CLINICAL REVIEW

For the full versions of these articles see bmj.com

The assessment and management of

rectal prolapse, rectal intussusception,
rectocoele, and enterocoele in adults
Oliver M Jones, Christopher Cunningham, Ian Lindsey
Oxford Pelvic Floor Centre, Surgery
and Diagnostics, Churchill Hospital,
Headington, Oxford OX3 7LJ, UK
Correspondence to: O M Jones
oliver.jones@orh.nhs.uk
Cite this as: BMJ 2011;342:c7099
doi: 10.1136/bmj.c7099

Rectal prolapse is an extrusion of the full thickness of the

wall of the rectum beyond the anal verge. Internal rectal
prolapse, or intussusception, is defined as a full thickness
prolapse of the rectum that does not protrude through the
anus. Rectal prolapse and intussusception often coexist
with a rectocoele (herniation of the rectovaginal septum
anteriorly into the vagina) and an enterocoele (deep herniation of the rectovaginal peritoneum). Globally, these
problems are often referred to as pelvic floor dysfunction,
and this review focuses on the posterior compartment, the
rectum, around which these pathologies occur.
Patients with these conditions are often unable to empty
the rectum effectively (obstructed defecation syndrome) and
make up about half of the estimated 2-27% of the population
with constipation; the remainder have a problem of colonic
inertia.1 They may also get additional symptoms including
faecal incontinence and pain.

SUMMARY POINTS
Pelvic floor disorders are common and debilitating and often have secondary symptoms
such as anal fissure or haemorrhoids
Disorders of the posterior compartment often co-exist and dysfunction of the middle and
anterior compartments may also be present
Detailed assessment with history, examination, and specialist tests is key
Patients with substantial symptoms resistant to conservative measures should be referred
for consideration of surgery

Clitoris
Urethra
Vagina
Vestibule
Perineal body
Anus
Anal sphincter
Gluteus maximus
Coccyx bone

Fig 1 | Anatomy of the pelvic floor

BMJ | 5 FEBRUARY 2011 | VOLUME 342

Ischiocavernosus
Bulbocavernosus
Transversus
perineum
Levator ani:
Pubococcygeus
Iliococcygeus

Interest in rectal prolapse has recently increased, with a

multicentre randomised trial (PROSPER) now completed
comparing surgical techniques. The advent of laparoscopic
surgery also offers a potentially less invasive, better tolerated, and more durable surgical solution. Initial surgical
attempts at treating intussusception were disappointing
and led to its virtual abandonment for many years in favour
of conservative measures. However, in recent years, good
results with acceptable morbidity have been reported for
perineal and laparoscopic/abdominal approaches, so that
patients with substantial symptoms should be referred for
consideration for surgery. We review evidence from epidemiological studies, observation studies, case series, and
randomised trials to discuss the assessment and management of external prolapse, intussusception, rectocoele, and
enterocoele.

Who gets pelvic floor dysfunction?

Pelvic floor dysfunction can affect men and women of any
age. However, it is more common in women, reflecting
the fact that obstetric injury is its most common cause.2
Women may not present until many years after the injury
for several reasons, including a reluctance to seek medical
advice or a perception that nothing can be done. The pelvic
floor changes with age and sphincter pressures may fall,
unmasking dysfunction in middle and old age that was not
clinically apparent at the time of injury.3
The prevalence of posterior compartment pelvic floor
dysfunction inevitably depends on how the condition is
defined. Constipation has a reported prevalence in North
America of between 1.9 and 27.2%,4 and a similar proportion have some faecal incontinence.5 Symptoms may
be many and varied, and often patients will be told that
they have haemorrhoids, an anal fissure, or irritable bowel
syndrome, while the underlying pelvic floor dysfunction
is overlooked.
What is the anatomy of the pelvic floor function and
dysfunction?
When functioning normally, the pelvic floor is a dynamic
structure that supports the pelvic viscera and functionally maintains continence but can relax to allow defecation and urination. It can be thought of as three layers: the
325

