Int J Colorectal Dis (1999) 14:245–249

© Springer-Verlag 1999

O R I G I N A L A RT I C L E

M. Pescatori · C. Quondamcarlo

A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment

Accepted: 18 June 1999

Abstract The management of rectal internal mucosal prolapse (RIMP) is not based on an accepted classification of the lesion which helps to choose the appropriate treatment. The aim of this prospective study was to report a new endoscopic grading of RIMP and to evaluate its clinical value. Thirty-two patients (7 men, 25 women; mean age 56 years, range 28–72) affected by symptomatic RIMP were prospectively classified as follows: RIMP was defined as first degree when detectable below the anorectal ring on straining, as second degree when it reached the dentate line, and as third degree when it reached the anal verge. Anal manometry was carried out in 26 patients, and anal ultrasound and defecography in 6 prior to surgery. A correlation was found between the occurrence and severity of symptoms and the degree of the prolapse as obstructed defecation, bleeding and fecal soiling affected mainly patients with third-degree RIMP. At manometry the maximal resting tone was 60±23 mmHg and voluntary contraction 96±41 mmHg (mean±SEM). At anal ultrasound the mean internal sphincter thickness was 2.1±0.2 mm, and external sphincter thickness was 7.0±0.8 mm. A significant rectocele and rectal intussusception (n=2) and a nonrelaxing puborectalis muscle on straining (n=2) were observed at defecography in cases with third-degree RIMP. The anorectal angle was 100±75° at rest, 63±20° on squeezing, and 115±9° on straining. A conservative treatment with high-fiber diet and/or rubber band ligation was carried out in all cases of first and in most patients with second-degree RIMP (n=26). Those who required surgery, i.e., stapled transanal excision of the prolapse (n=6), had either severely symptomatic third-degree RIMP with solitary ulcer syndrome (n=4) or second-degree RIMP (n=2). A positive outcome was achieved in 71% of cases. The proposed classification evaluated by the present study may M. Pescatori (✉) · C. Quondamcarlo Coloproctology Unit, UCP Villa Claudia, Via Flaminia Nuova, 280, I-00191 Rome, Italy e-mail: [email protected], Fax: +39-06-3295353 or 36303751

be of clinical value in managing rectal internal mucosal prolapse. Key words Rectal mucosal prolapse · Constipation · Proctoscopy

Introduction Excessive straining during defecation may cause symptoms such as constipation and incontinence when the anterior rectal wall is pushed down into the upper anal canal. An important factor in the development of symptoms is the weakened pelvic floor with perineal descent, which increases the anorectal angle and leads to a prolapse of the anterior rectal and bulging into the anal canal [1, 2]. The degree of symptoms depends on a number of factors, including the size and the extent of the prolapse. The selection of treatment, usually based upon the severity of symptoms and the local findings, ranges between conservative measures such as high-fiber diet and rubber band ligation [3] and surgical procedures such as mucosal prolapse either manual or stapled local excision [4]. Of the 242 patients with rectal internal mucosal prolapse (RIMP) diagnosed at proctoscopy observed at our Institution between January 1982 and June 1996, 223 were treated by conservative measures, with a positive outcome of 85%; 109, most of whose prolapse reached the anal verge, underwent either transanal submucosal excision or obliterative suture, with a positive outcome of 74% (unpublished data). Here we propose an endoscopic classification of RIMP which may help in selecting the proper treatment. The aim of this preliminary prospective study was thus to provide a treatment-related grading of the prolapse.

