Annals of Coloproctology

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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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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.

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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
Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm for obstructed defecation syndrome
Michele Schiano di Visconte, Sonia Sarnari
World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef
The Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of obstructed and ineffective defecation syndrome
Adolfo Renzi, Luigi Brusciano, Pasquale Talento, Luigi Marano, Francesca Iacobellis, Antonio Vallo, Giovanna Frezza, Maurizio Grillo, Alessio Palumbo, Elisa Palladino, Benedetto Neola, Fabrizio Foroni, Michele Lanza, Massimo Antropoli, Carmine Antropoli,
Annals of Coloproctology.2026; 42(2): 151. CrossRef
Early outcomes of transverse perineal support in obstructed defecation syndrome with pathological perineal descent; a prospective cohort study
Haitham M. Azmy Basiouny, Ali Ahmed Shafik, Mohamed Yehia Elbarmelgi, Osama Refaie, Mohamed Tamer, Mahmoud Adel Abu Alwafa, Ahmed Mohamed Abdelaal
BMC Surgery.2026;[Epub] CrossRef
Tailoring surgery for obstructed defecation and its evolution into ineffective defecation: a new staging of the syndrome and a site-specific decision algorithm
Adolfo Renzi
Annals of Coloproctology.2026; 42(3): 372. CrossRef

Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography: Hyun Nam Baek, Yong Hee Hwang, Yong Hwan Jung; J Korean Soc Coloproctol. 2010;26(6):395-401. Published online December 31, 2010; DOI: https://doi.org/10.3393/jksc.2010.26.6.395

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Abstract PDF

Purpose

The aim of this study was to evaluate the clinical significance of perineal descent (PD) in pelvic outlet obstruction patients diagnosed by using defecography.

Methods

One hundred thirty-six patients with pelvic outlet obstruction (POO; median age 49 years) had more than one biofeedback session after defecography. Demographic finding, clinical bowel symptoms and anorectal physiological studies were compared for PD at rest and PD with dynamic changes.

Results

Age (r = 0.33; P < 0.001), rectocele diameter (r = 0.31; P < 0.01), symptoms of incontinence (P < 0.05) and number of vaginal deliveries (r = 0.46; P < 0.001) were correlated with increased fixed PD. However, the female gender (P < 0.005), rectal intussusceptions (P < 0.05), negative non-relaxing puborectalis syndrome (P < 0.00005) and rectocele (P < 0.0005) were correlated with increased dynamic PD. Duration of symptoms, number of bowel movements, history of pelvic surgery and difficult defecation were not related with PD. There was no significant correlation between fixed and dynamic PD and success of biofeedback therapy.

Conclusion

Age, vaginal delivery and diameter of the rectocele are associated with increased fixed PD. Female gender, rectal intussusceptions and a rectocele are correlated with increased dynamic PD. Biofeedback is an effective option for POO regardless of severity of PD.

