Anatomic Specificity in the Diagnosis and Treatment of Internal Rectal Prolapse IRWIN R . BERMAN, M.D., D. H U B E R T MANNING, M.D., KELLY D U D L E Y - W R I G H T , R . N .

Colon and Rectal Clinic and Glynn Brunswick Memorial Hospital, Brunswick, Georgia

Berrnan IR, Manning DH, Dudley-Wright K. Anatomic specificity in the diagnosis and treatment of internal rectal prolapse. Dis Colon Rectum 1955;25:816-826. Distal bowel evacuation was studied by cineddecography in 85 women with obstinate constipation, tenesmus, and incomplete evacuation in whom a diagnosis of internal rectal intussusception was clinically suspect. Sixty-five patients showed radiographic evidence of intussusception-mostly of the distal rectum, without rectosacral separation. Patients with distal intussusception who did not respond to nonoperadve measures were treated by Delorme's transrectai excision with excellent results. Internal rectal intussnscepdon is a real and demonstrable entity which may be symptomatically disabling and whose documentation may be integral to effective and anatomically specific treatment. The syndromes of perineal descent, solitary rectal ulcer, levator syndrome and so-called recurrent hemorrhoids may be diagnostic intermediaries in the evolution of internal rectal intussusception. [Key words: Defecation; Dyschesia; Constipation; Outlet obstruction; Intussusception; Rectal prolapse; Procidentia; Defecography; Rectocele; Enterocele; Perineal descent; Solitary ulcer;, Delorme procedure; Transrectal excision; Ripstein procedure; Rectopexy; Hemorrhoids; Rubber band ligation; Levator syndrome]

has usually relied upon clinical impression, rarely accompanied by readily reproducible objective criteria. In [act, internal rectal intussusception is quite common, perhaps up to ten times as common as external prolapseP Internal intussusception of the rectum has been recognized previously by evacuation proctography, or cinedelecography.~,a, 6,7 The process has been described as beginning with a circular fold 6 to 8 cm within the rectum, which acts as a locus for the rectal wall to intussuscept into the lumen, ultimately filling the ampulla and blocking the anal canal during straining?, s-n Evidently, logistic or other impediments to routine defecography previously have left radiographic study of defecation more as a tool for research than as a clinical aid. As a result, failure of accurate documentation of intussusception has sustained reluctance among many surgeons to offer a surgical solution for a benign problem that represents no threat to life, in spite of often severe limitations on the quality of life. Surgical therapy of true external prolapse has evolved to relative uniformity in recent years, with the reasonably widespread application of some form of abdominal rectopexy to patients who can sustain a major operation, s, 10,lz By contrast, surgical therapy of internal intussusception has been less clear, and most surgical remedies have assumed that since internal intussusception may be a precursor of external prolapse, n its treatment should be identical. This assumption is flawed by the inherent difficulties in applying a major surgical procedure to some of the more fragile patients, most in need of relief, and by the possibility that application of a full-blown abdominal procedure to limited intussusception may represent overenthusiastic therapy in any age group. Moreover, the application oI abdominal rectopexy to patients with internal intussusception has been accompanied by variable re-

OBSTINATE CONSTIPATION, TENESMUS, AND INCOMPLETE EVACUATIONare common but often diagnostically

elusive complaints. While usually of limited clinical importance, constipation may be associated with considerable morbidity when pelvic symptoms are present? In general, however, the problem has been of little surgical interest. Furthermore, surgical procedures for constipation have generally been regarded with suspicion, except when they have been accompanied by demonstrable obstruction or an abnormality of ganglion cells. In recent years, surgical interest in morbid oudet constipation has been rekindled with the finding that some patients who show no demonstrable blockage may have functional oudet obstruction secondary to internal rectal intussusception. 2-4 Whereas external prolapse (procidentia) of the rectum is readily recognized by clinical inspection, diagnosis of internal intussusception of the rectum

Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, May 6 to 10, 1985. Address reprint requests to Dr. Berman: 2301 Parkwood Drive, Brunswick, Georgia 31520.