CLINICAL REVIEW

Fig 2 | Full thickness rectal

prolapse in a patient in the
left lateral position bearing
down gently. This patient
also has a cystocoele

pelvic fascia, the pelvic floor muscle, and the urogenital

diaphragm. The urethra, anorectum, and vagina all pass
through the pelvic floor. The levator ani, the predominant
muscle of the pelvic floor, originates from the pubis before
passing like a sling behind the urethra, vagina, and anorectum, closing the urogenital and anorectal hiatuses through
its tonic action. It is supplied by the levator ani nerves,
which are direct branches from segments S2-4, with anatomists reporting variable contribution from the pudendal
nerve.6 The urogenital diaphragm lies just anterior to the
levator ani and its predominant muscle is the deep transverse muscle of the perineum (fig 1).
The pelvic floor is often considered in terms of three
compartments: anterior, middle, and posterior. This
review focuses predominantly on the posterior compartment, the rectum, although pelvic floor dysfunction often
straddles all three compartments. As a consequence,
patients with pelvic floor disorders may present to a range
of health professionals in various specialties.

How might a patient present initially?

Patients may present with a single symptom but often
report several problems. Some patients present with a
lump at the anal verge, typically after defecation, that
Symptoms of pelvic floor dysfunction and associated mechanisms of causation
Symptom
Lump at anal verge

Faecal incontinence: urge

Faecal incontinence: passive

Constipation: slow transit

Constipation: difficulty with defecation

Pain: abdominal and pelvic

326

Typical causes and mechanisms

External rectal prolapse. Differential diagnosis includes anal or
rectal cancer, thrombosed or prolapsed haemorrhoids, and rectal
mucosal prolapse
Tear and scarring of external anal sphincter (obstetric, surgical/
iatrogenic, trauma/abuse). Damage to the pudendal nerves
(obstetric, straining/stretching). Inflammatory bowel conditions
(colitis, infective diarrhoea, radiation proctitis)
Tear and scarring of internal anal sphincter. External prolapse or
intussusception. Prolapse may cause incontinence through bypassing
the sphincter mechanism, stimulating reflex sphincter relaxation (the
recto-anal inhibitory reflex or repeated sphincter dilatation. Damage
to the pudendal nerves (obstetric, straining/stretching)
Colonic atony and lack of peristalsis
Intussusception dropping down and occluding bowel lumen
during defecation causing unsuccessful or incomplete evacuation,
straining, sensation of blockage, and thin stools. Rectocoele
trapping stool. Sensation of stool going the wrong way,
incomplete evacuation, and need to digitate to empty rectocoele.
Enterocoele causing small bowel to drop into pelvis and occlude
rectocoele or to compress the rectum anteriorly. Anismus causing
paradoxical contraction of the puborectalis and external anal
sphincter during attempts at defecation
Constipation from poor evacuatory function may cause abdominal
pain. Intussusception and enterocoele producing a pressure
sensation within the pelvis

might reduce spontaneously or require reduction by pressure. In external rectal prolapse (fig 2) the rectal muscular
wall can be felt in the prolapsed tissue, allowing distinction between this and other causes of a lump, such as
mucosal prolapse or haemorrhoids.
Many patients report faecal incontinence with a predominant problem of control of flatus or stools. Incontinence can be divided into passive, which manifests as
leakage of which the patient is often initially unaware,
or urge, when a patient becomes aware of the need to
open their bowels but cannot get to the toilet in time. Asking the patient if they have had to change their lifestyle
or wear a pad because of the incontinence will gives an
impression of the severity of the problem.7
Patients may have more of a problem with what they
describe as constipation. Establish what is meant by
this term; for some patients it means stool infrequency
whereas for others it might mean a difficulty with defecation. Patients may show signs of obstructed defecation
syndrome, which is typically characterised by a sensation
of incomplete evacuation or of a blockage, hard or thin
stools, the need to digitate vaginally or anally, straining,
repeated (often unsuccessful) visits to the toilet, and
anorectal pain (table).

