terracciano, Domenico Barbato, Ludovico Docimo, Massimo Antropoli, Alessio Palumbo, Michele Lanza, Emanuele Mario Caputi, Antonio Brillantino; Ann Coloproctol. 2025;41(4):330-337. Published online August 25, 2025; DOI: https://doi.org/10.3393/ac.2025.00073.0010

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Abstract PDF

Purpose
To evaluate the safety and long-term efficacy of stapled transanal rectal resection (STARR) combined with the transverse perineal support (TPS) procedure in the surgical treatment of obstructed defecation syndrome (ODS) associated with internal rectal prolapse and excessive perineal descent (PD).
Methods
This multicenter observational case-control study involved 7 European centers. During the initial study period, patients underwent STARR alone (group 1), while in the subsequent period, patients received STARR combined with TPS (group 2). All patients were followed clinically at 6, 12, 36, and 60 months, and were offered radiological evaluation between 3 and 5 years postoperatively.
Results
The median postoperative ODS score was similar between groups at 6 months (6 [range, 2–15] vs. 5 [range, 2–13]; P=0.16, Mann-Whitney U-test), but at 36 months, it was significantly lower in group 2 compared to group 1 (11 [range, 5–16] vs. 5 [range, 2–15]; P<0.001, Mann-Whitney U-test), with stable results maintained through 5 years. The success rate followed a similar trend. Postoperative maximum PD during straining remained unchanged in group 1, whereas it significantly decreased compared to preoperative values in group 2.
Conclusion
The addition of TPS to STARR in the surgical treatment of ODS associated with internal rectal prolapse and excessive PD appears to significantly improve long-term success rates and correct descending perineum.

Citations

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Laparoscopic Resection Rectopexy with Transanal Specimen Extraction for Complete Rectal Prolapse: Retrospective Cohort Study of Functional Outcomes
Mustafa Ates, Sami Akbulut, Emrah Sahin, Kemal Baris Sarici, Ertugrul Karabulut, Mukadder Sanli
Journal of Clinical Medicine.2026; 15(2): 718. CrossRef
Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm for obstructed defecation syndrome
Michele Schiano di Visconte, Sonia Sarnari
World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef

Annual long-term functional outcomes after transanal repair for symptomatic rectocele: Akira Tsunoda, Hiroshi Kusanagi; Received April 22, 2022 Accepted July 7, 2022 Published online November 15, 2022; DOI: https://doi.org/10.3393/ac.2022.00283.0040 [Epub ahead of print]

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Abstract PDF

Purpose
This study was performed to assess the long-term annual functional outcomes and quality of life (QOL) after transanal rectocele repair.
Methods
We evaluated retrospectively collected data from patients who underwent transanal repair for symptomatic rectocele between February 2012 and December 2018. The Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI), and several QOL questionnaires (e.g., the Patient Assessment of Constipation-QOL [PAC-QOL], Fecal Incontinence QOL, and the 36-Item Short Form Survey [SF-36]) were administered before surgery and annually after surgery. Additionally, physiological assessments and defecography were performed before and after surgery. Substantial symptom improvement, indicated by at least a 50% reduction in the CSS or FISI score, was evaluated postoperatively. All postoperative follow-up results were compared with the preoperative data.
Results
Thirty-two patients were included in the study. The median follow-up period was 5 years (range, 0.5−7 years). Postoperative defecography showed that the rectocele size significantly decreased (P<0.0001). However, the physiological assessment did not reveal postoperative changes. The CSS score 1 year after surgery was significantly lower than the preoperative score (P<0.0001) and remained significantly low until the long-term follow-up. Constipation improved by more than 80% 2 to 5 years postoperatively, and fecal incontinence improved in 2/3 of the patients after 5 years. The PAC-QOL scores significantly improved (all P<0.05) over time until the 3-year and long-term follow-ups, and 6 of the 8 SF-36 scores significantly improved at specific points postoperatively.
Conclusion
Transanal rectocele repair provides long-term improvement for constipation and constipation-specific QOL.