SUlts.4,I0,13,14

The diagnosis of constipation differs from individual to individual in that frequency and consistency of bowel

816

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evacuation may be interpreted as normal or abnormal depending on the patient, l, ~5Most patients with chronic constipation respond readily to over-the-counter selfmedication or to symptomatic treatment by physicians, especially when organic blockage has been excluded by conventional diagnostic means. Patients included in the present study, for the most part, represent chronically constipated patients whose constipation was associated with tenesmus, pelvic pressure, and incomplete evacuation as they strained against an intact sphincter. When multiple incomplete evacuation was frequent, it was somedmes inaccurately interpreted by the patient as "diarrhea." Patients described an aching sensation, a feeling of a "ball in the rectum," "something in the rectum that could not come out," or a sensation of closure of the rectal opening accompanied by infrequent bowel movements. Frequent use of laxatives was common, and many patients claimed that several weeks elapsed between bowel movements if no laxative was taken. Many patients had discovered a variety of mechanical mechanisms for enhancing bowel evacuation, such as shifting from side to side on the commode or applying manual pressure to the buttocks, perianal area, perineum, or vagina. Occasional passage of blood and/or mucus per rectum was fairly common, as were intermittent pain in the lower back, buttocks, pelvis, thighs, or abdomen. These symptoms indicate dyschesia. Finally, many of our patients had been to a variety of physicians, including surgeons, gastroenterologists, and psychiatrists. Many had been studied in considerable detail with conventional barium contrast studies and endoscopy. A nondiagnostic barium enema had been obtained in most patients. In our own practice, we recognized that some of these chronically constipated patients, who initially responded to nonoperative measures, returned later with worsening of their symptoms despite initial response to treatment. In some patients, sphincterotomy for stenosis or ligation of internal hemorrhoids was performed followed by symptomatic relief, but symptoms later recurred. In a number of them, physical findings suggested the possibility of internal rectal prolapse which, unlike procidentia, was usually associated with good anal sphincter tone. Findings suggesting internal intussusception included megarectum and a palpable suggestion of internal prolapse on straining in the Sims or squatting position. Sigmoidoscopic findings included distal mucosal edema, friability, proctitis, mucosal prolapse, and solitary rectal ulcer.14,16 Internal intussusception was best demonstrated by asking the patient to strain during withdrawal of the rigid sigmoidoscope. The confirmation of internal rectal prolapse by cinedefecography in some of our early patients led to its later use in all patients with severe chronic constipation and associated pelvic symptoms in whom a diagnosis of internal intussusception was suspect.

Materials and Methods Patients with severe chronic constipation associated with symptoms of rectal pressure, tenesmus, incomplete evacuation, or the necessity to apply manual pressure to achieve evacuation were recognized as candidates for a diagnosis of internal intussusception. Digital examination in the Sims or squatting position was followed by sigmoidoscopy performed in the Sims position, with and without voluntary straining maneuvers. In patients whose diagnosis of internal intussusception was supported by physical examination as described in the preceding section, and in whom other problems had been excluded by barium enema and/or endoscopy, cinedefecography was performed. With the patient in the lateral decubitus position, high-density barium was instilled into the rectum under fluoroscopic control to the level of the mid- to proximal sigmoid colon. Patients were examined without specific preparation, although many were studied directly after two packaged enemas had been taken for office examination. After identification of the level of instilled barium, the patient was then seated on a modi-

FIG. 1. Wide foot platform and structurally modified c o m m o d e chair used for cinedefecography.

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FIG. 2. Normal de[ecogram obtained during straining shows good sacral fixation, no intussusception and minimal perineal descent.

fled (narrowed) radiolucent commode chair (Billy Wise Associates, Brunswick, GA) in the erect position (Fig. 1). T h e availability of this efficient system has resulted in uniform acceptance of the procedure by radiologists and technical staff, who view it as less troublesome than a barium-enema study. Measurements of the modified commode were 17 inches across by 18 inches deep with an 11 1/4 X 16 1/4 inch seat-opening 21 inches from ground level (Fig. 1). T h e chair was placed on a 20 X 24 inch foot-plate modification, and the patient instructed to retain the barium load. Patients were examined at rest, then during straining without evacuation, followed by straining and forced evacuation. Spot films were taken during the course of cinedefecography for permanent documentation. Radiographic interpretation was made in terms of the changing relationships of rectum and sigmoid colon to each other and to the sacrum and ischial tuberosities. T h e duration of examination was usually less than 15 minutes and required no additional special equipment. Figure 2 illustrates a normal study obtained during straining. Following cinedefecography, the patient returned the films directly to our office and was given a regimen to improve bowel evacuation, usually in the form of increased intake of fiber and fluids, and intrarectal instillation of hydrocortisone foam. Results

