You are in Home >> Outcome/results

Long-term results of LVMR in male patients

 border=Email this page
 

03/03/2014

Outcomes of lateral ventral mesh rectopexy (LVMR) in male patients operated upon in a tertiary referral centre

 


AE Owais, H Sumrien, K Mabey, K McCarthy, GL Greenslade*, AR Dixon

Departments Coloproctology & *Chronic Pain, North Bristol NHS Trust & SPIRE Hospital Bristol.

Correspondence to Mr Tony Dixon

Anthony.Dixon@nbt.nhs.uk

 

Keywords: Laparoscopic ventral mesh rectopexy, external rectal prolapse, ODS, rectal intussusception, male gender, Denonvilliers’ fascia, pelvic pain, PROMs


Abstract

Aim: Laparoscopic ventral mesh rectopexy (LVMR) has utility in rectal prolapse, obstructive defaecation syndrome (ODS), faecal incontinence (FI) and multi-compartment pelvic floor dysfunction. However, its use has been questioned in males. The aim of this study was to determine its efficacy in males.

Method: Examination of a password protected LVMR electronic database between 2002-13. In addition to clinical outcomes, quality of life (QOL), Cleveland Clinic Incontinence Score (CCIS), Obstructive Defecation Syndrome (ODS) score, Visual Analogue Scores (VAS) for bowel and urinary symptom severity, Numerical Rating Scale (NRS) for pain and patient reported outcome measures (PROMs) were evaluated

Results: 68 males, median age 35yrs, BMI 26 underwent LVMR for external prolapse (18) or grade III-V rectal intussusception (50). Misdiagnosis was common; 10% had chronic idiopathic pelvic pain and 60% had undergone haemorrhoidal surgery.  80% had an uncomplicated recovery with 24% performed as day cases. There were no cases of impotence or retrograde ejaculation. Median CCIS improved from 4 (IQR 0-8) to 0 (IQR 0-0); p = 0.00 and ODS scores improved from 18.5 (IQR 16-22) to 6 (IQR 5-8); p=0.00. Patients reported significant improvements in NRS for pain and QOL (BBSQ-22) at 3 months (p=0.000); QOL was maintained at 4 years as were VAS for bowel symptoms (p=0.000). 56 (82%) were asymptomatic at their last follow-up; 6 (8.8%) had persisting symptoms.

Conclusion:  LVMR is an effective treatment of external and symptomatic internal rectal prolapse [ODS, faecal incontinence, pelvic pain] in males leading to significant improvements in QOL and function scores.

 

 

What is new in this paper? This is the first case series examining the use of LVMR in male patients with internal and external rectal prolapse presenting with faecal incontinence, ODS and pelvic pain.


INTRODUCTION

Nerve sparing laparoscopic ventral mesh rectopexy (LVMR) is recognised as a treatment for external rectal prolapse and symptomatic high-grade intussusceptions.  In females, there is increasing evidence that it not only reduces rectal prolapse but improves faecal incontinence and obstructed defecation (1-4). Samaranayake et al., performed a systematic review of ventral rectopexy identifying 12 nonrandomized case series with a total of 728 patientsSeven used the Orr-Loygue procedure and five LVMR. Recurrence rates for external prolapse were estimated at 3.4% (95% CI, 2.0%–4.8%) with an overall 24% mean decrease in postoperative constipation (95% CI, 6.8%–40.9%). The mean decrease in FI was 45% (95% CI, 35.6%–54.1%).

 

In women pelvic organ prolapse (POP) develops in response to weakness of the pelvic diaphragm and disruption of the anterior and posterior layers of the recto-vaginal suspensory (Denonvilliers’) fascia running between the sacrospinous ligaments and perineal body with insertions into the parametrium, paracolpium and arcus tendineus fascia pelvis of the vagina. Disruption of this central support mechanism allows excessive sagging of the levator plate with consequential widening of the diaphragmatic hernia, which leads to middle compartment descent and the development of a rectocele, rectal prolapse, enterocele and/or vaginal/vault prolapse. This weakness arises as a result of disordered collagen synthesis, childbirth, hysterectomy, obesity and ageing 1-6

 

Pelvic organ support in males is also multi-structural and includes the levator-ani and muscles of the penis, Denovilliers’ fascia and prostate.  Full thickness external prolapse is less common (ratio 1:6)6-8 and its aetiology poorly understood being usually attributed to a combination of chronic constipation, disordered behaviour and excessive straining.  In addition, it is not generally appreciated that males can also develop rectal intussusception and ODS, with the symptoms of defective evacuation, perception of prolapse, rectal/pelvic pain, faecal incontinence [urge, passive and post defecatory leak], mucus discharge and bleeding erroneously “explained” by haemorrhoids and IBS.