Citations

Citations to this article as recorded by

IUGA Opinion Paper on Obstructed Defecation: Management of Clinical and Proctographic Rectoceles
Suneetha Rachaneni, Hans Peter Dietz, Pallavi Latthe, Annie Sirany, Anna Spivak, Anupreet Dua
International Urogynecology Journal.2026; 37(1): 75. CrossRef
Transvaginal repair of rectocele for obstructed defecation syndrome: a case report
Liman Zhang, Jie Yang, Qiang Wang, Lili Wang, Shuzhen Su, Lifang Wang, Shiyuan Li
Journal of Surgical Case Reports.2025;[Epub] CrossRef
Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size
Akira Tsunoda, Tomoko Takahashi, Satoshi Matsuda, Hiroshi Kusanagi
International Journal of Colorectal Disease.2023;[Epub] CrossRef

Benign proctology,Surgical technique

Transperineal rectocele repair is ideal for patients presenting with fecal incontinence: Marie Shella De Robles, Christopher J. Young; Ann Coloproctol. 2022;38(5):376-379. Published online October 19, 2021; DOI: https://doi.org/10.3393/ac.2021.00157.0022

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Abstract PDF

Purpose
Rectocele can be associated with both obstructed defecation and fecal incontinence. There exists a great variety of operative techniques to treat patients with rectocele. The purpose of this study was to evaluate the clinical outcome in a consecutive series of patients who underwent transperineal repair of rectocele when presenting with fecal incontinence as the predominant symptom.
Methods
Twenty-three consecutive patients from April 2000 to July 2015 with symptomatic rectocele underwent transperineal repair by a single surgeon.
Results
All patients had a history of vaginal delivery, with or without evidence of associated anal sphincter injury at the time. The median age of the cohort was 53 years (range, 21–90 years). None were fully continent preoperatively. However, continence improved to just rare mucus soiling or loss of flatus in all patients 6 months after their surgery. There was no operative mortality. Postoperative complications including urinary retention and wound dehiscence occurred in 3 patients.
Conclusion
Fecal incontinence associated with rectocele is multifactorial and may be caused by preexisting anal sphincteric damage and attenuation. Our experience suggests that transperineal repair provides excellent anatomic and physiologic results with minimal morbidity in selected patients presenting with combined rectocele and anal sphincter defect.

Citations

Citations to this article as recorded by

IUGA Opinion Paper on Obstructed Defecation: Management of Clinical and Proctographic Rectoceles
Suneetha Rachaneni, Hans Peter Dietz, Pallavi Latthe, Annie Sirany, Anna Spivak, Anupreet Dua
International Urogynecology Journal.2026; 37(1): 75. CrossRef
Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm for obstructed defecation syndrome
Michele Schiano di Visconte, Sonia Sarnari
World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef
Fecal Incontinence Outcomes Following Transvaginal Posterior Vaginal Wall Repair
Jersey B. Burns, Amr El Haraki, Jesseca Crawford, Candace Y. Parker-Autry
International Urogynecology Journal.2025; 36(5): 1061. CrossRef
The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation
Karim Alavi, Amy J. Thorsen, Sandy H. Fang, Pamela L. Burgess, Gino Trevisani, Amy L. Lightner, Daniel L. Feingold, Ian M. Paquette
Diseases of the Colon & Rectum.2024; 67(10): 1244. CrossRef

Benign proctology,Biomarker & risk factor

Factors Predicting the Presence of Concomitant Enterocele and Rectocele in Female Patients With External Rectal Prolapse: Akira Tsunoda, Tomoko Takahashi, Kenji Sato, Hiroshi Kusanagi; Ann Coloproctol. 2021;37(4):218-224. Published online January 12, 2021; DOI: https://doi.org/10.3393/ac.2020.07.16