246 Fig. 1A–D Grading of rectal internal mucosal prolapse. A Normal pattern. B Rectal mucosa prolapsing into the anal canal below the anorectal ring (ARR), first degree. C Rectal mucosa descending at the level of the dentate line (DL), second degree. D Rectal mucosa reaching the anal verge (AV), third degree

Patients and methods The prolapse is considered of first degree when the rectal mucosa is detectable beyond the anorectal ring at proctoscopy on straining with the patient in Sims’ position, second degree when it reaches the dentate line, and third degree when it reaches the anal verge (Figs. 1, 2). All patients treated surgically presented with a circumferential prolapse at endoscopy. Thirty-two consecutive patients with symptomatic RIMP seen at our Unit between October 1996 and March 1997 were evaluated prospectively by means of our classification (7 men, 25 women; mean age 55 years, range 28–72). Patients with hemorrhoids were excluded. All underwent clinical examination and proctoscopy. Disposable self-light flute beak anoscopes with an internal size of 23 mm were used (Sapimed, Alessandria, Italy). No intestinal preparation was carried out prior to the examination; 26 patients received anal manometry by means of microballoons mounted on tiny catheters and connected to a polygraph via pressure transducers (Medtronic, Milan, Italy). Those who had more severe symptoms and were therefore candidates for surgery received defecography and rotating probe anal ultrasound carried out as previously described by others [5, 6]. The reference values for anal manometry were considered those recorded in a group of ten normal volunteers in our laboratory. The reference values for anal ultrasound were those reported in the literature [5]. The severity of symptoms and the clinical response to either conservative (high-fiber diet, bulk laxatives, rubber band ligation, biofeedback) or surgical (stapled transanal prolapse excision) using a circular 33-mm stapler (Ethicon Endosurgery, Cincinnati, Ohio, USA) were recorded. The two patients with third-degree RIMP with spastic

floor syndrome also had a pre-postoperative course of biofeedback training. The treatment outcomes were then investigated. Followup was carried out at least 6 months after treatment in 34 patients by an independent observer who used a detailed questionnaire.

Results Eight patients were found to have a first-degree, 14 a second-degree, and 10 a third-degree RIMP. Most patients (n=23, 72%) complained of chronic straining at stool, sense of tenesmus, and incomplete defecation. Rectal bleeding was reported by 6 patients (18%) and fecal incontinence by 3 (9%). Mild anal discomfort, mucus discharge, and soiling were also reported, and a correlation between severity of symptoms and the degree of RIMP was found, as shown in Table 1. Most symptoms affected patients with third-degree prolapse. Twenty-six subjects underwent conservative treatment. Of these, eight had first-degree, two second-degree, and six thirddegree RIMP. Six patients received surgical treatment; four had a third and two a second-degree prolapse. At manometry the resting tone was 60±23 mmHg and voluntary contraction 96±41 mmHg. Sphincter relaxation on straining was detected in 60% of cases.

247 Fig. 2A, B Proctoscopic view. A third-degree RIMP (large arrow) reaching the anal verge (small arrow) Fig. 3A, B Ultrasound pattern of circumferential second-degree rectal internal mucosal prolapse. A The prolapse (arrow) is surrounded by the hypoechoic (dark) circle, representing the internal anal sphincter at the level of the middle anal canal. B Proctoscopic view; arrow dentate line

Table 1 Prolapse degree and clinical picture Symptoms

First degree (n=8)

Second degree (n=16)

Third degree (n=10)

Obstructed defecation Rectal bleeding Anal discomfort Mucus discharge Fecal soiling

8 0 4 2 0

10 0 1 10 0

10 6a 1 6 3

a Four

patients had a solitary rectal ulcer syndrome

At anal ultrasound the thickness of the internal sphincter was 2.1±0.2 mm, and that of the external sphincter 7±0.8 mm; these values are considered within the normal range. Some degree of postobstetrical stretch of the external sphincter anteriorly was detectable in

three women. Circumferential mucosal prolapse was clearly detectable at anal ultrasound (Fig. 3). Defecography confirmed the presence of a RIMP. A rectocele and a small proximal rectal intussusception were also found in two patients. In the six patients who required surgical treatment, preoperative defecography showed an anorectal angle of 100±7.5° at rest, 63±20° on squeezing, and 115±9° on straining. The distance between anorectal angle and ischiatic tubarosities was 4.5±1.3 cm at rest, 2±0.8 cm on straining, and 6.7±1.6 cm on squeezing. Histological study of the specimens from four patients showed fibromuscular hyperplasia with edema in the lamina propria and extension of smooth muscle fibers upwards between the crypts, glandular hyperplasia, and thickening of the muscularis mucosae, i.e., solitary rectal ulcer syndrome.