 

Although LVMR has been reported in men1 including a small cohort with high-grade internal prolapse the evidence to support its beneficial outcomes is limited and has been questioned. The traditional approach to external prolapse has remained a perineal procedure, which eliminates the small but potential risk of autonomic nerve damage during a pelvic dissection.  We report our experience of LVMR in a large cohort of males and describe a likely anatomical mechanism that makes them susceptible to the development of these conditions.

 

 

 

 

 

 

 

 

 

 

 

 

 

Patients and methods

All male patients managed by LVMR over the 12 years between 2002 and 2013 were analysed.  Data collected included patient demographics [age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification], ODS (obstructed defecation), Wexner (CCIS) faecal incontinence scores9, 10, operative information and clinical course to last follow-up.  A validated Quality of Life questionnaire 11 (Birmingham Bowel and Urinary Symptoms Questionnaire - 22 (BBSQ-22) was completed preoperatively and at regular intervals thereafter (3, 12, 18, 24, 36 and 48 months).  Primary outcomes were effects upon function (ODS, CCIS and bowel disturbance VAS (visual analogue scores), Numerical Rating Scale (NRS 0-10) for pain and impact of symptoms upon QOL.

 

All patients underwent physical examination, defecatory sigmoidoscopy and dynamic proctography and when considered appropriate, EUA and laparoscopy.  Anorectal physiology (ARP) was performed in the majority of the patients with internal rectal prolapse. Patients having ARP also underwent a period of biofeedback conservative therapy

 

 

Statistical analysis

Results were tabulated on an Excel® spreadsheet (Excel for Windows®, Microsoft Corporation, Redmond, Washington, USA) and then analysed on an ‘intention-to-treat’ basis using SPSS® for Windows® version 16 (SPSS®, Chicago, Illinois, USA).  Results for non-parametric data were expressed as medians and interquartile ranges (IQR). 

 

Surgical Technique

LVMR in men is performed in Lloyd Davis with the patient catheterised. A three ports technique is used with a 10 mm 300 scope at the umbilicus and two 5 mm operating ports in the right iliac fossa placed 10cms apart. The sigmoid colon and mesentery are retracted to the left hand side. Using a diathermy hook the dissection starts with a peritoneal incision at the level of the sacral promontory on the right hand side.  The dissection is extended caudally avoiding the hypogastric nerves, along the side of the mesorectum to the deepest part of the rectovesical pouch, which in these patients universally lies well below the seminal vesicles and the upper part of the prostate.

 

A finding common to all 68 patients is a trend towards tall patients of modest BMI, a very deep capacious gynecoid pelvis (figure 1) with a deep rectovesical pouch or “pseudo pouch of Douglas” reminiscent of a post hysterectomy pelvis, a very mobile mesorectum with a long mesentery and a complete absence of Denovilliers’ fascia; so that once the peritoneum has been incised the pneumo-peritoneum aids the dissection of the areola plane, which is easily continued between the rectum and the prostate anteriorly down towards the pelvic floor (figure 2.). These common findings suggest it is a primary anatomical origin that predisposes patients to develop prolapse, rather than abnormalities developing secondary to the prolapse.

 

A lightweight Titanium coated polypropylene 20x4 cm strip of mesh (Tilene, PFM, Nuremburg, Germany) is then sutured to the rectum using 3/0 PDS (Ethicon, Edinburgh, Scotland) starting at the level of the pelvic floor and continuing proximally for 18 cm up to the level of the sacral promontory. The tail of the mesh is then fixed to the promontory using titanium tacks.  Lateral peritoneum (“neo-uterosacral ligaments”) is then sutured above and to include the mesh with additional elevation of the mesorectum at the promontory. Catheters are removed at completion of the surgery.

Results

During the study period (2002-13) 68 of 736 LVMRs (9.2%) were performed on male patients, ASA I (40), II (17), III (11).  Their median age was 34.5 (IQR 17.75-51.25) years and BMI 26 (IQR 24-27.25).  18 had external prolapse, whilst the remainder had Oxford grades III (6), IV (38) and V (6) rectal intussusceptions. Additional evacuatory proctography findings included: enterocele (29), rectocele (12) and rectocele alone (2).  Anorectal physiology was performed in 33 patients and the parameters are summarised in table 1.

