One of the causes of chronic constipation in women is anterior rectal protrusion.
Rectocele (RC) is also known as anterior rectal distention. It is a condition that affects women. In adult women, especially after having children, the recto-vaginal septum becomes weak, and with increasing age and muscle atrophy, the rectal wall may protrude forward, i.e., in the direction of the vagina, forming an anterior rectal protrusion. As the arrow in the figure
shows.
Etiology
The anterior rectal wall is supported by the rectovaginal septum, which consists mainly of the intrapelvic fascia and contains the midline crossed fibrous tissue of the levator anus and the perineal body. If the rectovaginal septum is lax, the anterior rectal wall tends to bulge forward, similar to a herniated protrusion. It is often seen in women with chronic constipation that leads to long-term increase in intra-abdominal pressure, multiple mothers, those with poor defecation habits, and elderly women with perineal flaccidity.
In China, through routine examination, anorectal dynamics, pelvic floor electromyography, fecal imaging and anorectal rotation function in 45 patients with prolapse of the rectum, the following insights into the etiology and mechanism of prolapse of the rectum were made. During normal defecation, the abdominal pressure rises, the pelvic floor muscle relaxes, the rectal angle of the anal canal becomes blunt, the pelvic floor is funnel-shaped, the anal canal becomes the lowest point, and the feces is expelled under the pressure of defecation. Due to the influence of sacral flexure, the vertical division of the descending fecal mass becomes the defecation power, while the horizontal division acts on the anterior rectal wall to make forward protrusion. In men, the rectum is less likely to protrude anteriorly because of the firmness of the front, whereas in women, the horizontal component acts on the anterior wall of the rectum to make it protrude anteriorly because of the hollowness of the front. In men, the rectum is less likely to protrude anteriorly because of the firmness of the front, whereas in women, the horizontal force acts on the rectovaginal septum because of the hollowness of the front. The rectovaginal septum has a perineal fascia that passes through it, and there are fibers of the levator muscle that are intertwined in the midline, both of which can greatly strengthen the rectovaginal septum to resist the above horizontal force, so that the anterior rectal wall does not protrude too far forward during defecation and change the direction of fecal mass movement.
Childbirth, dysplasia, fascial degeneration and long-term increase in abdominal pressure can cause damage and relaxation of the pelvic floor. In particular, childbirth can cause tearing of the interwoven fibers in the anal raphe fissure and extreme stretching or tearing of the abdominal perineal fascia, thus damaging the strength of the rectovaginal septum and affecting its resistance to horizontal fractional forces of defecation and gradual protrusion forward. Most of the patients in this group had postpartum onset, suggesting that the occurrence of this disease is related to transvaginal birth; the disease occurs mostly in middle age, suggesting that it may be related to the degeneration of connective tissue.
After the anterior protrusion occurs, its top breaks through the pelvic diaphragm and becomes the lowest point during defecation, and its longitudinal axis is in the same direction as the downward movement of feces, so that the fecal masses going down the sacral curve enter the anterior protrusion first. Due to the change of the direction of the pressure of defecation and its partial dissipation, the pressure on the posterior rectal wall is reduced and the defecation receptors mainly located in this area are not sufficiently stimulated, so that the pelvic floor muscles cannot fully relax and open the upper opening of the anal canal and it is difficult to introduce feces into the anal canal. The perineal distension forces the patient to exert more pressure, forming a vicious circle that makes the anterior process deepen and the pelvic floor go down continuously. In patients with pelvic floor spasm syndrome, the pelvic floor muscles contract paradoxically during difficult defecation, providing active protection to the anterior rectal wall and pelvic floor, so that the pelvic floor descends less and the anterior rectal protrusion is shallower in this group. This suggests that there is a very close relationship between rectal protrusion and pelvic floor relaxation, and that damage to the pelvic floor is likely to be the initiating factor, and that the resulting rectal protrusion in turn aggravates the decline of the pelvic floor, and that the two can be causally related to each other.