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Influence of Pubovisceral Avulsion on Perineal Body Descent and Prolapse Development
Durwash Badr, Liam C. Martin, Henry Chill, Alireza Hadizadeh, Ghazaleh Rostaminia, Steven D. Abramowitch
International Urogynecology Journal.2026; 37(5): 1317. CrossRef
Early outcomes of transverse perineal support in obstructed defecation syndrome with pathological perineal descent; a prospective cohort study
Haitham M. Azmy Basiouny, Ali Ahmed Shafik, Mohamed Yehia Elbarmelgi, Osama Refaie, Mohamed Tamer, Mahmoud Adel Abu Alwafa, Ahmed Mohamed Abdelaal
BMC Surgery.2026;[Epub] CrossRef
Diagnostic performance of three-dimensional high-resolution anorectal manometry in identifying descending perineal syndrome
Hua Chu, You Wang, Chunrong Ma, Lijun Du
Frontiers in Medicine.2026;[Epub] CrossRef
Evaluation of Perineal Descent Measurements on Pelvic Floor Imaging
Isabelle M. A. van Gruting, Kirsten Kluivers, Aleksandra Stankiewicz, Joanna IntHout, Kim W. M. van Delft, Ranee Thakar, Abdul H. Sultan
Journal of Clinical Medicine.2025; 14(2): 548. CrossRef
Association of body composition with the symptoms of pelvic floor disorders in middle-aged women: a longitudinal study
Mari A. Kuutti, Enni-Maria Hietavala, Hanna-Kaarina Juppi, Sarianna Sipilä, Pauliina Aukee, Eija K. Laakkonen
Menopause.2025; 32(9): 810. CrossRef
Enhancing clinical practice: The role of digital rectal examination in diagnosing functional defecation disorders
Lian-Jun Zhu, Xing-Lin Zeng, Xiang-Dong Yang
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
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, Mass
Annals of Coloproctology.2025; 41(4): 330. CrossRef
Rectal prolapse (62.2, 62.3), adults
Yu. A. Shelygin, S. I. Achkasov, D. V. Alyoshin, O. M. Biryukov, V. S. Groshilin, V. N. Kashnikov, I. V. Kostarev, N. V. Kostenko, A. I. Moskalev, A. A. Mudrov, A. V. Muravyov, N. V. Oleinik, V. V. Polovinkin, V. M. Тimerbulatov, A. Yu. Titov, O. Yu. Fome
Koloproktologia.2024; 23(3): 10. CrossRef
Rectal prolapse (62.2, 62.3), adults
Yu. A. Shelygin, S. I. Achkasov, D. V. Alyoshin, O. M. Biryukov, V. S. Groshilin, V. N. Kashnikov, I. V. Kostarev, N. V. Kostenko, A. I. Moskalev, A. A. Mudrov, A. V. Muravyov, N. V. Oleinik, V. V. Polovinkin, V. M. Тimerbulatov, A. Yu. Titov, O. Yu. Fome
Koloproktologia.2024; 23(3): 10. CrossRef
The role of obesity on urinary incontinence and anal incontinence in women: a review
SK Doumouchtsis, J Loganathan, V Pergialiotis
BJOG: An International Journal of Obstetrics & Gynaecology.2022; 129(1): 162. CrossRef
The Digital Rectal Examination
Gregory S. Sayuk
Gastroenterology Clinics of North America.2022; 51(1): 25. CrossRef
Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders
Ian Paquette, David Rosman, Rania El Sayed, Tracy Hull, Ervin Kocjancic, Lieschen Quiroz, Susan Palmer, Abbas Shobeiri, Milena Weinstein, Gaurav Khatri, Liliana Bordeianou
Techniques in Coloproctology.2021; 25(1): 3. CrossRef
Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders
Ian Paquette, David Rosman, Rania El Sayed, Tracy Hull, Ervin Kocjancic, Lieschen Quiroz, Susan Palmer, Abbas Shobeiri, Milena Weinstein, Gaurav Khatri, Liliana Bordeianou
Diseases of the Colon & Rectum.2021; 64(1): 31. CrossRef
Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdom
Ian Paquette, David Rosman, Rania El Sayed, Tracy Hull, Ervin Kocjancic, Lieschen Quiroz, Susan Palmer, Abbas Shobeiri, Milena Weinstein, Gaurav Khatri, Liliana Bordeianou
Female Pelvic Medicine & Reconstructive Surgery.2021; 27(1): e1. CrossRef
European society of neurogastroenterology and motility guidelines on functional constipation in adults
Jordi Serra, Daniel Pohl, Fernando Azpiroz, Giuseppe Chiarioni, Philippe Ducrotté, Guillaume Gourcerol, A. Pali S. Hungin, Peter Layer, Juan‐Manuel Mendive, Johann Pfeifer, Gerhard Rogler, S. Mark Scott, Magnus Simrén, Peter Whorwell
Neurogastroenterology & Motility.2020;[Epub] CrossRef
Pathophysiology of the functional constipation in elderly
Michael D. Levin
Pelviperineology.2019; : 53. CrossRef
Systematic review with meta‐analysis: defecography should be a first‐line diagnostic modality in patients with refractory constipation
Ugo Grossi, Gian Luca Di Tanna, Henriette Heinrich, Stuart A. Taylor, Charles H. Knowles, S. Mark Scott
Alimentary Pharmacology & Therapeutics.2018; 48(11-12): 1186. CrossRef
Defecatory Dysfunction and the Pelvic Floor
Ajay Rane, Sapna Dilgir
Current Obstetrics and Gynecology Reports.2017; 6(3): 237. CrossRef
Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation
Rahmatollah Rafiei, Azadeh Bayat, Masoud Taheri, Zahra Torabi, Lotfollah Fooladi, Saideh Husaini
The Korean Journal of Gastroenterology.2017; 70(1): 39. CrossRef
Descending perineum syndrome: a review of the presentation, diagnosis, and management
Zaid Chaudhry, Christopher Tarnay
International Urogynecology Journal.2016; 27(8): 1149. CrossRef

Anorectal Physiology in the Rectal Prolapse Patient.: Son, Kyung Soo , Joo, Jae Sik , Wexner, Steven D; J Korean Soc Coloproctol. 1998;14(3):467-476.