 

The median pre-operative ODS score was 18.5 (IQR 16-22) and CCIS 4 (IQR 0-8). 18 men (26%) had recurrent prolapse having undergone STARR (Stapled Trans Anal Rectal Resection) (9), Delorme’s (6) and posterior-sutured resection rectopexy (3) [one open].  41 (60%) had undergone unnecessary haemorrhoidal surgery with no symptom improvement; two had SNS implants, which again had no impact on symptoms (table 2). Seven were referred from the chronic pelvic pain clinic having undergone multiple previous treatments to include: prostatic biopsy (for prostatitis), anal dilatation, lateral sphincterotomy and Botox; median NRS scores for pelvic pain were 9 (IQR 7-10). 

 

Median operative time was 1 hour (IQR 45-80 min).  Details of the mesh type used and the peri-operative complications are summarised (table 3); there was no mortality.  All procedures were completed laparoscopically, with a median length of stay of 1 day (IQR 1-1); 16 (24%) were discharged as day cases.  The median duration of follow up was 16 months (IQR 8-37). The number of patients who were followed up and completed the BBSQ-22 questionnaire and the VAS scores are summarised (table 4).

 

Functional results:

The median preoperative CCIS improved from 4 (IQR 0-8) to 0 (IQR 0-0); p= 0.00 and the median ODS score improved from 18.5 (IQR 16-22) to 6 (IQR 5-8); p=0.00. 56 men (82%) were asymptomatic at their last follow-up; Six (8.8%) had persisting symptoms to include ODS (2) and occasional urgency (4).  The remainder reported a resolution of the majority of their symptoms apart from a continued need for laxatives (3) or occasional abdominal pain.

 

 

 

Quality of Life:

BBSQ-22 analysis (table 5.) demonstrates a statistical significant improvement in Quality of Life at three months (p=0.000), which was then maintained for up to 4 years (p=0.018) follow-up.  Bowel symptom severity scores (VAS) also improved and again this persisted with time (table 6). Whilst bladder function as assessed by VAS improved initially, this improvement was not statistically significant at two years (table 7).

 

PROM’s

52 patients (77%) completed patient reported outcome measures at each follow-up assessment. Overall 37 felt that their LVMR had been very successful, 14 somewhat successful whilst one felt that their symptoms were unchanged.  48 felt it was the right decision to undergo surgery, 4 were unsure.  40 felt that the end outcome had been better than expected, 10 different than expected (not better or worse), one just as expected and one worse than expected.

 

Chronic idiopathic pelvic pain:

In the seven patients referred with chronic pain, NRS for pain fell sharply after surgery to a median of 2 (IQR 0-3) at 3 months; p=0.000.  Surgery was also effective in restoring QoL and eliminating the pain component of the BBSQ-22 assessment sufficient that all but one patient could be withdrawn from their high dose Gabapentinoid anticonvulsants and be discharged.  The one “failure” is awaiting EUA/laparoscopy to evaluate and treat continuing posterior wall prolapse.

 

Recurrence:

Recurrent symptoms were observed in 5 patients, three of whom developed symptoms within 6 months of surgery, one at three years and one at seven. Causes included progressive slow transit constipation (2), posterior grade IV intussusception (1), left lateral grade IV intussusception (1) and mucosal prolapse (1).  There were no cases of recurrent external prolapse.

 

 

 

 

 

 

 

 

Discussion

This study, the only one in the literature reporting outcomes of LVMR in male patients suggests that, as in women, the technique is a safe and effective treatment of both external rectal prolapse and symptomatic recto-anal intussusception presenting with obstructive defecation (ODS), faecal incontinence and pelvic pain.  Our data suggests that LVMR improves not only symptoms, but also more importantly quality of life.  It is also effective in managing recurrent symptomatic disease e.g., post STARR (Stapled Trans Anal rectal Resection) or persisting urgency post STARR.