T o date, over 150 examinations have been performed, and included only eight male patients. This paper describes the results of study of the first 85 patients in w h o m

Dis.Col.g:Rect. November1985

internal intussusception was studied. All patients were women, most multiparous, 21 to 82 years old, whose follow-up after study was not less than six months. T h e identification of internal rectal intussusception was positive in 65 of these 85 patients, confirming dinical suspicion in most, but failing to confirm such clinical suspicion in 20 of 85 patients. Megarectum was a c o m m o n associated finding. Rectocele a n d / o r enterocele were also present in some patients. While pelvic descent of the sigmoid was common, increase in the distance between rectum and sacrum, considered evidence of a mesorectum, 3 was uncommon. In [act, rectosacral separation was demonstrated in only 23 patients with intussusception and in several without intussusception. Seven patients in the group with intussusception and rectosacral separation showed only proximal rectal intussusception (Figs. 3A-D); six showed both proximal and distal intussusception; and ten showed only distal intussusception. T h e remaining 42 patients with abnormal defecograms had only distal intussusception of the rectum, varying in magnitude. Figures 4 A - H illustrate individual examples from a spectrum of patients with distal intussusception, also illustrating the occurrence of rectocele, enterocele, and perineal descent. Many patients in all groups retained significant barium even after evacuation. Rectosacral separation for the purpose of this dynamic study was determined by the distance between rectum and sacrum during straining as compared with the resting position. In a few patients, rectosacral separation occurred without intussusception. In patients with intussusception and rectosacral separation, 5 to 12 crn increase in separation occurred during straining. Rectosacral separation is thought to represent the presence of a mesorectum, which allows rectal mobility, considered an integral element in the "classical" interpretations of the development of rectal prolapse. 3, n T h e fact that a significant mesorecturn was produced during straining in only 23 patients with proven internal intussusception suggested to us that the mesorectal abnormality with true procidentia may be a result rather than a causative factor in procidentia. 2,8 T h e finding of distal intussusception without rectosacral separation in 42 patients and the observation that significant rectosacral separation may occur without any intussusception support this view. Perineal descent has been associated with inefficient defecation in a number of reportsY Perineal descent during straining was greater than 4 cm below the ischial tuberosities in all but 12 of the 58 patients with distal intussusception (with or without rectosacral separation). Perineal descent during straining in these patients ranged from 4 to l0 cm below the ischial tuberosities. Of the seven patients with rectosacral separation and only proximal intussusception, only one patient showed more than 4 cm perineal descent.

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FIG. 3A-D. Individual examples of rectosacral separation accompanied by proximal rectal intussusception on cinedefecography. Only seven of eighty-five patients demonstrated this abnormality on x-ray.

Efficiency of defecation is also enhanced by straightening of the anorectal angle during straining in the squatting or sitting position. 9 In patients with proximal intussusception and rectosacral separation, less straightening of this angle was observed during straining and evacuation. In addition, more persistent proximal rectal angulation during straining was observed in patients with a mesorecrum than in patients with simple distal intussusception. Conceivably, some of this difference may be a measurement artifact actually related to the formation of a mesorectum.

Of the 52 patients with distal intussusception only, 25 patients had a history of previous anorectal procedures (mostly hemorrhoidectomy, hemorrhoidal ligation, or sphincterotomy). One patient had undergone previous low anterior resection and later abdominal rectopexy with recurrence of symptoms. In the seven patients with proximal intussusception and rectosacral separation, two had undergone previous anorectal surgery. Of the six patients with both proximal and distal intussusception and with rectosacral separation, three had undergone previous anorectal surgery. Previous pelvic or vaginal

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Dis. Col. & Rect.

l~ovemt,er1985

FIG.4A-H. Spotfilms showing the spectrum of individual patients (49 of 85) with distal rectal intussusceptionduring straining. Severalfilms show the associatedoccurrenceof rectoceleand/or enterocele. Perineal descentwas commonlyobserved(Seealso facingpage).