Evaluating a patient with symptoms of pelvic floor

dysfunction
Clinical examination
Clinical examination of the patient with pelvic floor dysfunction should start with an inspection of the perineum
to look for evidence of scarring, fissures or haemorrhoids,
previous episiotomy, soiling, and visible prolapse. Where
facilities permit, the patient can be asked to sit on a commode or toilet and asked to strain to attempt to demonstrate a suspected prolapse. Digital rectal examination
may give an accurate impression of resting and squeeze
anal canal pressure.8 More specialist evaluation might
include asking the patient to bear down during digital
examination to assess for paradoxical contraction, suggesting anismus or simultaneous vaginal and rectal
examination in the standing patient for detection of an
enterocoele. Where facilities permit, proctoscopy and
rigid sigmoidoscopy ensure that there is not a luminal
aspect to the problem such as a rectal cancer.
Conservative measures and whom to refer
In patients with extensive symptoms of incontinence a
few conservative measures may bring about substantial
improvement. Constipating agents such as codeine phosphate or loperamide may improve continence. Results of
a randomised, double blind crossover trial suggested that
in patients with chronic diarrhoea and incontinence, loperamide improves episodes of incontinence and severe
urgency.9 Dietary changes in patients with faecal incontinence may also improve symptoms. Another randomised
trial suggested no difference between high fibre diet with
loperamide and a low fibre diet with loperamide. However, the authors commented that both groups had significantly improved continence compared with baseline
and that there individual responses varied greatly, with
some favouring more fibre and others less.10
BMJ | 5 FEBRUARY 2011 | VOLUME 342

CLINICAL REVIEW

Box 1 | Assessment and decision making process in the Oxford Pelvic Floor Centre
Detailed history and functional scoring systems by questionnaire
Detailed obstetric history and history of pelvic, gynaecological, and proctological surgery
Examination of patient
Anal sphincter assessment using anorectal physiology and endoanal ultrasound
Assessment of colonic motility using a transit study and evacuatory function using
defecating proctography

Fig 3 | Examples of defecating proctogram (left) and transit study (right) with patient seated
on a commode. Curved arrows show the intussusception forming. Solid line delineates the
rectocoele. Dotted line outlines the small bowel opacified with oral contrast that is slipping
into the pelvis, forming an enterocoele. In the transit study, the large number of retained radioopaque shapes indicate slow transit constipation

By contrast, patients with constipation may benefit

from laxative treatments. Patients whose condition is
not resolved by conservative treatments and who have
substantial residual symptoms should be considered for
investigation.

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Investigation
Few tests can be arranged by the non-specialist before
referral. The exclusion of other conditions, including cancer, is important, although local policies will determine
whether patients are sent straight to tests, such as colonoscopy, or are seen in clinic first.
The specialist evaluation of the pelvic floor involves
several different specialtiesin the Oxford Pelvic Floor
Centre, the multidisciplinary team includes colorectal surgeons, urologists, gynaecologists, radiologists, research
fellows, specialist nurses, physiologists, and physiotherapists. The assessments done by this team are described
in box 1. Anorectal physiology and an endoanal ultrasound may also be useful. Physiology gives an impression of sphincter muscular function, rectal sensation, and
neuropathy. A special electrode may be used to assess
pudendal nerve function more formally by stimulating
the nerve at the ischial sphine and measuring the time
taken to elicit sphincter contraction. Endoanal ultrasound
delineates sphincter anatomy, identifies thickening of
the internal anal sphincter (often seen in patients with
internal and external rectal prolapse), and will show any
scarring or tears.11
Defecating proctography studies the dynamics of defecation. Barium paste is administered into the rectum
and oral contrast given to opacify the small bowel and
facilitate identification of an enterocoele. Women may be

BMJ | 5 FEBRUARY 2011 | VOLUME 342

asked to consent to insertion of contrast into the vagina

to delineate its position. The patient is then asked to try
to evacuate their bowels while the episode is recorded
by videofluoroscopy (fig 3). Proctographic abnormalities
may be seen in asymptomatic healthy people, emphasising the importance of interpretation in the light of symptoms and clinical findings.12
Magnetic resonance defecography is an alternative to
standard proctography, although except in open coil scanners, the patient has to be studied in the supine position.
A transit study is an abdominal radiograph taken after
the patient has taken radio-opaque markers in the preceding days according to a standardised protocol (fig 3).
The number of markers remaining within the colon helps
to identify those patients with prolonged colonic transit.

