Obesity and bariatric surgery: a systematic review of associations with defecatory dysfunction.

BACKGROUND: Obesity rates are rapidly growing in the developed world. While upper gastrointestinal disturbances and urinary incontinence are independently associated with obesity, the relationship between obesity and defecatory dysfunction is less well defined. OBJECTIVES: To summarize the literature on faecal incontinence, diarrhoea and constipation in obese patients and its effects of bariatric surgery. SEARCH STRATEGY: A Medline search was carried out on articles published from January 1966 to March 2010. SELECTION CRITERIA: Original articles on adult obese or morbidly obese patients were identified, including results following bariatric surgery that reported faecal incontinence, diarrhoea or constipation. Other forms of pelvic floor dysfunction were excluded. Main outcome measures included faecal incontinence, diarrhoea and constipation rates and their severity in obese patients and following bariatric surgery. RESULTS: Twenty studies reported defecatory outcomes in obese patients (n = 14) and after bariatric surgery (n = 6). While constipation rates were similar, the rates of faecal incontinence and diarrhoea were higher in obese patients compared with non-obese patients. The exact rates of these conditions, and the correlations between body mass index (BMI) and faecal incontinence, diarrhoea and constipation, were not clear. Faecal incontinence improved after Roux-en-Y gastric bypass in studies with preoperative data. The effects of bariatric surgery on diarrhoea were unclear. CONCLUSION: Few studies have assessed the correlations between obesity and defecatory function and the effect of bariatric surgery. Studies were often not well controlled and used non-uniform instruments to assess bowel function. Obesity appears to be correlated with higher rates of faecal incontinence and diarrhoea. The effects of bariatric surgery on these conditions are not well defined. Well-controlled studies correlating outcome with physiological pelvic floor function are needed.

Results of combined medical and surgical treatment of recto-vaginal fistula in Crohn's disease.

AIM: Surgical repair of recto-vaginal fistula (RVF) in Crohn's disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. METHOD: A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. RESULTS: Fifty-one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. CONCLUSION: RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.

Faecal incontinence in men.

AIM: A few studies have specifically addressed faecal incontinence (FI) in men. We sought to describe patterns of male FI, assess treatment outcome and compare some aspects of FI between men and women, including quality of life. METHOD: Prospectively recorded data on 85 consecutive male patients evaluated for FI at our pelvic floor centre in 2004 and 2005 were reviewed and compared with a cohort of 408 female patients. Treatment outcome in men was assessed by questionnaire. RESULTS: The aetiology of FI could be determined in 61 (72%) men and was most commonly related to anal surgery (n = 23), prostate cancer therapy (n = 9) and spinal injury (n = 9). Eight patients had idiopathic soiling only. Mean age, Fecal Incontinence Severity Index (FISI) and quality of life scores were similar between men and women. Maximal mean resting pressure (MRP) and squeeze pressure (MSP) were on average higher in men than in women [MRP 56.9 (26.2) vs 40 (20.4) mmHg; P < 0.0001]; [MSP 98.1 (67.3) vs 39.4 (28.5) mmHg; P < 0.0001]. Sphincter defects involved the external sphincter less often in men (35 vs 70%, P = 0.004). Differences in faecal incontinence quality of life (FIQL) and SF-36 scores between men and women were minimal. After a median follow up of 2 years, complete resolution of symptoms was reported in 17% and improvement of symptoms in another 48% of men. CONCLUSION: Although physiological and anatomical features of FI differ between men and women, its severity and impact on quality of life are similar. External sphincter defects are less common in men; hence, direct sphincter repair is less frequently an option. Evaluation and treatment improves symptoms in more than half of male patients.

Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty.

