Annals of Coloproctology

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Original Articles

Anorectal physiology & pelvic floor disorder

Laparoscopic ventral mesh rectopexy with and without transverse perineal support using biological mesh for rectal prolapse and perineal descent: postoperative course and functional outcomes: Maria Clelia Gervasi, Giorgio Brancato, Lorenzo Crepaz, Ahmad Tfaily, Alberto Di Leo; Ann Coloproctol. 2025;41(5):453-461. Published online October 28, 2025; DOI: https://doi.org/10.3393/ac.2025.00080.0011

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Abstract PDF Supplementary Material: Purpose
Laparoscopic ventral mesh rectopexy (LVMR) is effective for the treatment of rectal prolapse. However, descending perineal syndrome may impair the outcomes of LVMR. The aim of this study was to assess the safety and functional outcomes of LVMR performed with and without transverse perineal support (TPS).
Methods
This was a retrospective study of 143 consecutive female patients treated with LVMR with or without TPS between 2018 and 2022. Patients with rectal prolapse and perineal descent who underwent surgery were included. Obstructed defecation syndrome and fecal incontinence were evaluated using the Cleveland Constipation Score (Wexner score) and St. Mark’s Incontinence Score, respectively. Perineal descent was defined using defecography. Biological meshes were utilized in all cases.
Results
No significant differences were recorded between with- and without-TPS groups at baseline. TPS was performed in 110 patients (76.9%). Surgical morbidity was higher in the with-TPS group (12.7% vs. 0%, P=0.047), primarily due to seroma formation. Almost all complications were mild (Clavien-Dindo grades I–II). In both groups, digital aid for defecation (P<0.001), prolonged straining (P=0.004), and hematochezia (P<0.001) nearly disappeared postoperatively, though constipation and laxative/enema use persisted in 22.4%. Fecal incontinence significantly decreased from 43.4% to 11.2% (P<0.001). TPS appears to have a potentially favorable effect in reducing the constipation score. Both constipation and incontinence scores remained low up to 24 months after surgery. Operative time was significantly longer in the LVMR with-TPS group (P<0.001).
Conclusion
LVMR with TPS appears safe and feasible. TPS may provide better surgical outcomes compared to LVMR alone for patients with symptomatic rectoceles and descending perineum syndrome.

Anorectal physiology & pelvic floor disorder

Transverse perineal support improves long-term outcomes in patients undergoing stapled transanal rectal resection for obstructed defecation syndrome: a multicenter observational case-control study: Adolfo Renzi, Luigi Marano, Pasquale Talento, Luigi Brusciano, Angela Pezzolla, Domenico Izzo, Carmine Antropoli, Francesco D’Aniello, Giandomenico Di Sarno, Gianluca Minieri, Grazia Cantore, Gianmattia Terracciano, Domenico Barbato, Ludovico Docimo, Massimo Antropoli, Alessio Palumbo, Michele Lanza, Emanuele Mario Caputi, Antonio Brillantino; Ann Coloproctol. 2025;41(4):330-337. Published online August 25, 2025; DOI: https://doi.org/10.3393/ac.2025.00073.0010

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1 Web of Science
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Abstract PDF

Purpose
To evaluate the safety and long-term efficacy of stapled transanal rectal resection (STARR) combined with the transverse perineal support (TPS) procedure in the surgical treatment of obstructed defecation syndrome (ODS) associated with internal rectal prolapse and excessive perineal descent (PD).
Methods
This multicenter observational case-control study involved 7 European centers. During the initial study period, patients underwent STARR alone (group 1), while in the subsequent period, patients received STARR combined with TPS (group 2). All patients were followed clinically at 6, 12, 36, and 60 months, and were offered radiological evaluation between 3 and 5 years postoperatively.
Results
The median postoperative ODS score was similar between groups at 6 months (6 [range, 2–15] vs. 5 [range, 2–13]; P=0.16, Mann-Whitney U-test), but at 36 months, it was significantly lower in group 2 compared to group 1 (11 [range, 5–16] vs. 5 [range, 2–15]; P<0.001, Mann-Whitney U-test), with stable results maintained through 5 years. The success rate followed a similar trend. Postoperative maximum PD during straining remained unchanged in group 1, whereas it significantly decreased compared to preoperative values in group 2.
Conclusion
The addition of TPS to STARR in the surgical treatment of ODS associated with internal rectal prolapse and excessive PD appears to significantly improve long-term success rates and correct descending perineum.