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Abstract PDF

Purpose
External rectal prolapse (ERP) is frequently associated with other pelvic disorders, such as enterocele, rectocele, and perineal descent. Evacuation proctography makes it possible to visualize the development of such anatomical abnormalities. The aim of this study was to identify the variables that would predict associated abnormalities in patients with ERP.
Methods
Between February 2010 and August 2019, 124 female patients with ERP, who were evaluated using proctography were included in this study. Enterocele was diagnosed when the extension of the loop of the small bowel was located between the vagina and rectum. A significant rectocele was defined as >20 mm in diameter. Multivariate analysis was used to establish which morphological parameters best predicted the presence of enterocele or rectocele.
Results
Sixty-five patients had ERP alone, while 59 patients (47.6%) had additional findings on proctography. The most frequently associated abnormality was enterocele with 48 of the patients (38.7%) having this condition. Rectocele was detected in 17 of the 124 patients (13.7%). The median length of the ERP was 30 mm (range, 7 to 147 mm). The results of the stepwise multiple regression analysis showed that a history of hysterectomy and the length of the ERP were significantly associated with the presence of enterocele. The analysis showed that the longer the prolapse, the higher the incidence of enterocele. A history of hysterectomy was also significantly associated with the presence of rectocele.
Conclusion
Patients with ERP often have associated anatomical abnormalities and should be investigated thoroughly before planning surgical treatment.

Citations

Citations to this article as recorded by

Transverse perineal support improves long-term outcomes in patients undergoing stapled transanal rectal resection for obstructed defecation syndrome: a multicenter observational case-control study
Adolfo Renzi, Luigi Marano, Pasquale Talento, Luigi Brusciano, Angela Pezzolla, Domenico Izzo, Carmine Antropoli, Francesco D’Aniello, Giandomenico Di Sarno, Gianluca Minieri, Grazia Cantore, Gianmattia Terracciano, Domenico Barbato, Ludovico Docimo, Mass
Annals of Coloproctology.2025; 41(4): 330. CrossRef
Small intestine prolapse after vaginal hysterectomy with vaginal dome rupture. A clinical case
Aydar M. Ziganshin, Irina G. Mukhametdinova, Victoria F. Allayarova, Elina A. Shayhieva
Journal of obstetrics and women's diseases.2023; 71(6): 107. CrossRef
Comments on: factors predicting the presence of concomitant enterocele and rectocele in female patients with external rectal prolapse
Ingrid Melo-Amaral, Adrian Teran-Cardoza, Cristopher Varela
Annals of Coloproctology.2022; 38(1): 93. CrossRef
Robot-Assisted Colorectal Surgery
Young Il Kim
The Ewha Medical Journal.2022;[Epub] CrossRef
Treatment of Hemorrhoid in Unusual Condition-Pregnancy
Hyo Seon Ryu
The Ewha Medical Journal.2022;[Epub] CrossRef

Benign proctology

Analyzing the Role of Anal Sphincter Pressure in Rectocele Formation: Süleyman Büyükaşık, Mehmet Abdussamet Bozkurt, Selin Kapan, Halil Alis; Ann Coloproctol. 2020;36(5):330-334. Published online March 16, 2020; DOI: https://doi.org/10.3393/ac.2019.09.15

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Abstract PDF

Purpose
Constipation is a common entity in society with various factors in the etiology. In this study, we evaluated the role of anal sphincter pressure of patients who refer to surgery clinic with complaint of constipation.
Methods
Sixty patients who refer to surgery clinic with complaint of constipation and were diagnosed with constipation due to Rome III criteria between July 2010 and September 2014. These patients were evaluated with defecography and were divided into 2 groups based on presence of rectocele. Both groups’ anal sphincter pressures were evaluated using anal manometry and findings were compared.
Results
The patients with rectocele and without rectocele using defecography were inspected with anal manometry regarding resting tone pressure, squeeze pressure, maximum squeeze pressure and simulated defecation response pressure, first sensation volume, urge sensation volume, and maximum tolerable volume. Results were compared and no significant difference was found regarding groups with rectocele and without rectocele (P > 0.05).
Conclusion
We have proved the hypothesis arguing that increased sphincter pressures do not play a role in the formation of rectocele by inducing an obstruction and the formation of dilation in proximal bowel, and demonstrated that the presence of rectocele is not dependent on an increase in sphincter pressures.