PURPOSE: Preoperative anorectal physiology studies have become part of the standard evaluation of fecal incontinence. This study was undertaken to see whether anorectal physiology results predicted surgical outcome after anterior sphincteroplasty. METHODS: Between 1985 and 1994, 191 females with a mean age of 37 (range, 20-74) years underwent anterior sphincteroplasty for anal sphincter disruption. A follow-up questionnaire was sent to all patients, and there were 158 respondents (83 percent). Mean follow-up was 43 (range, 6-120) months. Obstetric injuries accounted for incontinence in 91 percent of the 158 patients who responded to the questionnaire. Mean duration of incontinence was 4.2 years (range, 3 months-51 years) before surgery. Preoperatively, patients were incontinent to solid stool (53 percent), liquid stool (33 percent), gas (3 percent), and unspecified (11 percent). RESULTS: Subjectively, the results were as follows: 129 patients (82 percent) improved, 17 (11 percent) were initially improved but subsequently deteriorated, 7 (4 percent) were unchanged, and 5 (3 percent) were worse. Objectively, postoperative continence was classified as follows: excellent (normal) in 23 percent, good (incontinent to gas or minor stain) in 39 percent, fair (incontinent to stool an average of less than once per month) in 26 percent, and poor (incontinent to stool an average of greater than once per month) in 12 percent. Preoperative continence level (incontinent to solid vs. liquid stool) was predictive of postoperative continence classification. Preoperative anorectal manometry was not predictive of clinical outcome (n = 128). There was no significant difference in postoperative continence classification among patients with normal, unilaterally abnormal, and bilaterally abnormal pudendal latency (n = 89). CONCLUSIONS: Clinical rather than manometric assessment predicts continence after anterior sphincteroplasty.

Patient satisfaction after surgical treatment for fistula-in-ano.

PURPOSE: The surgical treatment of fistula-in-ano frequently results in recurrence of the fistula or postoperative anal incontinence. Despite these problems, most patients are satisfied with the results of their surgery. To clarify this apparent discrepancy, we attempted to identify factors that affect patient's lifestyles and may contribute to their satisfaction. METHODS: A questionnaire was mailed to 624 patients surgically treated for cryptoglandular fistula-in-ano at the University of Minnesota during a five-year period. Three hundred seventy-five patients returned their questionnaires. Patients who were followed up for a minimum of one year were included in this retrospective study. Associations between postoperative complications and patient satisfaction were identified by chi-squared tests and multiple logistic regression. Attributable fractions for patient dissatisfaction were calculated using study population dissatisfaction rates. RESULTS: Patient satisfaction was strongly associated with fistula recurrence, difficulty holding gas, soiling of undergarment, and accidental bowel movements. Effects of incontinence on patient quality of life were also significantly associated with patient satisfaction as was the number of lifestyle activities affected by incontinence. Patients with fistula recurrence reported a higher dissatisfaction rate (61 percent) than did patients with anal incontinence (24 percent), but the attributable fraction of dissatisfaction for incontinence (84 percent) was greater than that for fistula recurrence (33 percent). Patient satisfaction was not significantly associated with age, gender, history of previous fistula surgery, type of fistula, surgical procedure, time since surgery, or operating surgeon. CONCLUSION: Patient satisfaction after surgical treatment for fistula-in-ano is associated with recurrence of the fistula, the development of anal incontinence, and with the effects of anal incontinence on patient lifestyle. In our series of patients treated mainly with laying open of the fistula tract, patients with fistula recurrence had a higher dissatisfaction rate than did patients with anal incontinence. However, because anal incontinence was more prevalent than fistula recurrence, a higher fraction of dissatisfaction was attributable to anal incontinence.

Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence.

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha >0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement.

Standards for anal sphincter replacement.

PURPOSE: Anal sphincter replacement offers a new treatment option for patients with severe refractory fecal incontinence or for those who require abdominoperineal resection for localized malignancy. The purpose of this study was to review the current status of anal sphincter replacement, formulate a consensus statement regarding its current use, and outline suggestions for future development. METHODS: Four areas of interests were selected: indications for sphincter replacement, continence scoring and quality of life, choice of therapy, and dissemination of new technology. A questionnaire regarding these issues was developed and circulated to working party members; its results served as the basis for this consensus document. RESULTS: Both electrically stimulated skeletal muscle neosphincter and artificial anal sphincter are options for patients with end-stage fecal incontinence. Electrically stimulated skeletal muscle neosphincter is also appropriate for reconstruction after surgical excision of the anorectum in selected cases. Avoidance of complications requires strict attention to sterile technique, prophylactic antibiotics, and deep venous thrombus prophylaxis. A standardized scoring system is proposed that evaluates both continence and evacuation. Quality of life is a critical endpoint for assessing sphincter replacement, and use of The American Society of Colon and Rectal Surgeons incontinence-specific quality-of-life instrument is recommended. As the efficacy of sphincter replacement becomes proven, dissemination of the technique should occur in a controlled manner to ensure adequate surgeon training, minimization of complications, and optimization of results. CONCLUSIONS: Sphincter replacement by electrically stimulated skeletal muscle neosphincter and artificial anal sphincter provide a continent option for patients with end-stage fecal incontinence and those requiring abdominoperineal resection. The guidelines offered in this document are intended to facilitate the controlled and safe development and acceptance of these new techniques.

Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index.

PURPOSE: The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index. METHODS: The Fecal Incontinence Severity Index is based on a type x frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores. RESULTS: Surgeons and patients had very similar weightings for each of the type x frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale. CONCLUSIONS: Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool.

Effect of delivery on anal sphincter morphology and function.

PURPOSE: Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States. METHODS: Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients. RESULTS: Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P < 0.05), and manometric results were reduced. Three of these seven patients had a third-degree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section. CONCLUSIONS: The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.

Long-term cost of fecal incontinence secondary to obstetric injuries.

INTRODUCTION: Anal incontinence is eight times more frequent in females than in males because of injuries sustained at childbirth. The aim of the present study was to determine the long-term costs associated with anal incontinence related to obstetric injuries. METHODS: Sixty-three patients with anal incontinence caused by obstetric sphincter injuries answered questionnaires regarding previous treatments, symptoms, and use of protective products. Of the patients, 31 were treated surgically, 11 with biofeedback, 6 with a combination of surgery and biofeedback, and 15 conservatively. Treatments and their respective costs were obtained from patient records, patient questionnaires, billing database, and Health Care Financing Administration's 1996 inpatient database. Costs were expressed in 1996 dollars. RESULTS: The mean incontinence score changed from 26 at evaluation to 16 at follow-up (P < 0.001). The average cost per patient was $17,166. Evaluation and follow-up charges totaled $65,412, and physiologic assessment accounted for 64 percent of these costs. Treatment charges totaled $559,341, and physician charges accounted for 18 percent of these charges. CONCLUSIONS: Fecal incontinence after childbirth results in substantial economic costs, and treatment is not always successful. New treatment modalities, such as artificial bowel sphincter or dynamic graciloplasty, should be assessed to determine their cost-effectiveness.

Complete rectal prolapse: evolution of management and results.

UNLABELLED: Optional treatment for complete rectal prolapse remains controversial. PURPOSE: We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. METHODS: We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64: range, 12-231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). RESULTS: Median age of patients was 64 (11-100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineal rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61 vs. 30 percent, P = 0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomy vs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8 vs. 5 days, P = 0.001). Perineal procedures, however, had a higher recurrence rate (16 vs. 5 percent, P = 0.002). Functional improvement was not significantly different, and most patients were satisfied with treatment and outcome. CONCLUSIONS: We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate.Patient satisfaction]

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE: Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. METHODS: One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. RESULTS: Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. CONCLUSIONS: Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.

Anal sphincter integrity and function influences outcome in rectovaginal fistula repair.

PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defect on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preoperative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry studies. Follow-up was by mailed questionnaire in 36 patients (69 percent) and by telephone interview in 12 (23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18-70) years, and median follow-up was 15 (range, 0.5-123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before surgery. There were 27 endorectal advancement flaps and 35 sphincteroplasties (28 with and 8 without levatoroplasty). RESULTS: Success rates were 41 percent with endorectal advancement flaps and 80 percent with sphincteroplasties (96 percent success with and 33 percent without levatoroplasty; P = 0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function (P = not significant). For sphincteroplasties, success rates were 73 vs. 84 percent for normal and abnormal sphincter function, respectively (P = not significant). Results were better after sphincteroplasties vs. endorectal advancement flaps in patients with sphincter defects identified by endoanal ultrasound (88 vs. 33 percent; P = not significant) and by manometry (86 vs. 33 percent; P = not significant). Poor results correlated with prior surgery in patients undergoing endorectal advancement flaps (45 percent vs. 25 percent; P = not significant) but not sphincteroplasties (80 vs. 75 percent; P = not significant). CONCLUSIONS: All patients with rectovaginal fistula should undergo preoperative evaluation for occult sphincter defects by endoanal ultrasound or anal manometry or both procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of previous repairs. Patients with clinical or anatomic sphincter defects should be treated by sphincteroplasty with levatoroplasty.

