Rectal internal mucosal prolapse in obstructed defecation: To band, to excise, to obliterate, or to pexy? "Beyond the Abstract," by Mario Pescatori, MD, FRCS, EBSQ

BERKELEY, CA ( - Two of the decisions that a colorectal surgeon has to make when dealing with a symptomatic, internal prolapse is whether to operate it or not, and, in case surgery is needed, which operation to perform.

Banding is a simple, ambulatory procedure that can be carried out when the size of the prolapse is small and of first or second degree -- i.e., if it descends below the anorectal ring at proctoscopy on straining or if it reaches the dentate line.

Transanal prolapse excision, either manual or stapled (Pescatori et al, Tech Coloproctol 1997), is indicated when the bulk of the prolapsing mucosa is likely to be a real cause of obstructed defecation. It may be followed by dehiscence and bleeding in case of circumferential excision of the prolapse.

Transabdominal pexy is indicated when the prolapse is more a recto-rectal than a recto-anal intussusception. In this case the best operation is likely to be the ventral colporectopexy, either laparoscopic or open, via a cosmetic sovrapubic Pfannestiel incision. The novel transanal mini-invasive operation described in our paper consists of a combination of anterior excision and posterior pexy and ligation of the rectal internal prolapse or recto-anal intussuscepton, when it is circumferential, and is aimed at decreasing the risk of both dehiscence and bleeding. It also may be performed when dealing with small external prolapse, 2-3 cms in size.

According to our theory of obstructed defecation seen as an iceberg syndrome (Pescatori et al, Colorect Dis 2006), apart from rectocele and rectal internal mucosal prolapse, all patients present with at least 2 occult lesions, either functional or organic. Therefore, the association with anxiety-depression or anismus or rectal sensation or enterocele or urogenital prolapse needs to also be diagnosed and treated. Otherwise the cure of the internal prolapse alone is unlikely to relieve patients’ constipation.

Written by:
Mario Pescatori, MD, FRCS, EBSQ as part of Beyond the Abstract on This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Coloproctology Unit, Parioli Clinic, Via F. Giordano, 8–00197, Rome, Italy

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