When the pelvic floor descends, the pubic nerve, which innervates the pelvic floor muscles, is inevitably stretched. The end of this nerve is about 90 mm long and is stretched by no more than 12%. In this group of patients, the nerve is stretched by 19.4% during quiet time and by 31.3% during defecation. Read suggests that injury to the pubic nerve may result in decreased rectal sensory function, decreased rectal wall tone, and a blunted rectal contraction reflex. The literature confirms that the rectal attachments of the anal raphe and the puborectalis muscle have a large number of visceral nerve fibers distributed, so that the production of bowel movements and reflex contractions of the rectum may also be related to this. The abnormal decline of the pelvic floor inevitably caused damage to the above-mentioned visceral nerves. 54 patients had decreased anal canal systolic pressure, bowel sensory volume, rectal contraction wave and contraction rate, suggesting pelvic floor nerve damage. Nerve damage can aggravate pelvic floor dysfunction and further impair non-defecation function, forming a vicious circle of mutual causation.
The position of the injured pelvic floor nerves and muscles decreases abnormally, and the tissues and organs they support also decrease in relaxation, resulting in various pathologies. The findings suggest that the anterior rectal protrusion is almost always combined with other types of relaxation lesions, suggesting that the anterior rectal protrusion is part of a complex pathological process.
Proctus rectus is not an independent lesion, but may be a manifestation of pelvic floor laxity syndrome.
Clinical manifestations
Difficulty in defecation is the main symptom of rectal prolapse. When the abdominal pressure is increased by forceful evacuation, the fecal mass is rushed into the anterior protrusion under the action of pressure, and after stopping forceful evacuation, the fecal mass is squeezed back into the rectum, causing difficulty in evacuation. Because of the accumulation of fecal mass in the rectum, the patient feels the drop, defecation is not exhausted and strive to struggle, as a result, the abdominal pressure increases, so that the already relaxed rectovaginal diaphragm under greater pressure, thus deepening the protrusion, so forming a vicious circle, defecation difficulties are getting more and more serious, a few patients need to add pressure in the perianal and vaginal to help defecation, and even put their fingers into the rectum to dig out the fecal mass. Some patients have blood in the stool and pain in the anal canal.
Diagnosis
Based on the typical medical history, symptoms and signs described above, the diagnosis of proctal prolapse is not difficult. The current methods to diagnose this disease include: 1. rectal finger diagnosis Rectal finger diagnosis can palpate the weak and loose rectovaginal septum, protruding into the vagina, which is more obvious when forceful defecation. 2. fecal imaging can see the anterior rectal wall protruding forward, with difficulty in passing barium through the anal canal, and the morphology of the anterior protrusion is goose-headed or mound-like, with smooth edges. 3. colonic transport test Markers are gathered in the rectum and sigmoid colon area, commonly seen in patients with rectal protrusion Patients.
In medical anterior rectal protrusion defecography, it can be divided into three degrees: namely, mild, with a protrusion depth of 0.6-1.5 cm; moderate, 1.6-3 cm, and severe ≥3.1 cm.
In addition, Nichols et al. suggested classifying anterior rectal protrusion into low, intermediate and high. Low rectus prolapse is mostly caused by perineal tear during delivery; medium rectus prolapse is the most common and is mostly caused by birth trauma; high rectus prolapse is due to destruction or pathological laxity of the upper 1/3 of the vagina, the main ligament, and the uterosacral ligament, and is often associated with posterior vaginal hernia, vaginal ectropion, and uterine prolapse.
Treatment
Non-surgical treatment: It includes general treatment, correction of poor dietary habits and correction of poor bowel habits.
It is recommended to consume a high fiber diet and drink more water. Crude fiber can soften the stool, increase the stool volume and stimulate colon peristalsis. 3000 ml of water should be consumed daily, but it is important and inappropriate to drink more tea and coffee, both of which may affect bowel movement. After the above treatment due to diet and lifestyle habits caused by rectal prolapse constipation symptoms can often be quickly relieved.