 

Rectal prolapse and intussusception are more commonly recognised in females than males with a ratio in the order of 6:16-8.  They are also seen in children where the sex distribution is equal.  Although there exact cause is unknown a number of physiological and anatomic abnormalities are recognized1: a deep pouch of Douglas, a long rectal mesentry with poor posterior fixation with resultant loss of the rectums normal horizontal position, a redundant recto-sigmoid, levator diastasis, and a patulous weakened anal sphincter. It is unclear, however, if these abnormalities are primary or just secondary developments in response to prolonged straining or the prolapse.  External rectal prolapse is itself thought to begin as an intussusception starting 6-8 cm proximal to the anal verge12. The predominance of women suggests that birth trauma may be responsible. However, the fact that 35% are nulliparous suggests a more complex explanation e.g., disorders of collagen synthesis and its effects upon the fascial structural supports. Further more, 50% have undergone previous gynecological surgery1, 10-25% have middle compartment uterine prolapse and a third have a coexisting cystocele.   

 

Anorectal physiology studies demonstrate impaired sphincter function and a decreased resting pressure, which probably arises secondary to chronic stimulation of the recto-anal inhibitory reflex13. Maximum voluntary contraction pressures are variably affected depending on the continence of the individual patient.  Physiological assessment in men with external and internal prolapse14 has failed to shed any light into the mechanism of development, the only significant finding been that like women, resting pressures are lowest in those patients where the prolapse has become external.

 

So what about the use of dynamic defecography in men? In a small study15 of 65 men complaining of constipation and/or faecal incontinence, “normal” radiology was observed in 23% men vs. 5.5% of women (p<0.001).  Rectoceles were seen in 4.5% men vs. 44% (p<0.001) in women and enteroceles 10.5% vs. 30% (<0.001).  There were no differences between the sexes in the finding of an intussusception (57.6% vs. 45%).  Others, as in our study have reported male rectoceles (17%) in larger numbers16.  Whilst our finding of an additional enterocele in 43% of cases is significantly higher than the 10% previously reported17 it is similar to levels seen in women with high-grade intussusception and hysterectomy17 and probably reflects the severity of the congenital anatomical deficiencies, they look like a hysterectomized pelvis, predisposing to the development of pelvic floor weakness in otherwise normal physically active young men. The high quality/performance of the proctographic examination in our high volume centre may also result in a higher pick-up rate.

 

Although commonly cited predisposing factors in men include constipation and chronic straining, our laparoscopic and proctographic observations in this group of patients suggests an underlying primary anatomical problem.  Anatomical features common to this cohort of patients include: tall slim men of moderate BMI, a wide gynecoid pelvis with an apparent “pouch of Douglas” or deep rectovesical pouch and widely separated ischial spines, mobile and long mesorectum, descending perineum and an apparent absence anteriorly of Denonvilliers’ fascia.  The anterior dissection in LVMR is much easier than that encountered in a typical TME resection.   These anatomical and tissue findings go in part to explain the short-term failings of the more traditional approaches of Delormes’ and posterior rectopexy for external prolapse18.

 

Internal prolapse causing ODS is poorly, if at all recognised in men with non-diagnosis been the norm.  In our experience this has lead to large numbers undergoing various surgical interventions prior to being diagnosed with a pelvic floor disorder. Haemorrhoidal disease was the commonest misdiagnosis with 60% having had some sort of intervention; unsurprisingly the surgery was ineffective. This association has been recognised previously, with a small RCT showing that STARR to be a more effective treatment than stapled anopexy for 4th degree haemorrhoids found in association with internal rectal intussusception19.  The problem with STARR in this situation is that unlike LVMR, it doesn’t correct the causative anatomy only the effect and is thus prone to failure within the medium term20.  A further advantage with LVMR is the avoidance of the troublesome self-remitting post-operative faecal urgency seen in 72% at eight weeks19.

 

10% of our patients were referred from the chronic pelvic pain clinic for pelvic floor assessment. Results were good in six of the seven cases with significant reductions in VAS for pain sufficient to allow withdrawal of their medications and discharge. Chronic idiopathic rectal and perineal pain is poorly understood and frequently considered to be a psychological disorder. When actively sought, high-grade internal intussusception is seen in half of patients rising to 73% when ODS is present21.  We believe that the origin of the pain is a combination of ischaemia secondary to levator diastasis and stretching of the pudendal nerves.

 

Clinicians must remain aware that pelvic floor disorders/ODS occur in men and that pelvic pain can arise from structural deformity and investigate accordingly with a full and careful examination as well as a “defecatory” sigmoidoscopy1 and if necessary, repeated following a phosphate enema.  Video-defecography can be useful in identifying high-grade internal prolapse, and if it is of good quality will often show a “pseudo rectocele” and enterocele.  If it is normal and the narrative remains highly suggestive of prolapse, EUA with laparoscopy will provide confirmatory evidence.  Our experience, like that of others14 has failed to show that anorectal physiology adds anything to the diagnosis of, or clue as to the aetiology of these conditions.