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Ten patients were cured (31%), two improved (38%), and ten remained unchanged (31%). Overal1, 70% of the treated subjects had a positive outcome. In particular, constipation was relieved in 20 patients (63%). Nine of the patients requiring conservative treatment did not follow the therapeutic measures, and five of them were advised to consult a psychologist.

Discussion The significance of RIMP as an indicator of an underlying defecation or pelvic floor disorder is uncertain [6]. It is felt by the patient as something in the rectum that needs to be passed, thus inducing chronic straining. Most of our patients with RIMP complained of a sense of incomplete evacuation. RIMP can be detected by either proctoscopy or defecography, the latter having the advantage of depicting the mucosal abnormality in the whole rectum, but the disadvantage of using potentially harmful radiation. Proctoscopy may well distinguish between an anterior and a circumferential RIMP, and between the mucosal prolapse and the hemorrhoids. Moreover, it may well depict the relationship between the distal end of the prolapse and the anatomical structures of the anal canal, such as the anorectal ring, dentate line, and anal verge. We observed a correlation between size and descent of the mucosal prolapse and severity of symptoms in our series. Therefore the selection of treatment on the basis of our classification might be appropriate. Despite this, however, a number of potential biases must be discussed. One is the presence of internal hemorrhoids which may prolapse and dislocate the dentate line, thus making dif-

Fig. 4 Therapeutic flowchart in patients with rectal internal mucosal prolapse causing obstructed defecation

ficult to grade the prolapse. In the present study we excluded patients with piles to minimize this problem, but it may be encountered in the routine clinical practice. Moreover, associated anal diseases, such as fissures, condylomata, and external piles may indicate surgery even in the case of a first- or second-degree RIMP. On the other hand, it seems very reasonable that a bulking, circumferential, third-degree prolapse is more likely to cause a solitary rectal ulcer syndrome, especially if entrapped in paradoxically nonrelaxing sphincters, causing ischemia at the apex of the prolapse [7]. This condition, found in four of the six patients who had surgery, is more prone to be treated by surgical measures than by laxatives or rubber band ligations. As regards histology, our findings are considered together under the heading, “mucosal prolapse syndrome” [8, 9]. In six cases we found edema of lamina propria, ectasic mucosal capillaries, and submucosal blood vessels. Anal manometry and endosonography may show a damage of the external sphincter in parous women [10]. Overall, the prolapse did not seem significantly to affect the sphincter function and morphology, as both sonographic and manometric patterns were considered within the normal range. Anal manometry and endosonography may also reveal either a nonrelaxing striated sphincters on straining or a thickened muscular wall a with a clear picture of the prolapsing mucosa [11]. More recently Fransioli et al. [12] have demonstrated paradoxical contraction of puborectalis by means of a surface perineal ultrasound probe. Defecography should play a major role in patients with third-degree RIMP and severe symptoms who require surgery. In these cases the surgeon must be well aware of the anatomo-functional status of the whole rectum to avoid the risk of treating only the “tip of the iceberg,” excising a small amount of prolapsed mucosa and leaving behind the major bulk related to a proximal intussusception. A safer but more expensive dynamic mag-

