SHORT C O M M U N I C A T I O N S Rectoanal Pressures and Rectal Compliance in C h i l d r e n with Rectal Prolapse Hiroshi Suzuki, Shin-ichi AMANO, Makoto HONZUMIand Keiji IRIVAMA
A B S T R A C T : T h e results of anorectal m a n o m e t r y in 11 children with complete rectal prolapse were evaluated. Abnormalities of sphincter control or bowel movements occurred in 8 out of these 11 patients. Anal canal pressure of the patients was lower than in the controls, but there was no significant difference of resting pressure profiles of the anorectum between the patients and the controls, Rectoanal reflex was present in all the patients and in the controls. Rectal compliance was significantly lower in the patients, but there was no correlation between rectal compliance and sphincter control of the patients. KEY W O R D S :
rectalprolapse, anorectal m a n o m e t r y
The commonly held view that almost all rectal prolapses in children are of a self-limiting mucosal variety is not correct.1 Complete rectal prolapse is also seen in pediatric age groups and certain numbers of patients have abnormalities of spincter control or bowel movements. We report herein the results of anorectal m a n o m e t r y in 11 children with complete rectal prolapse. There were 7 boys and 4 girls. Their ages at the time of the examination ranged form 10 months to 11 years and 8 months. Five out of these 11 children were under 5 years of age. T h r e e patients had rectal prolapse alone, 6 h a d rectal prolapse and constipation, 2 had rectal prolapse, mental retardation, and anal incontinence. Forty-five age-matched controls, of which 26 were boys and 19 were girls, underwent the same examination. The Second Department of Surgery, Mie University School of Medicine, Tsu, Japan Reprint requests to: Hiroshi Suzuki, MD, The Second Department of Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu 514, Japan
Resting pressure profiles of the anorectum (rectal pressure, anal canal pressure, length of the anal canal, and basal rhythmic contraction of the anal canal), rectoanal reflex, and rectal compliance were measured by methods described elsewhere.~,s Resting pressure profiles of the anorectum and rectoanal reflex were examined i n all the patients and the controls, but rectal compliance could not be measured in 2 patients. T h e results were expressed as m e a n + SEM. The statistical significance of the difference was determined by Stutent's t-test, and Pvalues less than 0.05 were considered to be statistically significant. Resting pressure profiles of the anorectum of each patient together w i t h normal values are shown in Fig. 1. Resting pressure profiles of the anorectum of the patients and the controls were also expressed by m e a n __. SEM and are shown in T a b l e 1. Anal canal pressure was lower in the patients with rectal prolapse than in the controls, but there was no statistically significant difference. Rectal pressure, length of the anal canal, and basal rhythmic contraction of the anal canal of the patients did
JAPANESEJOURNALOF SURGERY,VOL. 15, No. 3 pp. 234-237, 1985
Volume 15 Number 3
Rectal prolapse i93.o
Pr
cmH20
HPZ
crn
cmH20
235
3.0 O 100
8 75[ %o9
O9
10
ml/cmH20
25
125 i5
2.5
2.0
RC
BRC
cycle/min
Fff to'.
12.5
O 20
10.0
15
7.5
1.5 50
s
OA
10
&
5,0
1.0 25
O0 ~0
A
2.5
0.5
0
Fig. 1. Resting pressure profiles of the anorectum and rectal compliance of patients with rectal prolapse. Normal range of each parameter is also shown. Pr, rectal pressure; Pac, anal canal pressure; HPZ, length of anal canal; B R C , basal rhythmic contraction; RC, rectal compliance; 9 prolapse only; O, prolapse with constipation; and A, prolapse with incontinence.
Table 1. Controls Patients
Resting Pressure Profiles of the Anorectum and Rectal Compliance
Pr cmHeO 6.5_+2.6 7.3-+3.9
Pac cmH20 81.7-+41.2 68.5+20.9
HPZ cm 2.4-+0.5 2.5+0.6
BRC /min 15.0+3.6 15.8-+3.7
RC m l / c m H 2 0 7.8-+3.3 4.5-+3.3
NS NS NS NS P•0.02 Pr, rectal pressure; Pac, anal canal pressure; HPZ, length of anal canal; BRC, basal rhythmic contraction of anal canal; RC, rectal compliance; and NS, not significant
not differ from those of the controls. There was no correlation between the resting pressure profiles of the anorectum and sphincter control of the patients but in one with mental retardation and anal incontinence. Noguchi and Yano 4 reported that overcontraction following transient relaxation of the anal canal was characteristic of patients with rectal prolapse, but we found no such p h e n o m e n o n in any of the patients in our series. Rectal compliance of the patients was lower in 7 out of 9 patients. Rectal compliance expressed as m e a n + SEM was significantly lower in the pa-
tients than in the control (P<0.02). However, there was no correlation between rectal compliance and sphincter control of the patients. Complete rectal prolapse is a rather rare condition in young children and pathophysiology of spincter control and bowel m o v e m e n t s of the patients with this disease is not well understood. There have been only a few documentations of rectoanal pressures in cases of complete rectal prolapse. Noguchi and Yano 4 studied rectoanal pressures of 7 children With rectal prolapse and found that there was no significant difference in the resting pressure
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Suzuki et al.