 

With reference to the procedure itself, our experience suggests that LVMR is safe. However, the operation is technically more difficult in male patients and we believe only experienced surgeons should undertake the procedure.  This is mainly due to the long learning curve and the potential risks to autonomic nerves including the sympathetic nerves travelling cranially from the lower reaches of the prostate. We encountered no major complications other than urinary retention seen in 10% (catheter removed in theatre) and all operations were completed laparoscopicaly with most discharged within 18 hrs; a quarter were completed as day cases.

 

Short term and longer term follow-up has shown that this cohort of patients tends to remain asymptomatic, except in those limited number of patients who had benign prostate bladder dysfunction; 91% having a favourable outcome. Moreover, patients’ quality of life, including pelvic pain rapidly improved/normalised and this improvement persisted with time. This continued improvement was observed in all but five (7.3%) patients; two had recurrent intussusception, the rest either slow transit constipation or mucosal prolapse. These patients were treated accordingly with revision laparoscopic surgery (left lateral mesh rectopexy, limited posterior sutured rectopexy, colectomy with ileorectal anastomosis) or PPH. The improved long-term outcomes compared to those reported in females1 is probably accounted for by the “uni-compartment” nature of their POP and the absence of a wide pelvic diaphragm.

 

This study is not without its limitations e.g., the small number of patients followed up for 4 years or more. However, the marked, persistent improvement in symptoms makes it unlikely that this observation is untrue.   Whilst accepting that there is a paucity of data regarding LVMR in males, we believe that these results suggest that the procedure is not only safe and can be performed without risk to potency and new onset retrograde ejaculation, but more importantly it significantly improves symptoms (ODS, FI and pelvic pain) and restores quality of life which looks likely to be maintained.  The intervention is also supported by PROMs.  High-grade internal rectal prolapse commonly underlies chronic idiopathic perineal/rectal pain and should be excluded, particularly when ODS is present. Surgical interventions should take the whole pelvic support system into account to avoid therapeutic errors, as should all clinicians dealing with patients with pelvic pain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Anorectal Physiology

35

Normal study

11

Paradoxical contraction, hyposensitive rectum

8

Paradoxical contraction, normal sensation

8

Low anal resting & squeeze pressure

2

Normal sphincter, hyposensitive rectum

2

Low max volume

2

 

Table 1. Summary of the ano-rectal physiology parameters

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Procedure performed

Number of patients

Banding of haemorrhoids

22

Milligan-Morgan haemorrhoidectomy

11

EUA

11

PPH

7

Prucalopride

6

Repeated courses of biofeedback

5

Rectal irrigation

3

Lateral Sphincterotomy

3

Prostate biopsy

2

SNS implant

2

Pain clinic

7

Digital dilatation anus

2

HALO

1

Botox to pelvic floor

1

 

Table 2: Surgical and medical interventions prior to LVMR


 

Mesh Used

(# Of patients)

Titaniumised Polypropylene

31

Polyester

22

Polypropylene

14

Biological

1

Complications

(30 days)

No complications

54

Urinary retention

7

Bruising

2

Broken tooth

1

Agitation

1

ST Depression

1

Urinary tract infection

1

 

Table 3: Mesh used and complications


 

 

Type of follow up

Number of patients followed up

 

Pre-op

3 month

1 year

18 month

2 year

3 year

4 year

QoL-22

65

58

37

21

15

8

7

VAS-Bowel

65

58

37

21

15

8

6

VAS- Bladder

65

58

37

21

15

8

6

 

Table 4: Number of patients followed up

 

 

 

 

 

 

 

 

 

 

 

Median Score at follow up (IQR1-3)

 

Pre-op

3 month

1 year

18 month

2 year

3 year

4 year

QoL-22

50

(46-54)

32

(30-37.75)

31

(29-33)

30

(29-35)

30

(28.5-31)

32

(29.5-33.5)

30

(28-31.5)

P-value

 

0.000

0.000

0.000

0.001

0.018

0.018

 

Table 5: BBSQ-22 Quality of Life scores over time


 

Median Score at follow up (IQR1-3)

 

Pre-op

3 month

1 year

18 month

2 year

3 year

4 year

VAS-

Bowel

120

(100-130)

20

(0-38.75)

5

(0-30)

5

(0-35)

0

(0-7.5)

2.5

(0-18.75)

5

(0-17.5)