Citations

Citations to this article as recorded by

A possible physiological mechanism of rectocele formation in women
Ge Sun, Robbert J. de Haas, Monika Trzpis, Paul M. A. Broens
Abdominal Radiology.2023; 48(4): 1203. CrossRef
Colonic pseudo-obstruction in a patient with dyssynergic defecation
Yejun Jeong, Yongjae Kim, Wonhyun Kim, Seoyeon Park, Su-Jin Shin, Eun Jung Park
International Journal of Surgery Case Reports.2022; 98(C): 107524. CrossRef
Treatment of Hemorrhoid in Unusual Condition-Pregnancy
Hyo Seon Ryu
The Ewha Medical Journal.2022;[Epub] CrossRef

Comparison of Long-term Clinical Outcomes according to the Change in the Rectocele Depth between Transanal and Transvaginal Repairs for a Symptomatic Rectocele: Choon Sik Chung, Sang Hwa Yu, Jeong Eun Lee, Dong Keun Lee; J Korean Soc Coloproctol. 2012;28(3):140-144. Published online June 30, 2012; DOI: https://doi.org/10.3393/jksc.2012.28.3.140

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Abstract PDF

Purpose

This study was aimed to compare the results of a transanal repair with those of a transvaginal levatorplasty and to determine the long-term clinical outcomes according to the change in the depth of the rectocele after the procedure.

Methods

Of 50 women who underwent a rectocele repair from March 2005 to February 2007, 26 women (group A) received a transanal repair, and 24 (group B) received a transvaginal repair with or without levatorplasty. At 12 months after the procedures, 45 (group A/B, 22/23 women) among the 50 women completed physiologic studies, including anal manometry and defecography, and clinical-outcome measurements. The variations of the clinical outcomes with changes in the depth of the rectocele were also evaluated in 42 women (group A/B, 20/22) at the median follow-up of 50 months.

Results

On the defecographic findings, the postoperative depth of the rectocele decreased significantly in both groups (group A vs. B, 1.91 ± 0.20 vs. 2.25 ± 0.46, P = 0.040). At 12 months after surgery, 17 women in each group (group A/B, 77/75%) reported improvement of their symptoms. However, only 11 and 13 women (group A/B, 55/59%) of groups A and B, respectively, maintained their improvement at the median follow-up of 50 months. Better results were reported in patients with a greater change in the depth of their rectocele (≥4 cm) after the procedure (P = 0.001)

Conclusion

In both procedures, clinical outcomes might become progressively worse as the length of the follow-up is increased.

Citations

Citations to this article as recorded by

Outcomes of laparoscopic ventral mesh rectopexy versus trans-vaginal repair in management of anterior rectocele, a randomized controlled trial
A. Sanad, A. Sakr, H. Elfeki, W. Omar, W. Thabet, E. Fouda, E. Abdallah, S. A. Elbaz
Techniques in Coloproctology.2025;[Epub] CrossRef
Tratamiento quirúrgico de los prolapsos genitales por vía vaginal
T. Thubert, M. Degez, C. Cardaillac, R. De Tayrac, M. Cosson
EMC - Urología.2024; 56(4): 1. CrossRef
Traitement chirurgical des prolapsus génitaux par voie vaginale
T. Thubert, M. Degez, C. Cardaillac, R. De Tayrac, M. Cosson
EMC - Techniques Chirurgicales - Urologie.2024; 41(3): 1. CrossRef
Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size
Akira Tsunoda, Tomoko Takahashi, Satoshi Matsuda, Hiroshi Kusanagi
International Journal of Colorectal Disease.2023;[Epub] CrossRef
Prise en charge chirurgicale de la rectocele – mise au point
M. Aubert, D. Mege, R. Le Huu Nho, G. Meurette, I. Sielezneff
Journal de Chirurgie Viscérale.2021; 158(2): 157. CrossRef
Surgical management of the rectocele – An update
M. Aubert, D. Mege, R. Le Huu Nho, G. Meurette, I. Sielezneff
Journal of Visceral Surgery.2021; 158(2): 145. CrossRef
ACG Clinical Guidelines: Management of Benign Anorectal Disorders
Arnold Wald, Adil E. Bharucha, Berkeley Limketkai, Allison Malcolm, Jose M. Remes-Troche, William E. Whitehead, Massarat Zutshi
American Journal of Gastroenterology.2021; 116(10): 1987. CrossRef
Early and late effects of the sequential transfixed stich technique for the treatment of the symptomatic rectocele without rectal mucosa prolapse
Fabio Gaj, Ivano Biviano, Antonello Trecca, Quirino Lai, Jacopo Andreuccetti
Minerva Chirurgica.2020;[Epub] CrossRef
Absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with rectal intussusception and fecal incontinence
Akira Tsunoda, Tomoko Takahashi, Hiroshi Kusanagi
International Journal of Colorectal Disease.2019; 34(10): 1681. CrossRef
Trattamento chirurgico del rettocele
G. Meurette, A. Vénara, P.-A. Lehur
EMC - Tecniche Chirurgiche Addominale.2018; 24(1): 1. CrossRef
Tratamiento quirúrgico de los rectoceles
G. Meurette, A. Vénara, P.-A. Lehur
EMC - Técnicas Quirúrgicas - Aparato Digestivo.2018; 34(1): 1. CrossRef
Surgery for constipation: systematic review and practice recommendations
U. Grossi, E. J. Horrocks, J. Mason, C. H. Knowles, A. B. Williams
Colorectal Disease.2017; 19(S3): 73. CrossRef
Traitement chirurgical des rectocèles
G. Meurette, A. Vénara, P.-A. Lehur
EMC - Techniques chirurgicales - Appareil digestif.2017; 34(4): 1. CrossRef