surgery (mostly hysterectomy, rectocele, or cystocele repair) had been performed in 35 of the 52 patients with distal intussusception, two of the seven patients with proximal intussusception, and rectosacral separation, and three of the six patients with both of the intussusception defects and rectosacral separation. Twenty of the 52 patients with distal intussusception only had both gynecologic and anorectal procedures in the past. A large percentage of patients in all groups were multiparous. Patient Management

Based on the results of cinedefecography, patients with absolute failure of dietary and topical nonoperative mea-

sures who had only distal intussusception were offered transrectal excision by the modified Delorme procedure, s Such refractory patients with proximal intussusception were initially offered abdominal rectopexy. Five patients with only slight improvement after nonoperative measures were managed by multiple rubber band ligations performed as a series of office procedures or as singlestage ligation of multiple segments under light anesthesia (Fig. 5). Transrectal excision of the prolapse with perineal repair has been performed in 31 patients, 14 of whom have been followed for greater than six months postoperatively. Excision of accompanying hemorrhoids and repair of associated rectocele, when present, was per-

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formed at the same time. When the rectocele was of significant size, transvaginal repair of the rectocele was performed by a gynecologist and followed by the transrectal excision at the same time. In cases of lesser rectocele defect, transrectal repair of associated rectocele was performed simultaneously with the mucosal excision, as described by Uhlig and Sullivan,5 with a few technical modifications. In almost all patients, length of the resected mucosal tube measured from 10 to 20 cm. Preoperatively, such patients were prepared as for colonic resection, and were not fed postoperatively until flatus was passed. Postoperative hospitalization rarely exceeded six days, and postoperative pain was relatively minimal, almost always less than with surgical hemorrhoidectomy

821

unless hemorrhoidectomy was also performed. In the group of patients with proximal intussusception and rectosacral separation, five patients had abdominal mesh rectopexy, with or without associated sigmoid resection, also prepared and followed as for colonic resection. In the follow-up period, including of six months or greater, all 14 patients with the Delorme procedure for internal intussusception have had relief of pelvic symptoms and of obstinate constipation, although perineal descent usually persisted (Fig. 6A, B). Urgency of bowel evacuation was common, but usually transient. One patient of the group of 31 has continued to have occasional rectal burning, relieved by small, warm enemas, and five patients have required occasional laxatives. All

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BERMAN, E T AL.

Dis. G~I.~: Rect. November198S

FIG. 5. Multiple ligation technique used for patients with limited intussusception and persistent symptoms or limited improvement after nonoperative measures. T w o of three rows of bands are shown.

have been advised to take fiber supplement (bran and psyllium seed preparations) on a regular basis. Mild to moderate transient stenosis of the rectoanal mucosal anastomosis occurred in six of the group. Permanent stenosis occurred in one patient, who bled into the anastomosis postoperatively. There was only one infection in this group, and no deaths. In patients with abdominal rectopexy, with or without sigmoid resection, relief of pelvic pressure symptoms was achieved but often was unaccompanied by predictable relief of bowel dysfunction. Some degree of postoperative bowel management has been required for most of this small group of patients, who probably represent a complex blend of impaired motility and intussusception. There were no infections or deaths in this group. T h e multiple ligation technique has been attended by neither complications nor deaths. While short-term results have been most favorable, much longer follow-up is needed.

Discussion

FIG.6A, B. Preoperativeand postoperativestraining defecography in an elderly patient with distal intussusception and perineal descent. The flask-like rectal configuration has been converted to a tubular shape by transrectal excision. Perineal descent was persistent, but asymptomatic.

One of the most interesting features of this study is the failure of defecography to document intussusception in 20 patients in w h o m internal intussusception was just as clinically suggestive as in the remaining 65 patients. It is interesting to speculate that this small group of patients may represent part of a continuum between simple mucosal prolapse, true internal intussusception, and obvious external prolapse. In this regard, the syndromes of the descending perineum, solitary rectal ulcer, levator syndrome, and recurrent hemorrhoids may be diagnostic

intermediaries in a spectrum of rectal disorders associated with laxity of all or part of the circumference of the anorectum and its supporting structures (Fig. 7). T h e ability of defecography to document what is not internal intussusception may thus be as important, as its documentation of what is internal intussusception, if only to avoid a misguided surgical procedure. Obviously, internal intussusception occurs more commonly than has previously been supposed. Yet ana-

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Defecatory Dyskinesias (Dyschezia)

FIG. 8A, B. Illustration of telescoping cup model used for patient education in the management of internal rectal intussusception.