Citations

Citations to this article as recorded by

Laparoscopic Resection Rectopexy with Transanal Specimen Extraction for Complete Rectal Prolapse: Retrospective Cohort Study of Functional Outcomes
Mustafa Ates, Sami Akbulut, Emrah Sahin, Kemal Baris Sarici, Ertugrul Karabulut, Mukadder Sanli
Journal of Clinical Medicine.2026; 15(2): 718. CrossRef

Case Reports

Benign bowel disease

A case report of a giant solitary juvenile polyp: from obstructed defecation syndrome to incontinence: Zhan Huai Teoh, Jien Yen Soh, Nasibah Mohamad, Norzaliana Zawawi, Andee Dzulkarnaen Zakaria, Zaidi Zakaria, Michael Pak-Kai Wong; Ann Coloproctol. 2024;40(Suppl 1):S27-S31. Published online November 25, 2022; DOI: https://doi.org/10.3393/ac.2022.00549.0078

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Abstract PDF: Juvenile polyps (JPs) are the most common polyps in pediatric patients. We present the case of an 18-year-old male patient with a giant solitary JP resembling solitary rectal ulcer syndrome (SRUS). The presenting history was rectal bleeding and symptoms of obstructed defecation syndrome. Colonoscopy revealed a polypoidal mass at the anorectal junction, with biopsy-confirmed SRUS. The symptoms worsened, and a protruding mass from the anus caused fecal incontinence. Pelvic magnetic resonance imaging showed a huge pedunculated mass occupying the low rectum with local compression of the urinary bladder. Transanal excision of the anal tumor was performed due to bleeding. A histopathological examination showed a JP with high-grade dysplasia. A histological examination to differentiate JPs and SRUS could be challenging based on a superficial forceps biopsy. Therefore, an excision biopsy is usually warranted with the understanding that adenomatous or malignant transformation is found in 5.6% to 12% of all JPs.

Side-to-Side Ileosigmoidostomy Shunting Surgery for the Treatment of Elderly Patients With Chronic Constipation: Yuda Handaya, Agung Maryanto, Marijata; Ann Coloproctol. 2017;33(6):249-252. Published online December 31, 2017; DOI: https://doi.org/10.3393/ac.2017.33.6.249

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Abstract PDF: Constipation is a digestive disorder that often occurs in the elderly; its main cause is bowel motility disorder. Treatments for patients with chronic constipation include pharmacotherapy, diet changes, and surgery if other therapies do not offer satisfactory results. We describe 4 patients, 2 men (70 and 65 years old) and 2 women (75 and 66 years old), who were diagnosed with chronic constipation (slow transit constipation) and treated with conventional therapy, but did not improve. For that reason, side-to-side ileosigmoidostomy shunting surgery was performed. After the surgery, the average time until normal defecation was 16 days, and the defecation frequency was 3 to 4 times a day with no need for a laxative. No patient had a recurrence of constipation. Based on these results, side-to-side ileosigmoidostomy shunting surgery is expected to restore digestive function and can be considered as an alternative therapy for elderly patients with chronic constipation.

Original Article

Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus: Umberto Pisano, Lesley Irvine, Justina Szczachor, Ahsin Jawad, Andrew MacLeod, Michael Lim; Ann Coloproctol. 2016;32(5):170-174. Published online October 31, 2016; DOI: https://doi.org/10.3393/ac.2016.32.5.170

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4 Web of Science
9 Citations

Abstract PDF

Purpose

Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus.

Methods

Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of <0.05 was significant.

Results

Forty-three patients (42 female patients) underwent anorectal physiology and radiology imaging. The median age was 54 years (interquartile range, 41.5–60 years). Anismus was seen radiologically and physiologically in 18 (41.8%) and 12 patients (27.9%), respectively. The agreement between modalities was 0.298 (P = 0.04). Using physiology as a reference, radiology had positive and negative predictive values of 44% and 84%, respectively. Rectoceles, cystoceles, enteroceles and pathological pelvic floor descent were not physiologically predictive of animus (P > 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08).

Conclusion

Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.