Psychiatric Investigation by Using the Minnesota Multiphasic Personality Inventory in Patients with Chronic Constipation.: Park, Ung Chae , Yoo, Young Bum , Kim, Jong Jun , Nam, Beom Woo; J Korean Soc Coloproctol. 2002;18(2):95-103.

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Abstract PDF: PURPOSE
Current study was designed to understand the personality and emotional composition of patients with chronic constipation. Specifically, the personality differences were evaluated in the ramified subgroups based on the physiologic characteristics.
METHODS
Forty patients (31 females and 9 males) of a mean age of 48 (range, 16~86) years underwent the MMPI among 310 patients with chronic constipation. MMPI (Minnesota Multiphasic Personality Inventory) profiles were utilized for psychologic assessment for all patients prior to making diagnosis. Three validity scales of MMPI included L (Lie scale), F (Infrequency scale), K (Suppressor scale). Ten clinical scales included HS (hypochondriasis), DP (depression), HY (hysteria), PD (psychopathic deviant), MF (masculinity- feminity), PA (paranoia), PT (psychasthenia), SC (schizophrenia), MA (mania), SI (social introversion). On the basis of findings with use of anorectal physiologic studies, subgroups were categorized as patients with rectocele (A1, n=22), patient without rectocele (A2, n=18), patients with nonrelaxing puborectalis syndrome (B1, n=10), patients without nonrelaxing puborectalis syndrome (B2, n=30). The MMPI profiles were compared between subgroup patients.
RESULTS
In overall patients, mean scores for scales HS, DP were elevated as compared with mean profiles (60~65 and 45~55, respectively). Male patients showed higher mean scores for scale SI than those of female patients (male vs. female; 63.5 vs. 53.9, P<0.05). A1 group showed higher mean scores for PD scale than those of A2 group (A1 vs. A2; 57.4 vs. 49.8, P=0.01). B1 group showed higher mean scores for DP scale than those of B2 group (B1 vs. B2; 67.5 vs. 59.8, P<0.05).
CONCLUSIONS
Present series provided that the MMPI is a valuable tool for assessing the psychologic functioning of patients with chronic constipation. It has revealed a different personality and emotional composition in the subgroup patients based on the anorectal physiologic studies. An aspect of social introversion, psychopathic deviant and depression should be emphasized. These findings can provide the fundamental information for guideline of future diagnostic evaluation and therapy in the patients with chronic constipation.

Investigation of Defecographic Findings in Patients with Pelvic Outlet Obstructive Disease.: Kim, Kyong Rae , Kim, Young Sok , Chung, Soon Sup , Ahn, Eun Jung , Oh, Soo Youn , Park, Ung Chae , Shon, Dae Ho , Sakong, Joon , Kim, Sang Woon , Kim, Jae Hwang , Shim, Min Chul; J Korean Soc Coloproctol. 2005;21(6):376-383.