M u c o s a l P r o l a p ! e _*H e m o r r h o i d s ] I

Solitary Ulcer

I i

"The Syndromes" Perineal Descent

I levator Syndrome

I

I

INTERNAl_. I N T U S S U S C E P T I O N FIG.7. Hypothetical interplay of muhiple factors in the evolution of internal rectal intussusception. Painful outlet constipation is the common denominator.

tomic demonstration of internal intussusception is of no greater importance in the absence of debilitating symptoms than anatomic demonstration of esophageal hiatal hernia. Symptomatic patients are educated about their problem using the analogy of a "falling stocking" or a model of a collapsible telescoping cup (Fig. 8). In addition to stool-bulking agents and a program of planned bowel evacuation, administration of topical hydrocortisone foam has been of great value in some patients (Fig. 9). In those who are only somewhat improved by these meastares, and in the most fragile patients, rubber band ligation may be performed either as staged outpatient office procedures, or as simultaneous multiple ligations under

light anesthesia (Fig. 5). Whereas multiple simultaneous ligations in patients with hemorrhoids often put increasing tension on the rectal mucosa as additional bands are applied, this problem occurs less frequently with the more lax anorectal lining in patients with intussusception. We have applied up to nine bands concurrently under anesthesia, inserting Allis forceps and ligator, using the finger as a guide rather than the anoscope for the last groups of bands. Postoperative pain following multiple simultaneous ligations, remarkably, is usually minimal, presumably secondary to pre-existing stretchtension on the pudendal nerves with chronic intussusception and descent. A preoperative and postoperative antibiotic was used in these patients. Perhaps our greatest deficiency in the management of outlet constipation is the failure to listen to patients whose complaints may be somewhat bizarre, and who themselves are frustrated by having found no relief despite consulting a number of physicians, often including internists, surgeons, gynecologists, gastroenterologists, psychiatrists, and even pain therapists. Many patients with these problems have spent hours of each day attending to bowel evacuation, and a common thread in some of the elderly patients after transrectal excision is that they achieve a level of physical activity that is far beyond their preoperative level. The son of one 75-year-old patient recently related that his mother was so relieved of her previous symptoms that he could no longer find her at home during the day! The major indication of internal intussusception is history of painful outlet symptoms with negative clinical evaluation and barium enema. Once the obvious mechanical causes of outlet constipation have been excluded by conventional contrast studies, and the "laundry list" of nonsurgical causes of constipation has been excluded, defecography is warranted in patients whose history and physical findings support a diagnosis of internal intussusception. Patients with nega-

824

Col.&Rect. November1985

Dis.

BERMAN, ET AL.

OUTLET CONSTIPATION DIAGNOSIS and MANAGEMENT

Positive History Positive Examination Positive Defecogram

I.

HighFiberDiet

FIG.9. Outline of therapeutic measures applied to patients with outlet constipation associated with documented intussusception.

Increase Liquid Intake Hydrocortisone Foam Warm Enemas Galvanic Stimulation?

f

Outlet Symptoms Relieved _

I

Constipation Relieved

[

I

Constipation Persists

I

Outlet Symp[omsPersist

I I Multiple Ligation Moderate I

Taper Hydrocortisone Suppo~ory PRN Follow At Intervals

I [ Transrectal Excision Severe

Resection/Suspension Motility Study

Relieved

Unrelieved

/~

I tive defecography or whose constipation does not appear to be outlet-related may be examined by motility studies after ingesting radiopaque markers. We have had no direct experience with manometrics in patients with outlet symptoms, a4,ts although it is difficult to conceive that the presence of partial prolapse would not confuse the interpretation of pressure readings. Efficient defecation assumes a balance between motility and absorption, channel efficiency (segmentation, spasticity, etc.), and the evacuation mechanism. The latter is probably most important with internal intussusception, which has been described as starting 6 to 8 cm above the anus, at or near the pelvic floor. 2 Some have suggested that failure of the puborectalis to relax during defecation may be an integral mechanism in the occurrence of internal intussusception. 9 The process is likely to be exaggerated or accentuated with aging, childbirth, chronic straining and other anorectal and pelvic difficulties (Fig. 7). Medical differential diagnoses include spastic colon, colitis, and irritable bowel, any of which could occur in association with symptoms of outlet obstruction and which the physician attempts to exclude as much as possible if the patient has been previously labeled with these diagnoses. One of our patients had been labeled "pain syndrome," and is distinctly pain-free following transrectal excision. Surgical diagnoses center especially