Citations

Citations to this article as recorded by

Magnetic resonance imaging assessment of the puborectalis muscle and anal sphincter in patients with anismus
Ayşenur Buz Yaşar, Abdullah Emre Sarıoğlu, Soner Türkoğlu
Northwestern Medical Journal.2025; 5(3): 135. CrossRef
Improvement in functional and mental outcomes after resection rectopexy for obstructive defecation syndrome ODS
Claudia Rudroff, Joshy Madukkakuzhy, Jakob Otten, Julia Schroer, Dana Richards, Sebastian Ludwig, Michaela Henning
Scientific Reports.2025;[Epub] CrossRef
Can Puborectalis Muscle and Abdominal Subcutaneous Adipose Tissue Thickness Indicate Dyssynergic Defecation?
Eren Çamur, Dilek Acar
New Trends in Medicine Sciences.2024; 5(3): 168. CrossRef
MR Defecography Findings Suggesting Anismus: Reliable or not Reliable?
Diğdem Kuru Öz, Nuray Haliloğlu, Ayşe Erden
Journal of Ankara University Faculty of Medicine.2023; 75(4): 515. CrossRef
Anismus Through Surgical Eyes
Lester Gottesman
Diseases of the Colon & Rectum.2022; 65(2): 137. CrossRef
Comparison of Anismus and Perineal Descent on Static Images of Magnetic Resonance Defecography: Can We Rule Out Anismus in Patients Who Can not Defecate?
Nuray Haliloğlu, Mustafa Fatih Arslan, Ayşe Erden
Turkish Journal of Colorectal Disease.2022; 32(1): 54. CrossRef
Magnetic resonance defecography findings of dyssynergic defecation
Nuray Haliloglu, Ayse Erden
Polish Journal of Radiology.2022; 87: 181. CrossRef
MRI DEFECOGRAPHY IN PELVIC FLOOR DESCENT SYNDROME (review)
E. P. Goncharova, I. V. Zarodnyuk
Koloproktologia.2020; 19(1): 117. CrossRef
Current Situation on the Diagnosis of Anismus-Discordances Between Imaging and a Physiologic Study
Kyung Ha Lee, Ji Yeon Kim
Annals of Coloproctology.2016; 32(5): 159. CrossRef

Case Report

A Case of Primary Ovarian Lymphoma Presenting as a Rectal Submucosal Tumor: Il Soon Jung, Seul Young Kim, Kyu Seup Kim, Kwang Hun Ko, Jae Kyu Sung, Hyun Young Jeong, Ji Yeoun Kim, Hee Seok Moon; J Korean Soc Coloproctol. 2012;28(2):111-115. Published online April 30, 2012; DOI: https://doi.org/10.3393/jksc.2012.28.2.111

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2 Citations

Abstract PDF

Primary ovarian lymphoma is a rare malignancy whose symptoms or signs are usually nonspecific. In this article, we report a very rare case initially presenting as a rectal submucosal-tumor-like lesion with a defecation disturbance caused by primary ovarian lymphoma with bilateral involvement. A 42-year-old woman visited chungnam national university hospital complaining of persistent defecation disturbance for 6 months. Colonoscopy demonstrated compression of the rectum by an extrinsic mass mimicking a rectal submucosal tumor. Magnetic resonance imaging detected bilateral ovarian tumors, 9.3 cm and 5.4 cm each in diameter, compressing the rectum without enlarged lymph nodes. The diagnosis was established following a bilateral adnexectomy and histological studies of the excised tissue. The tumor was classified as a diffuse large B-cell lymphoma. The patient was prescribed six cycles of standard CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, prednisolone) regimen and is presently on treatment.

Citations

Citations to this article as recorded by

Preoperative diagnosis of primary ovarian lymphoma: a case report and a decade of insights
Wei Liu, Houyun Xu, Jibo Hu, Xiping Yu, Junjie Zhou, Hongjie Hu
Frontiers in Oncology.2024;[Epub] CrossRef
Rectal follicular lymphoma
F. Castro-Poças, T. Araújo, A. Duarte, C. Lopes, M. Mascarenhas-Saraiva
International Journal of Colorectal Disease.2016; 31(2): 479. CrossRef

Original Article

Diagnosis of Non-relaxing Puborectalis Syndrome by using the Manometric Defecation Index.: Kim, Tae Won , Seong, Moo Kyung , Yoo, Young Bum; J Korean Soc Coloproctol. 2007;23(6):410-415.; DOI: https://doi.org/10.3393/jksc.2007.23.6.410