How can these problems be treated?

Rectal prolapse
In most instances, an acute prolapse will reduce spontaneously or with gentle pressure from the patient or doctor.
In some patients, associated oedema may make reduction
more difficult. Reduction in oedema can be facilitated by
application of ice wrapped in a cloth or sugar to the prolapsed rectum.13 Patients with troublesome symptoms
from their rectal prolapse (difficulties in reduction of prolapse, substantial incontinence, or obstructed defecation)
should be referred for consideration of surgery.
Surgery can be divided into two categories: perineal
and abdominal. Perineal procedures (Delormes or Altmeier operation) can be performed under a spinal anaesthetic, which may be an advantage in elderly and frail
patients. Abdominal rectopexy (surgical fixation of the
rectum by an open or laparoscopic abdominal approach)
is sometimes perceived to have a lower prolapse recurrence rate.14 However, a Cochrane review of a dozen trials involving 380 patients was unable to draw any firm
conclusions regarding the relative efficacy of perineal
compared with abdominal approaches.15 The results of a
larger multicentre randomised trial comparing resectional
and non-resectional techniques and the abdominal versus
perineal approach (the PROSPER study16) are awaited.
Laparoscopic rectopexy combines the perceived
advantages of low recurrence rate from an abdominal
approach with the advantages of minimally invasive
surgery. A recent meta-analysis of comparative studies
of 688 patients suggested that laparoscopic surgery took
longer to perform but was associated with a shorter hospital stay.17 It did not show any difference in morbidity or
mortality. However, a case series from two tertiary referral
pelvic floor centres suggested that laparoscopic surgery is
very well tolerated in older people. It reported outcomes
of laparoscopic rectopexy in 80 patients older than 80. A
mortality of 0%, recurrence of 3%, morbidity of 13%, and
median length of stay of 3 days was reported.18
Traditional rectopexy involved dissection posterior to
the rectum, which resulted in denervation that tended
to exacerbate constipation.19 Resection rectopexy sought
to offset this problem by resection of the sigmoid but at
the expense of an anastomosis with its attendant risks,
including leakage.20 Laparoscopic ventral rectopexy and
Orr-Loygue rectopexy limit dissection to anterior to the
327

CLINICAL REVIEW

TIPS FOR THE NON-SPECIALIST

Detailed history and examination often uncover symptoms suggesting pelvic floor
dysfunction
Faecal incontinence and obstructed defecation often coexist, despite their apparently
contradictory symptoms
Many patients with incontinence and soft or loose stools benefit from stool modification
with constipating agents, such as codeine phosphate or loperamide
Patients with obstructed defecation should be given a trial of an osmotic laxative
UNANSWERED QUESTIONS
What are the long term outcomes of different approaches to external rectal prolapse?
Is external rectal prolapse an extreme version of intussusception or do the disease
processes differ?
What are the normal parameters for defecating proctography, especially in relation to
intussusception, and how can we better use proctography to predict treatment outcome?
What is the relative efficacy of stapled transanal resection and laparoscopic ventral
rectopexy in the treatment of obstructed defecation?
SOURCES AND SELECTION CRITERIA
We searched the Cochrane databases using the terms rectal prolapse, rectocoele, and
intussusception. We also searched Medline, Embase, and PubMed using the search terms
rectal prolapse, intussusception, rectocoele, enterocoele, STARR (stapled transanal rectal
resection), and rectopexy.
A PATIENTS PERSPECTIVE
After years of problems with constipation, being unable to empty the bowels without
assistance, a sensation of the bowel coming down, and the additional distress of
incontinence on walking for short distances and a ruined holiday made me pluck up the
courage to seek help. I was referred to the Oxford Pelvic Floor Clinic.
The consultant explained that I would need a series of tests that sounded embarrassing
but were handled sensitively. The diagnosis of a rectocoele, rectal intussusception, and
slow transit constipation was made. I was referred initially to the biofeedback nurse for
advice and exercises, which helped but did not resolve the problem. I was offered a ventral
mesh rectopexy, which the consultant said offered roughly an 80% chance of substantial
improvement.
I only needed to be in hospital overnight and the discomfort was minimal. I found the
advice that had been given by the biofeedback nurse helped greatly in the first week or so.
I have been very pleased with the result. I travel with confidence. I just need to take a small
dose of Movicol [a macrogol] to help with some constipation and as a bonus my bladder
control has improved too.

