Rectum Conditions and Treatment
What is Bowel Incontinence?
Bowel incontinence is being unable to control the gas and/or stool from coming out of the anus. This is a problem most people don’t talk about. Bowel incontinence is a symptom or sign of conditions causing muscle damage and weakness in that area which causes bowel incontinence.
What causes bowel incontinence?
Causes of muscle damage in this area include:
Damage during childbirth
– The muscles around the anus may be damaged (torn or split)during child birth.
– Nerves may become damaged in the pelvic floor or nerves to the anus.
Surgery the anal area: May affect the anal muscles and result in bowel control problems.
Aging process: This may also weaken the anal muscles.
Diseases of the nervous system
Diarrhoea: Loose stools may be associated with bowel incontinence.
Symptoms of Bowel Incontinence:
• Loss of control of gas and/or liquid or solid stools.
• Urgency: rushing to the toilet with little delay.
• Passing stools with no awareness.
When should I consult a Dr ?
• Passing blood in the stools is a warning sign.
What the Dr will do at consultation:
You should tell the doctor about previous medical illnesses, medicines taken and about any childbirth:
• Try and find the underlying cause
• Severity of the symptoms and how this affects your lifestyle.
• A physical examination will be done to check for injuries.
Investigations which may be done:
• Ultrasound scan: probe inserted into anus to look for muscle damage.
• Anal Manometry: This can show how strong or weak the anal muscles are.
• Anal balloon: In the rectum to check for feeling or sensation or how stiff the back muscles are.
• Nerve studies: To check if the anal muscle nerves are working properly.
Possible treatment options:
Mild problems managed by diet changes and constipation medication. Severe ones need hospital treatment with surgical and non-surgical options.
• Managing the diarrhoea:
• Diet changes and exercise
• Managing constipation.
• Surgical repair.
• Stoma or colostomy: this can be considered for extreme cases of bowel incontinence:
• Biofeedback: Monitoring body functions and then training the patient to take over control
Rectal cancer is the third most common cancer in men and the second most common cancer in women. The cells that line the rectum may become damaged and start multiplying uncontrollably. This may lead to the formation of a polyp which may eventually cause cancer.
What are the symptoms of rectal cancer?
• Bleeding from the back passage
• A change in the frequency of bowel activity
• The passage of mucous or slime
• Weight loss and poor appetite
How is rectal cancer diagnosed?
The diagnosis is made by examination of the colon and rectum either with a flexible telescope (colonoscope) or a special test called a CT colonography. During colonoscopy a tiny portion of tissue (biopsy) is taken from the cancer for laboratory examination. A CT scan will be arranged to examine the lungs and liver to check that the cancer has not spread.
How is rectal cancer treated?
The best chance of curing rectal cancer is with surgery which aims to remove the part of rectum with the cancer along with the blood supply and lymph nodes (glands) that supply it. These operations can be done either with open surgery or key-hole (laparoscopic surgery). The exact type of operation will depend on the location of the cancer.
Is a stoma always necessary?
A stoma (colostomy, ileostomy), or artificial opening of the colon/small bowel on to the abdominal wall is NOT always necessary. A temporary stoma be be necessary to allow the bowel join to heal.
Are there any other forms of treatment?
• Radiotherapy: Some rectal cancers respond to a course of radiotherapy before surgery. This may make surgery easier and possibly prevent the cancer coming back.
• Chemotherapy: This can be given together with radiotherapy before surgery or on its own. After full recovery from surgery it may be appropriate to recommend a course of chemotherapy.
• Liver surgery: If the cancer has spread to the liver it may still be possible to attempt to cure the cancer by removing a segment of the liver at an operation.
What are the chances of cure?
Appropriate surgery offers the best chance of cure possibly combined with chemotherapy and radiotherapy. In early cancers the cure rate is greater then 90%, in cancers at a more advanced stage then the chances of cure are less than 50%.
Will I need to be seen again?
You will be checked on a regular basis following your treatment. The frequency with which you will be seen will depend on the stage of cancer and will be tailored to your own particular circumstances. This will usually include visits to the clinic, a CT scans and colonoscopy.
What is rectal prolapse?
This occurs when the normal supports of the rectum (the lower end of the colon) become weakened and the rectum drops down outside the anus. This often happens when the anal sphincter muscle have weakened and there is difficulty in controlling the bowels with leakage of stool and mucus. This is not the same as piles but some of the symptoms may be similar.
What causes rectal prolapse?
There are several reasons why rectal prolapse may develop
• Prolonged habit of straining to have bowel movements.
• After childbirth which may show later in life.
• Rare genetic connective tissue illness.
• Natural aging process: ligaments weaken and the anal sphincter muscle loses strength.
• Neurological problems: (the brain, spine and nerves) may lead to prolapse.
How is rectal prolapse diagnosed?