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Abstract PDF: PURPOSE
Defecography is a dynamic investigation which can influence clinical decision making in patients with pelvic outlet obstructive disease (POOD). The current study was designed to establish defecographic findings in patients with POOD. Specifically, we sought to assess the physiologic characteristics of categorized types by using anorectal physiologic tests.
METHODS
One hundred seven patients (disease group; 45 men, 62 women) with POOD were retrospectively categorized as type I [non-relaxation of puborectalis (NRPR) only, n=19], type II [NRPR and rectocele, n=20], type III [NRPR, rectocele, and dynamic perineal descent (PD), n=17], type IV [deformed rectocele, mild-to-moderate fixed PD, and absence of NRPR, n=29], and type V [rectocele, severe fixed PD, and absence of NRPR, n=20] on the bases of defecographic findings. The ability to evacuate, the frequency/degree of intarectal intussusception (IRI), and the size of the rectocele were evaulated in these defecographic types of POOD. Age, duration of symptoms, and the physiologic findings of anal manometry and EMG/PNTML were compared for the five types. Eighteen healthy volunteers who had no defecation difficulty were used to estimate the normal findings of defecography.
RESULTS
The age and the sex showed no significant differences among the types. The duration of symptoms was gradually lengthened from type I to V (P<0.01). The ability to evacuate in patients with POOD was significantly worse (failed to effectively evacuate) compared to that in the healthy volunteers (P<0.01). The frequency of IRI was increased more and more from type I to V (P<0.01). The size of the rectocele was significantly increased in types V compared to the other types (P<0.01). Manometric and neurologic findings, including EMG/PNTML, revealed no significant differences among the types.
CONCLUSIONS
Even though there were no specific differences in the findings of the anal manometric and neurologic tests, the evacuation dynamics; were different in the five defecographic categories of patients with POOD. Specifically, these differences were relevants to the presence of NRPR, rectoceles, IRI, and perineal descent.

Pathogenesis and Surgical Treatment of Rectal Prolapse Syndrome.: Kim, Jin Cheon , Kim, Chang Nam , Park, Sang Kyu , Kim, Sook Young , Yu, Chang Sik; J Korean Soc Coloproctol. 1998;14(2):225-234.

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Abstract PDF: The rectal prolapse syndome is a disease entity includes rectocele and rectal prolapse, presenting prolapse(procidentia) of rectum. In rectocele, rectum is prolapsed anteriorly into the vagina, whereas in procidentia, inferiorly out of the anus. This study was aimed at analyzing pathogenesis and adequacy of surgical treatment in rectocele and rectal prolapse. Twenty-one patients with rectocele and 18 patients with rectal prolapse were assessed pre- and post-operatively in respect to symptoms and signs, pathogenesis, defecography, and manometry. In analysis of symptoms and sings, constipation was the commonest in both diseases(86% of rectocele and 67% of rectal prolapse) and incontinence was not infrequently found in both diseases as well(14% of rectocele and 33% of rectal prolapse). In analysis of the underlying causes, two patients with rectal prolapse had prolapse from childhood. Defecography showed anorectal angle of rectal prolapse in rest and push period. They were significantly wider than those of rectocele(p<0.05). The perineal descent of rectal prolapse was longer than that of rectocele. In analysis of the associated factors, average number of delivery was more than three times in both diseases(3.5 of rectocele and 5.1 of rectal prolapse). We could easily find previous operation history in both diseases. Among them, hysterectomy was the most frequent, especially in patients with rectocele. The hemorrhoids was associated more common in rectocele than in rectal prolapse(p<0.05). Preoperative maximal resting pressure of rectal prolapse was more significantly decreased than that of rectocele(p<0.05). The sensation of fullness was significantly decreased in patients with rectal prolapse postoperatively(p<0.05). Patients with rectocele underwent levator plication by transrectal or vaginal approach. Patients with rectal prolapse underwent posterior rectopexy in 11 patients, resection and rectopexy in 3 patients, Delorme's operation and Thiersch operation in 2 patients each. Constipation was significantly improved in patients with rectocele postoperatively(p<0.05). Incontinence was markedly improved in patients with rectal prolapse postoperatively(p<0.05). At the interview about subjective improvement of symptom, 95% of patients with rectocele and 89% of patients with rectal prolapse were satisfied with surgery. In conclusion, rectocele and rectal prolapse can be categorized as rectal prolapse syndrome because both diseases have anatomical derangements caused by similar pathogenesis such as altered bowel habits, anatomical factor, delivery, past history of hysterectomy, and hemorrhoids. Levator plication and posterior rectopexy seem to be useful surgical methods of anatomical repair for the respective disease.