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Abstract PDF: PURPOSE
Currently, various tools are used for the diagnosis of nonrelaxing puborectalis syndrome (NRPRS), one of major causes of chronic constipation. Defecography, electromyography (EMG), balloon expulsion test, and a colon transit time study one examples of such tools, but none can be said to be the most accurate and effective one. A diagnosis is only made when two or more examinations show positive findings simultaneously. The aim of this study is to assess the correlation between EMG and the manometric defecation index (DI), which is a relatively new parameter, for the diagnosis of NRPRS.
METHODS
Forty-two chronically cornstipated patients without any history of anal or abdominal surgery underwent both anorectal manometric and EMG tests. The manometric defecation index (DI) was defined as the ratio between the peak rectal pressure and the peak anal pressure when the pressures were measured simultaneously during push by the catheter with longitudinally arranged side holes. The ratio of EMG activity was defined as the ratio between the peak amplitude during push and the peak amplitude during rest when EMG activities were measured by using an anal plug electrode. The two variables were compared prospectively, and their correlation was analyzed.
RESULTS
The manometric DI and the ratio of EMG activit in 42 patients were 0.80+/-0.75 and 1.50+/-0.65, respectively. The correlation coefficient between the two variables was -0.50 (P= 0.001).
CONCLUSIONS
The manometric DI and the ratio of EMG activit were correlated significantly. Therefore, it can be said that the anorectal manometric test can replace the EMG test for diagnosis of NRPRS, which has less convenient access for most colorectal surgeons.

Review

Evaluation and Treatment of Pelvic Floor Disorders.: Lee, Sang Jeon; J Korean Soc Coloproctol. 2007;23(3):206-220.; DOI: https://doi.org/10.3393/jksc.2007.23.3.206

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Abstract PDF: Pelvic floor disorders are of interest to many surgeons who specialize in organ systems within this region. Colorectal surgeons are especially interested in disorders of the posterior compartment, which may broadly be divided into defecation disorders and fecal incontinence. These disorders distress patients socially and psychologically and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, are often incompletely understood, and cannot always be determined. However, over the past decades, advances in the understanding of these disorders, together with rational methods of evaluation in anorectal physiology laboratories, radiology studies, and new surgical techniques, have led to promising results. This review summarizes the evaluation and treatment strategies, as well as the recent updates on the clinical and the therapeutic aspects of pelvic floor disorders.

Original Articles

Early Experience with a Stapled TransAnal Rectal Resection for Obstructed Defecation Syndrome.: Shin, Jong Keun , Kwak, Chang Shin , Park, Jung Soo , Choi, Sung Il , Lee, Jae Bum , Park, Hyun Joo , Lee, So Jin , Lee, Doo Han , Kim, Do Sun; J Korean Soc Coloproctol. 2007;23(1):1-9.; DOI: https://doi.org/10.3393/jksc.2007.23.1.1

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Abstract PDF: PURPOSE
This study was designed to assess the early outcome of a stapled transanal rectal resection (STARR) in obstructed defecation syndrome (ODS) patients with rectocele and rectal intussusception.
METHODS
From January to December in 2005, 41 patients with the symptoms of obstructed defecation and the findings of rectocele and rectal intussusception in defecography, who failed in conservative management, were enrolled in this study. All patients underwent the STARR procedure. Preoperatively all patients received colonoscopy, a colon transit time test, cinedefecography, etc. The constipation score was evaluated by using the Cleveland Clinic Florida (CCF) constipation score preoperatively and at 1 month and 3 months after operation.
RESULTS
The mean age of the patients was 55.3 (19~76) years. There were three males and thirty-eight females. The mean operation time was 39.3 (25~80) minutes, and the mean hospital stay was 4.2 (4~6) days. Complications were fecal urgency in 9 cases (21.9%), which improved after 3 months, bleeding in 5 cases (12.2%), and anastomotic stenosis in 1 case (2.4%). At postoperative defecography, both intussusception and rectocele had disappeared in most patients. All constipation symptoms were significantly improved (P < 0.01). The mean CCF constipation score was 17.6 (11~24) preoperatively, and improved to 9.1 after 1 month and 8.2 after 3 months (P < 0.01). The overall patient satisfaction was graded as excellent, good, fairly good and poor in 19 cases (46.3%), 13 cases (31.7%), 4 cases (9.7%), and 5 cases (12.2%), respectively.
CONCLUSION
The STARR procedure seems to be a safe and effective procedure in ODS patients with rectocele and rectal intussusception. However, further study of the long-term results is required.

Difference between Genders in Patients with Obstructive Defecation: Analysis of 1,513 Defecograms.: Park, Duk Hoon , Yoon, Seo Gue , Yoon, Jong Seop , Lee, Jong Ho , Rhoe, Hee Jung , Moon, Min Joo , Kim, Hyun Shig , Lee, Jong Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2002;18(2):73-82.