You will need to be seen in clinic to assess your symptoms and to carry out a physical examination. Diagnosis can be made with a careful history by asking you a series of questions and a complete anorectal (anus and rectum) examination. You may be asked to “strain” or push as if having a bowel movement or even sit on a portable toilet and bear down in order to show the size of the prolapse. Sometimes a rectal prolapse may be internal. Anorectal Physiology studies may be done on the anal sphincter to look at its structure and function Sm.
How is rectal prolapse treated?
Although constipation and straining may contribute to the development of rectal prolapse, simply correcting these problems may not improve the prolapse. There are many different ways to surgically correct rectal prolapse. One operations is done through the abdomen called a Rectopexy and the other through the anus called the “perineal” approach. Abdominal repair can also be done through key hole surgery (an operation done through a small holes in the tummy with no need for a much larger cut as is the case with open surgery). The decision to recommend an abdominal rectal surgery or perineal surgery takes into account many factors, including age, physical condition, extent of prolapse and the results of various tests.
How successful is treatment?
More than half of patients are completely relieved of symptoms, or are significantly helped, by the appropriate procedure. Success depends on factors such as the status of a patient’s anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient. Chronic constipation and straining after surgical correction should be avoided.
What is a Rectocele?
A rectocele is a bulge of the front wall of the rectum into the back wall of the vagina. Small rectoceles have no symptoms. Other pelvic organs such as the bladder (cystocele) and the small intestine (enterocele) can bulge into the vagina, leading to similar symptoms.
Causes of rectoceles?
• Weakening of the pelvic floor: advancing age, post menopause, multiple vaginal deliveries.
• Chronic constipation
• Excessive straining with bowel movements .
• Multiple gynecological operations.
Symptoms of rectoceles?
The majority of patients have no symptoms.
• Difficulty with evacuation during a bowel movement.
• The need to press against the back wall of the vagina in order to have a bowel movement.
• Faecal incontinence.
• Increased frequency of passing stools
• Sensation of a bulge or fullness in the vagina
• Tissue protruding out of the vagina.
• Discomfort with sexual intercourse and vaginal bleeding.
Diagnosis of rectoceles:
• Digital examination of vagina and rectum.
• Vaginal speculum examination.
• Daefecating proctogram: Special x ray can confirm.
Treatment of rectoceles:
Should be treated if having significant symptoms that interfere quality of life.
Non-surgical treatment of rectocele:
• Avoiding constipation and straining:
• High fiber diet and increased water intake
• Avoid straining during bowel movements.
• Avoid prolonged sitting periods in the toilet.
Surgical treatment options:
Surgical management should be considered if the above fails. The aim is to remove the extra tissue that makes up the rectocele and reinforce the rectovaginal septum. This can be done by plication (stitching the tissue together). A mesh (a prosthetic material or patch) can also be used to reinforce the repair.
• The Stapled Transanal Rectal Resection (S.T.A.R.R.): removes the redundant tissue.
• Laparoscopic repair: Ventral mesh rectopexy
• Open abdominal surgery
Patient Information on STARR
Indications for STARR:
Obstructive defaecation syndrome (ODS) is a type of constipation due to the following:
• A Collapsed Rectum – rather like a telescope or sock that is folding in on itself.
• A Rectocoele or a prolapse of the wall between the rectum and vagina. Stools can be trapped when you try to empty your bowels resulting incomplete bowel emptying, soiling and increased toilet visits.
Symptoms of ODS:
• The need for regular laxatives and/or enemas .
• Frequent and/or longer visits to the toilet.
• Digitation/the need to put your fingers or thumb in your vagina or bottom to empty your bowels
• Straining, which can be prolonged and painful.
• A feeling if incomplete emptying of the bowels and chronic pelvic pains.
• Post evacuaton faecal soiling or faecal incontinence.
What the STARR procedure?
S.T.A.R.R. is an operation that involves removing, through your anus, the section of your rectum that contains the prolapse. The two remaining ends are then reconnected using special permanent medical staples.
Benefits of STARR:
• Easier and quicker emptying of your bowel without the need to strain or digitate
• Cure of incontinence.
• A more regular bowel habit and educed or no need for laxatives.
Post-operative bleeding and a bruised perineum is not usual but usually settles. Persistent bleeding requiring admission and or a transfusion very unusual (<1%). Some patients experience difficulty with passing urine and it may be necessary to pass a catheter into the bladder for a brief period. Post – operative infection is very rare.
Diet: Avoid foods that may constipate you or cause increased wind such as excess fibre.
What about work: Expect to be off work for at least one – two weeks following your surgery. Exercise may be gently introduced after one week.
And sex?: You can start sexual intercourse when you are comfortable. If any discomfort is felt leave it for a few days before trying again. Due to the close proximity of your operation site, anal intercourse should be avoided for a minimum of six months.