The Clinical and Physiologic Characteristics of Patients with Pelvic Outlet Obstructive Disease.: Ahn, Eun Jung , Jeong, Gyu Young , Cheon, Seung Hui , Lee, Eun Joung , Oh, Soo Youn , Chung, Soon Sup , Lee, Ryung Ah , Kim, Kwang Ho , Park, Eung Bum; J Korean Soc Coloproctol. 2005;21(6):362-369.

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Abstract PDF: PURPOSE
With recent anorectal physiologic studies, functional etiologies of pelvic outlet obstructive disease were evaluated in detail. The current study was designed to assess the clinical and the physiologic characteristics of patients with pelvic outlet obstructive disease.
METHODS
one hundred two (102) patients with pelvic outlet obstructive disease were evaluated with anorectal physiologic studies, including the colonic transit time (n=66), anorectal manometry (n=88), defecography (n=102), anal sphincter EMG (n=50), and colonoscopy or barium enema (n=77). The patients were categorized as group I (nonrelaxing puborectalis syndrome), group II (rectocele), group III (sigmoidocele), and group IV (rectoanal intussusception). The clinical and the physiologic characteristics were compared between the groups.
RESULTS
The mean age was 51.9 years, and the sex ratio was 1:1.9. the populations of the groups were group I 45.1% (n=46), group II 36.3% (n=37), group III 5.9% (n=6), and group IV 9.8% (n=10). In group II and group III, co-existing etiologies were more, and the incidences of female patients was higher (P<0.05). Delayed colonic transit time was noted in 11 patients (17%). Diverticula was observed in 6 patients (8%), polyps in 12 patients (16%), and melanosis coli in 14 patients (18%). On anorectal manometry, group I showed higher maximal voluntary contraction and mean squeezing pressure than the other groups (P<0.05). On defecography, group I had a shorter perineal descent at rest and a smaller anorectal angle at push (P<0.05).
CONCLUSIONS
The current study showed the clinical and the physiologic characteristics of the each functional etiology in patients with pelvic outlet obstructive disease. These results provide fundamental data for diagnosis of and tailored therapy for pelvic outlet obstructive disease.

Biofeedback Therapy for Patients with Rectocele.: Kim, Bong Soo , Hwang, Yong Hee , Choi, Kun Pil; J Korean Soc Coloproctol. 2001;17(2):69-75.

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Abstract PDF: PURPOSE
The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for rectocele.
METHODS
Twenty four female patients (mean age 43.8 years) with rectal emptying difficulties and a rectocele greater than 2 cm at defecography were evaluated before hand with a standardized questionnaires, immediately after biofeedback therapy, and at follow up. Defecography, manometry, colon transit studies and electrophysiology were also analyzed.
RESULTS
Follow up (mean 7.2; range 2~17 months) results were evaluated by an independent observer in 20 patients. At the end of biofeedback, 22 (92 percent) patients felt improvement in symptoms, including 13 (54 percent) with symptomatic relief. At follow-up, 14 (70 percent) patients felt improvement in symptoms, including 3 (15 percent) with complete relief of symptoms. There was a significant reduction in difficult defecation (from 79 to 29, 40 percent, from pre-biofeedback to post-biofeedback, at follow-up respectively; P<0.001, P<0.05), sensation of incomplete defecation (from 96 to 46, 60 percent; P<0.001, P<0.005), laxative use (from 54 to 25, 30 percent; P<0.05), enema use (from 21 to 0,0 percent; P<0.05), anal pain (from 21 to 0, 5 percent; P<0.05) and digitation (from 21 to 4, 5 percent). Normal spontaneous bowel movement was significantly increased from 50 percent pre-biofeedback to 83 post-biofeedback (P<0.05), 65 percent at follow-up. Abdominal pain (P<0.05) and digitation (P<0.05) related to poor results. High mean squeeze pressure (P<0.001) and high maximum squeeze pressure (P<0.05) on pre-biofeedback manometry were also related to a poor outcome. Age, duration of symptoms, parity, number of sessions of biofeedback, gynecologic surgery history, and rectocele size at defecography had no prognostic value. Anismus and colonic inertia did not influence the outcome of biofeedback.
CONCLUSIONS
Biofeedback is an effective treatment option for patients with obstructed defecation due to rectocele.