about hemorrhoids, fissures, and rectoceles, for which surgery may have previously been performed prior to a diagnosis of internal intussusception. The syndromes of "recurrent" hemorrhoids, rectal reservoir, proctalgia, solitary rectal ulcer, descending perineum, and levator syndrome also are diagnosed frequently in such patients. Physical findings may also be minimal in these entities despite notable symptoms, and relief may sometimes attend the same dietary and topical measures that may be effective in patients with documented internal intussusception. Other less commonly evoked differential diagnoses that have been applied to patients before a diagnosis of internal intussusception was made include coccygodynia, colitis cystica profunda, and mucin-producing lesions of the rectum. The benefit of documentation of internal intussusception by defecogTaphy in patients in whom it is suspected extends beyond the scientific method, pride in diagr. -~is and avoidance of missed diagnoses. Since suspect intussusception does not always exist, surgical misadventure and unpredictable results theoretically may be minimized. It is critical, however, that surgical therapy be guided by persistence of symptoms rather than by the anatomic abnormality alone. Many patients may have symptoms but may have little if any intussusception. Also, patients with significant internal intussusception on x-ray may

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have only limited symptoms. Surgical procedures are best reserved for patients whose symptoms of internal intussusception are documented by defecography, but who show a sustained unsatisfactory response to nonoperative measures. Where confusion exists despite clinical evaluation and defecography, tests of colonic transit, stool loading tests, electromyography, or manometrics may be considered.1, ~5In our patients, only motility studies have had significant testing in such instances of diagnostic confusion. The identification by cinedefecography of two major categories of internal intussusception--those with rectosacral separation and, more commonly, those without rectosacral separation, suggests that it may be inaccurate to assume that a slack, mobile rectum on a mesentery is requisite to internal intussusception,3 or that internal intussusception will necessarily progress to procidentia, in which a mobile rectum is inherently presenc u More likely, rectosacral separation, like a patulous sphincter, is an effect rather than a cause,2,s which ultimately allows full external prolapse in some patients with intema[intussusception. Hence, with the more limited abnormality in internal intussusception, it seems reasonable to apply an olberation of lesser physiologic impact if it will be of similar effectiveness. The perineal rectosigmoidectomy procedure t9 has merit and may have theoretical appeal over a transabdominal procedure, especially in the elderly and debilitated patient. However, in patients in whom no difficulty with fixation appears to exist, as was demonstrated in most of our patients, Delorme's transrectal excisions seems to provide a more reasonable approach, and may be used also in the elderly and debilitated patient. Reservoir capacity and rectal compliance are the factors most affected by the Delorme procedure, which converts the anorectal anatomy toward normal despite persistent perineal descent. Figure 6 illustrates the anatomic improvement that accompanied clinical relief after this procedure in one octogenarian with both abnormalities. As noted, similar excellent results attended almost all of the patients treated in this fashion. Sullivan's successful application of the procedure to patients with massive prolapse was followed by less than 15 percent late recurrence rate, suggesting that its application to patients with internal intussusception is likely to result in even greater and more lasting long-term success. Limited anesthetic requirement, postoperative pain, complications, and convalescence are additional positive features. Distal bowel evacuation depends upon the interaction between motility, reservoir capacity, and the muscular envelope of the pelvic floor. Delorme's transrectal excision has the beneficial effect of reducing reservoir capacity by removing the megarectum that is often present, and of enhancing the pelvic floor by vertical plication of the