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Abstract PDF: PURPOSE
The aim of our study was to evaluate the physiological spectrum of anorectal dysfunction among patients with full thickness circunferential rectal prolapse. MATERIAL AND METHODS: Between January 1988 and March 1995, 88 patients who visited department colorectal surgery, Cleveland Clinic Florida with rectal prolapse were studied. There were 8 males and 80 females, with a mean age 69 (range 28~101) years. Patients underwent a detailed history and the following anorectal physiology tests were performed: anal canal manometry, pudendal nerve terminal motor latency (PNTML) assessment, anal electromyography and cinedefecography.4 standard continence scoring system, based on the frequency and type of incontinence (0=full continence, 20=complete incontinence) was used. Patients with rectal prolapse (n=88) were divided into two subgroups: Group I=continent patients (n=33) and Group II= incontinent patients (n=55).
RESULTS
There were statistically significant differences between each group when comparing mean resting pressures, anal pressures, anal canal length, rectal compliance, rectoanal inhibitory reflex, increased fiber density, the occurrence of premature evacuation (p<0.001), and rectal capacity (p<0.05). However, dynamic changes of anorectal angle, resting anorectal angle, puborectalis length, and rectal sensitivity were not significantly different (p>0.05) between groups.
CONCLUSION
Continence may be disturbed in patients with rectal prolapse; knowledge of impairment in continence may assist in surgical management.

Investigation of Defecographic Findings in Patients with Pelvic Outlet Obstructive Disease.: Kim, Kyong Rae , Kim, Young Sok , Chung, Soon Sup , Ahn, Eun Jung , Oh, Soo Youn , Park, Ung Chae , Shon, Dae Ho , Sakong, Joon , Kim, Sang Woon , Kim, Jae Hwang , Shim, Min Chul; J Korean Soc Coloproctol. 2005;21(6):376-383.

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Abstract PDF: PURPOSE
Defecography is a dynamic investigation which can influence clinical decision making in patients with pelvic outlet obstructive disease (POOD). The current study was designed to establish defecographic findings in patients with POOD. Specifically, we sought to assess the physiologic characteristics of categorized types by using anorectal physiologic tests.
METHODS
One hundred seven patients (disease group; 45 men, 62 women) with POOD were retrospectively categorized as type I [non-relaxation of puborectalis (NRPR) only, n=19], type II [NRPR and rectocele, n=20], type III [NRPR, rectocele, and dynamic perineal descent (PD), n=17], type IV [deformed rectocele, mild-to-moderate fixed PD, and absence of NRPR, n=29], and type V [rectocele, severe fixed PD, and absence of NRPR, n=20] on the bases of defecographic findings. The ability to evacuate, the frequency/degree of intarectal intussusception (IRI), and the size of the rectocele were evaulated in these defecographic types of POOD. Age, duration of symptoms, and the physiologic findings of anal manometry and EMG/PNTML were compared for the five types. Eighteen healthy volunteers who had no defecation difficulty were used to estimate the normal findings of defecography.
RESULTS
The age and the sex showed no significant differences among the types. The duration of symptoms was gradually lengthened from type I to V (P<0.01). The ability to evacuate in patients with POOD was significantly worse (failed to effectively evacuate) compared to that in the healthy volunteers (P<0.01). The frequency of IRI was increased more and more from type I to V (P<0.01). The size of the rectocele was significantly increased in types V compared to the other types (P<0.01). Manometric and neurologic findings, including EMG/PNTML, revealed no significant differences among the types.
CONCLUSIONS
Even though there were no specific differences in the findings of the anal manometric and neurologic tests, the evacuation dynamics; were different in the five defecographic categories of patients with POOD. Specifically, these differences were relevants to the presence of NRPR, rectoceles, IRI, and perineal descent.

Effect of Vaginal Delivery on Perineal Descent and Pudendal Nerve Terminal Motor Latency.: Hur, Min Hee , Choi, Yoon Mi , Woo, Sang Wook , Kim, Sei Joong , Hong, Kee Chun , Kim, Jong Hwa , Woo, Ze Hong; J Korean Soc Coloproctol. 2000;16(2):67-72.

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Abstract PDF: PURPOSE
Significant associations between perineal descent (PD) and pudendal nerve terminal motor latency (PNTML) have previously been described in patients with fecal incontinence. This had led to the hypothesis that pelvic floor muscle and nerve injury initiated by childbirth might progress and cause fecal incontinence. Purpose: This study was undertaken to evaluate the association between vaginal delivery and PD, PNTML. Also, we evaluated the correlation between PD and PNTML.
Methods
Sixty one women who visited the Dept. of Surgery from Aug. 1998 to May. 1999 were randomly selected. Women were excluded, who had chronic constipation,operation within 6 months before the investigation, anal trauma, diabetes mellitus, and neurologic disease. They had a mean year of 43 12.5 years (range: 23~70), a mean vaginal delivery 1.9 1.5 (range: 0~6). PD at rest and during push, and PNTML were measured.
Results
PD during push (p=0.006) and the change of PD between at rest and during push (p=0.003) were significantly increased with increasing number of vaginal deliveries. Rt PNTML (p=0.08) and Lt PNTML (p=0.03) were significantly increased with increasing number of vaginal deliveries. There was correlation between Lt PNTML and change of PD (r=0.59, p=0.0).
Conclusions
PD and Lt PNTML was increased with repeated vaginal deliveries. Our findings support the hypothesis that damage induced by vaginal delivery to pudendal nerve and pelvic floor will progress.

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