History Patients may have associated gynecological conditions which may require multidisciplinary management. History of constipation is important because some of the operations may worsen constipation. Fecal incontinence may also influence the choice of management. Physical examination<unk>  may be confused easily with prolapsing hemorrhoids. Mucosal prolapse also differs from prolapsing (3rd or 4th degree) hemorrhoids, where there is a segmental prolapse of the hemorrhoidal tissues at the 3, 7 and 11 o'clock positions. Mucosal prolapse can be differentiated from a full thickness external<unk>  (a complete<unk>  by the orientation of the folds (furrows) in the prolapsed section. In full thickness<unk> , these folds run circumferential. In mucosal prolapse, these folds are radially. The folds in mucosal prolapse are usually associated with internal hemorrhoids. Furthermore, in<unk> , there is a sulcus present between the prolapsed bowel and the anal verge, whereas in hemorrhoidal disease there is no sulcus. Prolapsed, incarcerated hemorrhoids are extremely painful, whereas as long as a<unk>  is not strangulated, it gives little pain and is easy to reduce. The prolapse may be obvious, or it may require straining and squatting to produce it. The anus is usually patulous, (loose, open) and has reduced resting and squeeze pressures. Sometimes it is necessary to observe the patient while they strain on a toilet to see the prolapse happen (the perineum can be seen with a mirror or by placing an endoscope in the bowl of the toilet). A phosphate enema may need to be used to induce straining. The perianal skin may be macerated (softening and whitening of skin that is kept constantly wet) and show excoriation. Proctoscopy/sigmoidoscopy/colonoscopy These may reveal congestion and edema (swelling) of the distal<unk>  mucosa, and in 10-15% of cases there may be a solitary<unk>  ulcer on the anterior<unk>  wall. Localized inflammation or ulceration can be biopsied and may lead to a diagnosis of SRUS or colitis cystica profunda. Rarely, a neoplasm (tumour) may form on the leading edge of the intussusceptum. In addition, patients are frequently elderly and therefore have increased incidence of colorectal cancer. Full length colonoscopy is usually carried out in adults prior to any surgical intervention. These investigations may be used with contrast media (barium enema) which may show the associated mucosal abnormalities. Videodefecography This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination. It is usually not necessary with obvious external<unk> . Defecography may demonstrate associated conditions like cystocele, vaginal vault prolapse or enterocele. Colonic transit studies Colonic transit studies may be used to rule out colonic inertia if there is a history of severe constipation. Continent prolapse patients with slow transit constipation, and who are fit for surgery may benefit from subtotal colectomy with rectopexy. Anorectal manometry This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some. It may be used to assess for pelvic floor dyssenergia, (anismus is a contraindication for certain surgeries, e.g. STARR), and these patients may benefit from post-operative biofeedback therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse. Resting tone is usually preserved in patients with mucosal prolapse. In patients with reduced resting pressure, levatorplasty may be combined with prolapse repair to further improve continence. Anal electromyography/pudendal nerve testing It may be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan. There may be denervation of striated musculature on the electromyogram. Increased nerve conduction periods (nerve damage), this may be significant in predicting post-operative incontinence.
Rectal prolapse
Pelvic organ prolapse
Anal fistula
Vesicovaginal fistula
Anal fissure
Perianal cellulitis
Rectovaginal fistula
Anorectal abscess