rectum, sparing the nerves. Several case series suggest

that these techniques avoid de novo constipation and
may improve pre-existing constipation, even without
resection.21 22 Recurrence rates of less than 4% have
been reported from several case series with laparoscopic
ventral rectopexy.23 24 It is now our preferred approach to
the treatment of rectal prolapse.

Intussusception
Patients with symptomatic intussusception might benefit
from conservative measures including osmotic laxatives.
Although these are widely recommended in the surgical
literature,25 evidence for their efficacy is lacking.
Biofeedback is a process by which control of an action
that is not usually monitored consciously can be developed using systematic information.26 Its use in patients
with pelvic floor dysfunction is well established but
although some trials have compared it with a range of
treatment strategies, these are heterogeneous and of
variable quality.27 A Cochrane review of its role in faecal
incontinence commented on the poor quality of many of
328

the studies and showed no superiority for biofeedback

over other conservative treatments.28
The improvement in constipation and obstructed defecation in patients treated with laparoscopic ventral rectopexy
for external prolapse lead to the application of this operation to those patients with intussusception. Improvements
in symptoms of obstructed defecation and faecal incontinence associated with intussusception have been reported
in around 80% of patients in a number of case series.29
These outcomes are similar to those reported for external
prolapse, which suggests that there may be a link between
the two entities.
An alternative surgical approach to laparoscopic ventral
rectopexy is stapled transanal rectal resection or the related
procedure called transtar, which uses a different stapling
device. These are perineal procedures in which the redundant intussusception and deficient tissue of the rectovaginal septum contributing to the rectocoele is removed with a
stapling gun introduced per-anally. There has been reported
morbidity associated with the procedure including pain,
haemorrhage, and rarely septic problems.30 A combination
of urgency and faecal frequency is seen in many patients
immediately after surgery and may persist in around a fifth
of patients for up to a year.31 Results of a recent randomised
controlled trial suggested that stapled transanal resection of
the rectum is more effective than biofeedback for the treatment of intussusception and rectocoele.32

Rectocoele and enterocoele

A rectocoele and enterocoele often occur in association
with other manifestations of pelvic floor failure that may
determine treatment. Indeed, enterocoele is little more
than a marker for pelvic floor weakness.33 Both stapled
transanal rectal resection and laparoscopic ventral rectopexy are effective treatments for rectocoele and also
treat co-existing intussusception. Although a rectopexy
also treats an enterocoele, its presence is a relative contraindication to stapled transanal resection.
For patients with an isolated rectocoele, repair can be
performed via a transvaginal, transperineal, or transanal
approach; gynaecologists tend to favour the transvaginal
approach while colorectal surgeons more commonly use
the transanal approach. A recent Cochrane review evaluating randomised trials concluded that the transvaginal
approach may be associated with a lower rate of rectocoele
recurrence,34 although sexual dysfunction may occur.35 The
transvaginal approach also avoids the stretching of the
anal sphincter that occurs with the transanal approach,
which is an advantage in a patient group with a high prevalence of incontinence.36
Contributors: OMJ performed the literature search and wrote the initial
draft. All three authors revised the initial draft, prepared the illustrations, and
wrote the final draft.
Competing interests: All authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare: no support from any
organisation for the submitted work; no financial relationships with any
organisations that might have an interest in the submitted work in the
previous three years, no other relationships or activities that could appear to
have influenced the submitted work.
Provenance and peer review: Commissioned, externally peer reviewed.
Patient consent obtained.
BMJ | 5 FEBRUARY 2011 | VOLUME 342

