Iatrogenic Rectal Diverticulum With Pelvic-Floor Dysfunction in Patients After a Procedure for a Prolapsed Hemorrhoid
A 42-year-old man with a 4-month history of constipation came to the hospital. The patient complained of excessive effort for evacuation, unsuccessful attempts, and long periods spent in the bathroom. Medical history included a hemorrhoidectomy four years earlier. He is a current smoker with a smoking history of 10 packs/yr.\nA review of the symptoms showed no abnormality, except constipation. Physical examination revealed normal rectal tone and intact anorectal inhibitory reflex. Laboratory findings showed no specific abnormality. On sigmoidoscopy, a feces-filled pocket with a 2-cm-sized opening was located just above the anorectal junction (). After the fecal material had been removed by using forceps, which took about one hour, a huge rectal diverticulum was seen (). The rectal mucosa surrounding the saccular lesion was normal, except for mild hyperemia and edema. There was no evidence of a fistula. The colon transit time was in the normal range (), and anorectal manometry showed a reversed defecation index with increased anal and rectal pressure at straining, consistent with pelvic floor dysfunction, type I (). Defecography showed a filled defect with a broad base at the anterior wall of the rectum, leading to lumen narrowing. These findings seemed to be associated with the excessive effort for evacuation (). Pelvic magnetic resonance imaging confirmed the diagnosis of rectal diverticulum outpouching through the muscular layer of the intestine in the left posterolateral direction ().\nAs a huge rectal diverticulum with fecalith can cause severe inflammation or sepsis, we decided to perform surgery. The patient underwent a transanal diverticulectomy and a direct rectal-wall repair. After the operation, the chief complaint, constipation, was lessened. He was discharged without any complications from the surgery and with no remaining symptoms. At the two-month follow-up, no abnormalities, except for a minimal saccular lesion, were found on sigmoidoscopy.