825

muscular ring that surrounds the rectal mucosal tube) Since the rectum's wide-bottomed flask shape is made tubular by this operation, it is probably contraindicated in patients with diarrhea. However, preoperative diarrhea in patients in this group should occur only in the context of "overflow" incontinence associated with fecal impaction, unless there are other coexistent gastrointestinal problems. In actual fact, true impaction had occurred preoperatively in only a small number of patients in this series. Many others, despite lack of detectable impaction, felt as if they were impacted much of the time. The failure in this series of transabdominal mesh rectopexy, with or without sigmoid resection, to achieve more predictable relief of bowel function along with relief of pelvic pressure symptoms is consistent with variability of results of abdominal rectopexy for internal intussusception in other series. 4, to, ~3,14In our opinion, the procedure lacks merit for internal intussusception associated with constipation, unless motility is also improved. By contrast, in two of our patients with rectosacral separation and both proximal and distal intussusception, the Delorme procedure was performed with excellent results. However, the Delorme procedure has not yet been applied to patients lacking documented evidence of distal intussusception. The beneficial response to Delorme's transrectal excision in patients who have both intussusception and perineal descent without appreciable relief of descent and the beneficial response in such patients with preoperative suggestion of "solitary ulcer" suggest that these two entities may be stages in the evolution of or effects of internal rectal intussusception, t4' 17,20

Summary and Contusion Distal bowel evacuation was studied by cinedefecography in 85 women with obstinate constipation, tenesmus, and incomplete evacuation, in whom a diagnosis of internal rectal intussusception was indicated clinically. Sixty-five patients showed radiographic evidence of intussusception-mostly of the distal rectum, without rectosacral separation. Patients with distal intussusception who did not respond to nonoperative measures were treated by Delorme's transrectal excision with excellent results. Internal rectal intussusception is a real and demonstrable entity which may be symptomatically disabling, and whose documentation may be integral to effective and anatomically specific treatment. The syndromes of perineal descent, solitary rectal ulcer, levator syndrome, and recurrent hemorrhoids may be diagnostic intermediaries in the evolution of internal rectal intussusception. Acknowledgment The authorsacknowledgeElizabethWickfor her artwork.

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Dis. Col. & Rect. November198~

B E R M A N , E T AL.

References

1. Poisson J, Devroede G. Severe chronic constipation as a surgical problem. Surg Clin North Am 1983;63:193-217. 2. Broden B, Snellman B. Procidentia of the rectum studied with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum 1968;11:330-47. 3. Hoffman MJ, Koclner I J, Fry RD. Internal intussusception of the rectum. Dis Colon Rectum 1984;27:435-41. 4. Ihre T, Seligson U. Intussusception of the rectum--internal procidentia: treatment and results in 90 patients. Dis Colon Rectum 1975;18:391-6. 5. Uhlig BE, Sullivan ES. The modified Delorme operation: its place in surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979;22:513-21. 6. Ekberg O, Nylander G, Frans-Thomas F. Defecography. Radiology 1985;155:45-8. 7- Kuijpers IrtC, Strijk SP. Diagnosis of disturbances of continence and defecation. Dis Colon Rectum 1984;27:658-62. 8. Theuerkauf FJ Jr, Beahrs OH, Hill JR. Rectal prolapse: causation and surgical treatment. Ann Surg 1970;171:819-35. 9. White CM, Findlay JM, Price JJ. The occult rectal prolapse syndrome. Br J Surg 1980;67:528-30. 10. Gordon PH. Procidentia of the rectum. In: Principles of Colon and Rectal Surgery. Minneapolis: Univ Minn Press, 1982;156-166.

11. Ripstein CB. Procidentia of the rectum: internal intussusception of the rectum (stage 1 rectal prolapse). Dis Colon Rectum 1975; 18:458-60. 12. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia. Dis Colon Rectum 1985; 28:06-102. 13. Gordon PH, Hoexter B. Complications of the Ripstein procedure. Dis Colon Rectum 1978;21:277-80. 14. Keighley MR, Shouler P. Clinical and manometric features of the solitary rectal ulcer syndrome. Dis Colon Rectum 1984;27: 507-12. 15. Martelli H, Devroede G, Arhan P, Duguay C. Mechanisms of idiopathic constipation: outlet obstruction. Gastroenterology 1978;623-31.

16. Goligher J. Surgery of the anus, rectum and colon. 5th ed. London: Balliere Tindall, 1984:341-342. 17. Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. J R Soc Med 1966;59:477-82. 18. Spencer RJ. Manometric studies in rectal prolapse. Dis Colon Rectum 1984;27:523-5. 19. Gopal KA, Amshel AL, Shonberg 1L, Eftaiha M. Rectal procidentia in elderly and debilitated patients. Dis Colon Rectum 1984;27:376-81. 20. Langevin JM. The solitary rectal ulcer syndrome. In: Principles of colon and rectal surg. Minneapolis: Univ Minn Press, 1982:145-9.