Biofeedback improves functional outcome after sphincteroplasty.

UNLABELLED: The primary treatment for obstetric sphincter injury is overlapping sphincteroplasty. However, despite restoration of the anatomy, only 65 percent of patients are fully continent. PURPOSE: This study was undertaken to determine if postoperative biofeedback improved continence in patients with poor functional outcomes after sphincteroplasty. METHOD: Outcomes of 28 patients who underwent electromyographic biofeedback training after sphincteroplasty for obstetric sphincter injury were reviewed. Nine patients had an accompanying levatorplasty. Average age was 34 (range, 23-57) years. Patients began biofeedback a mean of 32 (range, 2-192) months postoperatively. Before beginning biofeedback, patients completed an incontinence questionnaire, bowel diary, and scored their incontinence. At the end of treatment, they were again asked to score their incontinence and rate their improvement. Using an incontinence scale with a maximum score of 30, the average incontinence score before biofeedback was 20 (range, 13-30). Incontinent episodes per week ranged from one to nine. Sixteen patients were incontinent to solid stool. RESULTS: Overall, the average posttreatment incontinence score decreased from 20 to 3 (P < 0.0001). Average number of incontinent episodes per week decreased from 5.4 to 1.4 (P < 0.0001) Twenty-five patients (89 percent) reported improvement in their continence. All had a posttreatment incontinent score of less than three. Three patients noted no improvement. Of those, one subsequently had a colostomy, one is waiting the implant of an artificial anal sphincter, and one has sought no further treatment. There were no complications reported. CONCLUSION: Biofeedback improves functional outcome after sphincteroplasty and is a reasonable option for patients with less than optimum outcome after sphincteroplasty.

Open vs. closed sphincterotomy for chronic anal fissure: long-term results.

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1-6) years. RESULTS: Differences in persistence of symptoms (3.4 OIS vs. 5.3 percent CIS), recurrence of the fissure (10.9 vs. 11.7 percent CIS), and need for reoperation (3.4 percent OIS vs. 4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3 vs. 23.6 percent; P 0.062), soiling underclothing (26.7 vs. 16.1 percent; P < 0.001), and accidental bowel movements (11.8 vs. 3.1 percent; P < 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.

Repair of simple rectovaginal fistulas. Influence of previous repairs.

The results of 81 endorectal flap advancements for simple rectovaginal fistulas are reported. Simple fistulas are defined as less than 2.5 cm in diameter, low or mid vaginal septum in location, and infectious or traumatic in origin. Essentially, the technique is advancement of a flap of mucosa, submucosa, and circular muscle over midline approximation of internal sphincter muscle. The mean patient age was 34 years old (range, 18 to 76 years). The causes were obstetrical injury (74 percent), perineal infection (10 percent), operative trauma (7 percent), and unknown (8 percent). Overall, the repair was successful in 83 percent of patients. Success correlated with the number of previous repairs, i.e., none: 88 percent success; one: 85 percent success; two: 55 percent success. There were 25 concomitant overlapping sphincteroplasty procedures. Only minor complications ensued, with no mortality. This repair is recommended for patients with no or one previous repair because of its lack of mortality, minimal morbidity, ease of concomitant sphincteroplasty, and avoidance of a colostomy. For patients with two or more earlier repairs, a muscle interposition should be considered.

Internal and overt rectal procidentia.

The etiology and treatment of rectal procidentia remain controversial despite its longtime recognition. In this article, the clinical manifestations, etiology, and therapeutic options of both forms of rectal prolapse and the associated syndromes of colitis cystica profunda and solitary ulcer of the rectum are reviewed.