Proctoscopy grading of the prolapse

1st degree

2nd–3rd degree

Usually conservative treatment-medical dietetic in most cases

Non relaxing puborectalis muscle

Biofeedback

Rubber band ligation

Non healing solitary ulcer relaxing puborectalis, no rectal intussusception

Transanal excision of mucosal prolapse

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netic resonance may also be of great help in more complex cases [13]. Defecography may also help to exclude cases with spastic floor syndrome whose constipation is more related to a now relaxing puborectalis than to an internal mucosal prolapse. Patients who underwent surgery in our series were able to relax their sphincters and open the anorectal angle on straining. A psychological assessment may also be required in these patients who tend to overstress their symptoms related to a minor anatomical abnormality; some of our patients did not follow the indication to a conservative treatment and remained symptomatic. One-fourth of those who complain of obstructed defecation may hidden a history of a severe trauma [14]. As regards the surgical treatment of patients with second- or third-degree RIMP, the quick and safe stapled transanal prolapsectomy has recently been carried out in patients, with good short-term results and no relevant postoperative complication [4]. In the case of transanal mucosal excision care should be taken to avoid excessive dilation of the sphincters, which may be weakened mainly in cases of concurrent perineal descent. Preoperative anal manometry, routinely carried out in our Unit, may minimize the risk of iatrogenic incontinence. A diagnostic-therapeutic flow-chart based upon the proposed classification of RIMP, is presented in Fig. 4. In conclusion, the findings of this preliminary prospective study appear to validate the proposed classification of RIMP; however, further confirmation in a larger series are still needed. The correlation between the clinicofunctional picture and the grading of the lesion may justify its use in the evaluation of patients with symptomatic rectal internal mucosal prolapse. Acknowledgements The authors thank Dr. U. Favetta, who performed anal ultrasound, Ms. L. Peticca and Mr. R. Maggio, who helped with the follow-up, and Ms. C. De Bono, who typed the manuscript. This study was accepted for poster presentation at the ISUCRS Congress in Malmö, 7–11 June 1998.

References 1. Parks AG, Porter NH, Hardcastle J (1966) The syndrome of the descending perineum. Proc R Soc Med 59:477–482 2. Rutter KRP (1985) Solitary ulcer syndrome of the rectum. Its relation to mucosal prolapse. In: Henry MM, Swash M (eds) Coloproctology and the pelvic floor. Butterworths, London, pp 282–298 3. Mattana C, Maria G, Pescatori M (1989) Rubber band ligation of hemorrhoids and rectal mucosal prolapse in constipated patients. Dis Colon Rectum 32:372–375 4. Pescatori M, Favetta U, Dedola S, Orsini S (1997) Stapled transanal excision of rectal mucosal prolapse. Techn Coloproct 1:96–98 5. Burnett SJD, Bartram CI (1991) Endosonographic variations in the normal internal anal sphincter. Int J Colorect Dis 6:2–4 6. Allen-Mersh TG, Henry MM, Nicholls RJ (1987) Natural history of anterior mucosal prolapse. Br J Surg 74:679–682 7. Devroede G, Beaudry R, Haddad H, et al (1973) Discrete ulcerations of the rectum and sigmoid. Am J Dig Dis 18: 695–702 8. Kang YS, Kamm MA, Engel AF, Talbot IC (1996) Pathology of the rectal wall in solitary rectal ulcer syndrome and complete prolapse. Gut 38:587–590 9. DuBoulay CEH, Fair Brother J, Isaacson PG (1983) Mucosal prolapse syndrome – a unifying concept for solitary ulcer syndrome and related disorders. J Clin Pathol 36:1264–1268 10. Sultan AH, Kamm MA, Hudson CN, Nicholls JR, Bartram CI (1994) Endosonography of the anal sphincters normal anatomy and comparison with manometry. Clin Radiol 49:368–374 11. Van Outryve MJ, Pelckmans PA, Fierens H, Van Maercke YM (1993) Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome. Gut 34:1422–1426 12. Fransioli A, Weber B, Cunningham M, Roche B, Marti MC, Hadengue A (1997) Dynamic evaluation of puborectalis muscle function by external perineal sonography. Techn Coloproctol 1:125–129 13. Lienemann A, Anthuberc, Baron A, Reiser M (1997) Dynamic MR. Colpocystorectography assessing pelvic floor descent. Eur Radiol 7:1309–1317 14. Devroede G (1995) Psycophysiological considerations in subjects with chronic idiopathic constipation In: Wexner SD, Bartolo DCC (eds) Constipation, ethiology, evaluation and management. Heineman, Butterworth, pp 103–134