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Abstract PDF: PURPOSE
The aims of this study were to find the difference in frequency between genders and to determine the correlation between age-related disease and other diseases in obstructive defecation.
METHODS
A consecutive series of 1,513 patients (343 males, 1,170 females) with obstructive defecation who undertook defecography and/or cinedefecography during 1 year period was analyzed.
RESULTS
The causes of obstructive defecation in males showed as spastic pelvic floor syndrome (SPFS) (48.3%), rectal prolapse (RP) (31.4%), descending perineum syndrome (DPS) (25.9%), enterocele or sigmoidocele (7.6%), and rectocele (7%). However, in females, the causes were rectocele (83.8%), DPS (49.2%), RP (37.6%), SPFS (32.5 %), and enterocele or sigmoidocele (11.2%). The SPFS was negatively correlated with enterocele or sigmoidocele, DPS, RP in both genders, but SPFS had no statistical correlation with rectocele. DPS was correlated with RP in both genders and with enterocele or sigmoidocele in females, but no statistical correlation was seen in males. The size of the rectocele showed a slight correlation with age in females (r=0.102, P=0.01). Age was correlated with rectal prolapse in females; however, it showed a negative correlation with SPFS in females.
CONCLUSIONS
The frequency of diseases causing obstructive defecation is different between genders. Age may not play a role in aggrevating the diseases causing obstructive defecation. Further pathophysiologic study of gender differences in patients with obstructive defecation is needed.

Clinical Significance of Amplitude in Pudendal Nerve Conduction Study in Patients with Defecation Disorders.: Joo, Jae Sik , Kim, Jae Do; J Korean Soc Coloproctol. 1998;14(2):241-246.

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Abstract PDF: Many different kinds of anorectal physiologic studies were performed for the evaluation of defecation disorders. Some of these studies are anorectal manometry and pudendal nerve conduction study. In pudendal nerve conduction study, pudendal nerve terminal motor latency (PNTML) was considered to be very useful for the evaluation and management of these patients. However, evaluation of amplitude in pudendal nerve conduction study has been clinically seldom used. Therefore, the aim of this study was to evaluate the clinical significane of amplitude in pudendal nerve conduction study in patients with defecation disorders by comparing to manometric profiles. MATERIAL AND METHODS: Between February, 1997 and February, 1998 all patients who underwent pudendal nerve conduction study and anorectal manometry for the evaluation of defecation disorders (constipation and fecalincontinence) were analyzed. Latency as well as amplitude in pudendal nerve conduction study were compared in both groups to the pressure profiles in manometric study according to the subgroups of these patients. Statistical analysis were performed by a Chi-square or Student's t-test and significance was assumed when p<0.05.
RESULTS
A total of 80 patients, forty constipation with a mean age of 55.3+/-14.5 (GI: range; 24~86) years and forty fecal incontinence with a mean age of 61.1+/-10.3 (GII: range; 37~74) years and a male to female ratio of 25:15 (GI), 28:12 (GII), were studied. PNTML in both sides in GI were significantly decreased in comparision to those of GII (GI: Rt, 2.17+/-0.7 ms Lt, 2.03+/-0.5 ms, GII: Rt, 2.50+/-0.7 ms, Lt 2.64+/-0.8 ms, p<0.05), However, there were no differences between the two groups in terms of amplitudes (GI: Rt 399.0+/-348 uV, Lt 426.8+/-403 uV, GII: Rt, 406.9+/-273 uV Lt, 392.9+/-291 uV, NS) in pudendal nerve conduction study. In manometric findings, even though maximal resting, mean, minimum and maximal pushing pressures were no differences in both groups, mean resting and maximal squeezing pressure were significantly increased in GI than those of GII (GI: 82.4+/-31 cmH20, GII: 60.5+/-25 cmH20 in mean resting pressure, GI: 213.1+/-108 cmH20, GII: 178.7+/-66 cmH20 in maximal squeezing pressure, p<0.05) When we analyzed the overall values of amplitudes according to the diagnosis, age, gender, and the value of PNTML, there were no statistically significant differences between the two groups. But, when the one side of PNTML shorter than the other side, it tended to have a high amplitude in that side than that of the other side in the same patient (the probability for trend was 74%).
CONCLUSION
Constipation patient has a shorter PNTML, higher mean resting, and maximal squeezing pressure than fecal incontinene patient. The amplitude in pudendal nerve conduction study had a trend of inverse correlation to the latency in the same patient. Therefore, amplitude in pudendal nerve conduction study might be useful to monitor or predict the outcome after treatment in patients with defecation disorders.

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