profiles of the a n o r e c t u m between the p a tients a n d 7 a g e - m a t c h e d controls. Keighley et al. 5 c a r r i e d out a n o r e c t a l m a n o m e t r y in 45 a d u l t patients with rectal prolapse. Twentyseven out of these 45 h a d rectal p r o l a p s e alone, the r e m a i n i n g 18 h a d rectal p r o l a p s e a n d anal incontinence. In their study, a n a l c a n a l pressures (basal a n d squeeze pressures) of the patients with rectal p r o l a p s e alone d i d n o t differ from the pressures in age- a n d sexm a t c h e d controls, b u t anal pressures of the patients with rectal p r o l a p s e a n d a n a l incontinence were significantly lower t h a n in the controls. O b e i d et al.6 studied anal pressures of 20 a d u l t patients with rectal prolapse a n d f o u n d t h a t there were no significant differences of resting tone of t h e internal a n a l sphincter between the patients a n d the controls, b u t t h a t f u n c t i o n a l p o w e r of the extern a l anal sphincter was lower in the patients. T e n out of these 20 patients h a d a b n o r m a l i ties in sphincter control or bowel movements. In the present study, 8 out o f 11 c h i l d r e n with c o m p l e t e rectal prolapse h a d a b n o r m a l s p h i n c t e r control or constipation, b u t there were no significant differences of resting pressure profiles of the a n o r e c t u m between the patients a n d the controls. O u r results a g r e e d with the findings of m a n o m e t r i c studes d o n e by Noguehi a n d Yano 4 in t h a t most c h i l d r e n with rectal p r o l a p s e h a d a n o r m a l resting pressure profile of the a n o r e c t u m . Lower sphincter tone f o u n d in almost all the a d u l t patients with rectal p r o l a p s e a n d i n a d e q u a t e s p h i n c t e r control is considered to r e p r e s e n t the origin of the disease a n d d a m a g e of sphincter muscles d u e to a l o n g s t a n d i n g disease.7 T h e r e have b e e n few reports on rectoa n a l reflex in c h i l d r e n with rectal prolapse. N o g u c h i a n d Yano 4 r e p o r t e d t h a t r e c t o a n a l reflex was present in all p e d i a t r i c p a t i e n t s with rectal prolapse. This in in a c c o r d a n c e with o u r findings. N o g u c h i a n d Yano 4 also p o i n t e d out t h a t overcontraction after rectoa n a l reflex, a r e b o u n d c o n t r a c t i o n o f the a n a l c a n a l after its transient relaxation, was characteristic of the patients with rectal p r o l a p s e a n d considered t h a t it was an expression of
u n c o o r d i n a t e d motility between the external a n d the i n t e r n a l anal sphincters. In the present study, however, we f o u n d no such overcontraction of the anal canal, in any patient. T h e present study disclosed that rectal c o m p l i a n c e o f c h i l d r e n with c o m p l e t e rectal prolapse was significantly lower t h a n t h a t of the controls. In previous studies, we f o u n d t h a t there was a close c o r r e l a t i o n between rectal c o m p l i a n c e a n d i n a d e q u a t e control of bowel m o v e m e n t s of patients who h a d u n d e r gone sphincter saving resection for rectal cancer,~ or of the patients with i d i o p a t h i c chronic constipation.~ In the present study, however, we f o u n d no c o r r e l a t i o n between rectal c o m p l i a n c e a n d s p h i n c t e r control or bowel movements of c h i l d r e n with complete rectal prolapse. T h e results of the present study m a d e it clear that most children with c o m p l e t e rectal prolapse have a n o r m a l sphincter tone ( n o r m a l resting pressure profiles of the a n o r e c t u m ) , n o r m a l motility of the sphincter ( n o r m a l r e c t o a n a l reflex), a n d decreased reservoir function of the r e c t u m (lower rectal compliance). F u r t h e r investigations on changes in sphincter control, bowel movements, a n d findings of a n o r e c t a l m a n o metry, before a n d after the t r e a t m e n t , are necessary for a b e t t e r u n d e r s t a n d i n g of the pathophysiology of rectal prolapse. (Received p u b l i c a t i o n on Aug. 26, 1984) References 1. Ki.ipfer CA, Goligher JC. One hundred consecutive cases of complete prolapse of the rectum treated by operation. BrJ Surg 1970; 57:481 487. 2. Suzuki H, Matsumoto K, Amano S, Fujioka K, Honzumi M. Anorectal pressure and rectal compliance after low anterior resection. Br J Surg 1980; 67: 655-657. 3. SuzukiH, Amano S, Honzumi M, Saijo H, Sakakura K. Rectoanal pressures and rectal compliance in constipated infants and children. Z Kinderchir 1980; 29: 330-336, 4. Noguchi T, Yano H. Investigation of rectal prolapse in childhood--In view of anorectal manometric study before and after treatment. Nihon DaichoKomon-Byo Gakkai Zasshi (J Jpn Soc Colo-Proctol)
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1982; 35:463-470 (in Japanese). 5. Keighley MRB, Makuria T, Alexander-Williams J, Arabi Y. Clinical and manometric evaluation of rectal prolapse and incontinence. Br J Surg 1980; 67:54 56. 6. Obeid SAF, Zidan H, Hassab MA. Anal sphincteric
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pressure studies in complete rectal prolapse. Dis Colon and Rectum 1979; 22:342 345. Parks AG, Swach M, Urich H. Sphincter denervation in anorectal incontinence and rectal prolapse. Gut 1977; 18: 656-665.