Correction of bad defecation habits 1, often forceful stool will affect the normal defecation reflex. 2, sitting on the commode to read a book, read the newspaper is not conducive to the continuous defecation reflex. 3, for bad sitting commode, to squatting defecation is more beneficial. Because the squatting position when the rectal angle increases, more conducive to the passage of feces. 4, for those who are accustomed to long-term laxative defecation, should immediately stop using laxatives. Under the guidance of a doctor to resume normal bowel habits.
In addition, some foreigners have performed botulinum toxin A injection therapy for patients with rectal protrusion with satisfactory results, and no complications occurred after follow-up.
Surgical treatment
1. Transrectal repair method
1.SULIVAN method In the mucosal part of the anterior rectal protrusion, a 2-0 intestinal thread is used to perform a “cigarette roll” (one side of the mucosa into the muscle layer, and then from the other side of the mucosa out of the needle) interrupted by 4-6 stitches to strengthen the longitudinal folding of the rectal muscle layer and eliminate the weak area of the vaginal rectal septum.
2.Block method According to the size of the anterior process, the rectal mucosal layer is clamped longitudinally with curved vascular forceps, and then the mucosal muscle layer is sutured continuously from bottom to top with 2/0 chromium intestinal thread until the pubic symphysis. The suture should be wide and narrow at the bottom to avoid the formation of a mucosal flap at the upper end to affect fecal evacuation.
3.PPH method After introducing the anal canal dilator and removing the internal pessary, submucosal sutures are performed under the anoscopic sutures at 3-5 cm above the dentate line according to the degree of rectal protrusion. The hemorrhoidal anastomosis is rotated open to its maximum extent. The anastomosis is introduced and the staple head is deepened to the upper end of the periosteal line, and the periosteal suture is tightened and knotted. The end of the suture is pulled out of the lateral hole of the anastomosis with a slinger. The suture is pulled moderately and the anastomosis is tightened. With vaginal palpation, the vaginal wall is confirmed to be intact and then firing is performed. After firing, the anastomosis is held in a closed position for 30 seconds to aid in hemostasis, and the anastomosis is unscrewed and removed from the anal canal. The anastomosis is inspected through the anoscopic suture ligature and if there is bleeding, an “8” suture across the anastomosis is possible.
4.Trans-perineal surgical repair A 4-5 cm long curved incision is made between the anus and the vagina, and the incision is made layer by layer, separated upward to 2-2.5 cm above the level of the dentate line.
5.Transvaginal repair Purse-sealing suture A long diamond-shaped incision is made from the lower middle of the posterior vaginal wall, the mucosa is separated bluntly until the cystic neck opening is fully and completely exposed, the mucosal flap is excised and the oval wound is exposed, a purse-sealing suture is made along the muscular tissue under the vaginal mucosal flap with 0-gauge intestinal thread, and then longitudinal interrupted suture is reinforced to close the wound.
6.Triangular incision repair A 3- to 4-cm-long transverse incision is made at the skin margin of the external vaginal opening, and the posterior wall is isosceles triangular on both sides, with a 4- to 5-cm-long longitudinal incision, bluntly separating the posterior vaginal wall to form a narrow upper and wide bottom trauma, followed by interrupted sutures with a No. 0 intestinal suture for the general incision and interrupted sutures for the upper and lower bottom side incisions to disappear the weak zone of the anterior rectal protrusion into the vagina.
In conclusion, anterior rectal protrusion is considered to be an important cause of defecation difficulties in women. Currently, surgery is the main treatment for anterior rectal protrusion, but the results are not very satisfactory. Under the premise of strict adherence to surgical indications, it is crucial to choose the appropriate surgical procedure among the many procedures according to the mild, moderate and severe degree of their protrusion.