Physiologic Characteristics and its Clinical Significances in the Patients with Pelvic Outlet Obstruction.: Park, Ung Chae , Chung, Soon Sup , Park, Seung Hwa; J Korean Soc Coloproctol. 2000;16(4):215-222.

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Abstract PDF: Current study was designed to assess the functional etiology of patients with pelvic outlet obstruction. Moreover, physiologic characteristics and theirs clinical significances were evaluated in the patients with ramified diagnosis.
METHODS
172 patients with pelvic outlet obstruction were performed 328 numbers of physiologic studies. These included cinedefecography (n=172), anal manometry (n=87), colonic transit time study (n=38), and anal EMG/PNTML (n=31). On the basis of physiologic findings, patient groups were categorized as rectocele (group I), nonrelaxing puborectalis syndrome (group II), anal dyschezia (group III), and rectoanal intussusception (group IV). The physiologic findings were compared between subgroup patients.
RESULTS
Incidence of categorized patients was 51.7% (group I, n=89), 22.7% (group II, n=39), 12.2% (group III, n=21), and 8.7% (group IV, n=15), respectively. The mean age of patients with group III were lower (p<0.05) than that of overall patients. The incidence of female patients was higher in group I and the incidence of male patients was higher in group II (p<0.0001). In cinedefecography, patients with group II showed smaller anorectal angle at strain (p<0.001), at dynamic change between rest and strain (p=0.002). In anal manometry, patients with group III showed higher mean resting pressures (p=0.001), higher maximum resting pressures (p<0.001), higher mean squeeze pressures, and higher maximal voluntary contraction (p=0.003) than those of patients with other group. In neurologic study, mean value of PNTML was 2.32 +/- 0.34 (range, 1.60~3.66) msec in overall patients. The size of rectocele was increased in proportion to patient's age (r=0.229, p<0.05), number of delivery (r=0.393, p=0.001), and degree of perineal descent (r=0.231, p<0.05). The degree of perineal descent was increased in proportion to patient's age (r=0.249, p<0.05).
CONCLUSIONS
Present series provided the diagnostic ramification of pelvic outlet obstruction by using the anorectal physiologic investigations. In addition to the function of puborectalis muscle, evacuation dynamics of anorectum should be emphasized. These findings could provide the fundamental information for guideline of future therapy in the patients with obstructed defecation.

Comparison of Rectoanal Physiologic Changes and Treatment Results between Transanal Repair and Transanal Repair with Posterior Colporrhaphy in Patients with Rectocele.: Kim, Joo Hyung , Kwon, Young Min , Lee, Yong Pyo; J Korean Soc Coloproctol. 2004;20(2):86-92.

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Abstract PDF: PURPOSE
Rectoceles are often associated with anorectal symptoms. Various surgical techniques have been described to repair rectoceles, but the surgical results vary. The aim of this study was to compare transanal repair (TAR) and transanal repair with posterior colporrhaphy (TAR+PC).
METHODS
The records of 58 patients operated on during a 56-month period were reviewed. Of those 26 patients had a TAR, and 32 patients had a TAR+PC. Interviews and anorectal physiologic studies were performed preoperatively and postoperatively.
RESULTS
The recurrence rate after a TAR+PC was lower than the recurrence rate after a TAR (TAR 19.2% vs. TAR+PC 3.1%). The rectal sensation (sensory threshold: TAR 64.8+/-18.9 ml vs. TAR+PC 56.1+/-23.67 ml; earliest defecation urge: TAR 116.4+/-29.5 ml vs. TAR+PC 104.8+/-31.2 ml) was more improved after a TAR+PC.
CONCLUSIONS
A TAR+PC for treatment of a rectocele is safe and effectively corrects obstructed defecation. The improvement probably relates, at least in part, to rectal sensational factors other than the dimensions of the rectocele.

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