P-value

 

0.000

0.000

0.000

0.001

0.012

0.028

 

Table 6: Bowel symptom severity Visual Analogue Score (VAS) over time

 

 

 

 

 

 

 

 

 

 

 

 

Median Score at follow up (IQR1-3)

 

Pre-op

3 month

1 year

18 month

2 year

3 year

4 year

VAS-

Bladder

0

(0-12)

0

(0-5.75)

0

(0-5)

0

(0-5)

0

(0-9.5)

0

(0-22.5)

0

(0-15)

P-value

 

0.037

0.516

0.025

0.063

0.197

0.285

 

Table 7: Visual Analogue Score (VAS) examining bladder symptom severity

 

 

 

AppleMark

Figure 1. Typical male pelvis with pseudo “pouch of Douglas”

AppleMark

Figure 2. Rectal dissection carried to lower border of prostate (seen superiorly) with rectum inferiorly

 

References

1. Slawik S, Soulsby R, Carter H, Payne H, Dixon AR. Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis. 2008 Feb;10(2):138-43.

2. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2008(4):CD001758.

3. Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis. 2010 Jun;12(6): 526-32.

4. Collinson R, Wijffels N, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results. Colorectal Dis. 2010 Feb;12(2): 97-104.

5. Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bissett IP. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis 2010; 12(6): 504–512

6. Altomare DF, editor. Rectal prolapse: Diagnosis and clinial management: Springer; 2008.

7. Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg 2005; 140(1): 63–73

8.   Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94(3): 207–210

9. Jorge, J.M. and S.D. Wexner, Etiology and management of fecal incontinence. Diseases of the Colon & Rectum, 1993. 36(1): p. 77-97.

10. Altomare, D.F., et al., Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome. Colorectal Dis, 2008. 10(1): p. 84-8.

11. Hiller, L., et al., Development and validation of a questionnaire for the assessment of bowel and lower urinary tract symptoms in women. BJOG, 2002. 109(4): p. 413-23.

12. Broden B, Snellman B. Procidentia of the rectum studied with cineradiography. A contribution to the discussion of causative mechanism. Dis Colon Rectum. 1968 Sep-Oct;11(5):330-47.

13. Spencer RJ. Manometric studies in rectal prolapse. Dis Colon Rectum. 1984 Aug;27(8):523-5.

14. Hotouras A, Murphy J, Abeles A, Allison M, Williams NS, Knowles CH, et al. Symptom distribution and anorectal physiology results in male patients with rectal intussusception and prolapse. J Surg Res. 2013 Dec 12.

15. C. Savoye-Collet, G Savoye, E Koning, A-M Leroi, and J-N Dacher. Gender influence on defecographic abnormalities in patients with posterior pelvic floor disorders. W.J.Gastrent 2010; 16 (4): 462-466

16. Chen HH, Iroatulam A, Alabaz O, Weiss EG, Nogueras JJ, Wexner SD. Associations of defecography and physiologic findings in male patients with rectocele. Tech Coloproctol. 2001; 5:157–161

17. Enterocele is a marker of severe pelvic floor weakness. Jarrett ME, Wijffels NA, Slater A, Cunnigham C, Lindsey I.  Enterocele is a marker of severe pelvic floor weakness. Colorectal Dis 2010; 12 (7 Online):e 158-62.

18. Senapati A, Gray RG, Middleton LJ, Harding J, Hills RK, Armitage NC, Buckley L, Northover JM; PROSPER Collaborative Group. PROSPSER: a randomised comparison of surgical treatments for rectal prolapse.  Colorectal Dis 2013; 15 (7): 858-68

19. Boccasanta P, Venturi M, Roviaro G.  Stapled transanal rectal resection verus stapled anopexy in the cure of haemorrhoids associated with rectal prolapse. A randomized controlled trial.  Int.J.Colorect Dis., 2007; 22 (3): 245-251

20. Goede AC, Glancey D, Carter H, Mills A, Mabey K, Dixon AR. Medium-term results of stapled trans anal rectal resection (STARR) for obstructed defecation and symptoms of rectal-anal intussusception.  Colorectal Dis 2011; 13 (9): 1052-7.

21. Hompes R, Jones OM, Cunnigham C, Lindsey I. What causes chronic idiopathic perineal pain? Colorectal Dis 2011; 13 (9): 1035-9.

 

 


All rights reserved © 2006. Bristol Surgery.
SPIRE Hospital, Bristol. 
{Contact us}
Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
vp