CLINICAL REVIEW

12
13
14
15
16
17
18

19
20

Analysis of temporal trends in

the BMJ archive
We searched the 170 year electronic archive of the BMJ for mentions of four
communicable diseases (malaria, cholera, influenza, and tuberculosis) and four
non-communicable diseases (ischaemic heart disease, hypertension, obesity, and
lung cancer). Titles and abstracts were searched, and further manual searches were
made of research articles.
The number of research articles on communicable diseases fluctuated with the
incidence of the individual diseases (such as with influenza pandemics), whereas
the number of articles on non-communicable diseases increased substantially
in the second half of the 20th century (figure (note the fivefold difference in scale
between the two plots)). Increased numbers of research articles on heart disease
and obesity in the 1960s and 1970s were preceded by an increase in non-research
articles on these topics.

Communicable diseases
Malaria
Cholera
Influenza
Tuberculosis*

4
3
2
1
0
25

Non-communicable diseases
Ischaemic heart disease
Blood pressure
Obesity
Lung cancer

20
15
10
5

This is an abridged version of an entry from last years competition for the most creative use of
the BMJ online archive. The authors data generated for their competition entry are available at
http://tinyurl.com/ydx4tju

18

Mangesh A Thorat thoratmangesh@gmail.com

Priya M Thorat
Hrisheekesh J Vaidya
Jayant S Vaidya, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London

Cite this as: BMJ 2010;340:c3306

See EDITORAL p 293

*The term "tuberculosis" was not used before the 1870s

BMJ | 5 FEBRUARY 2011 | VOLUME 342

0
-7

0
19

51

-5

0
19

31

-3

11
19

-1

91

0
-9
71

91
18

18

40

-7

11

00

10

-2

91

-9

71

19

19

21 Portier G, Iovino F, Lazorthes F. Surgery for rectal prolapsed: Orr-Loygue

ventral rectopexy with limited dissection prevents postoperativeinduced constipation without increasing recurrence. Dis Colon Rectum
2006;49:1136-40.
22 Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral
rectopexy for external rectal prolapse improves constipation and avoids
de novo constipation. Colorectal Dis 2010;12:526-32
23 Slawik S, Soulsby R, Carter H, Payne H, Dixon AR. Laparoscopic ventral
rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the
treatment of recto-genital prolapse and mechanical outlet obstruction.
Colorectal Dis 2008: 138-43.
24 DHoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal
prolapse: surgical technique and outcome in 109 patients. Surg Endosc
2006;20:1919-23.
25 Khaikin M, Wexner SD. Treatment strategies in obstructed defaecation
and fecal incontinence. World J Gastroenterol 2006;12:3168-73.
26 Bassotti G, Chistolini F, Sietchiping-Nzepa F, de Roberto G, Morrell A,
Chiaroni G. Biofeedback for pelvic floor dysfunction in constipation. BMJ
2004;328:393-6.
27 Koh CE, Young CJ, Young JM, Solomon MJ. Systematic review of
randomized controlled trials of the effectiveness of biofeedback for
pelvic floor dysfunction. Br J Surg 2008;95:1079-87.
28 Norton C, Cody JD, Hosker G. Biofeedback and/or sphincter exercises for
the treatment of faecal incontinence in adults. Cochrane Database Syst
Rev 2006;3:CD002111.
29 Collinson R, Wijffels N, Cunningham C, Lindsey I. Laparoscopic ventral
rectopexy for internal rectal prolapse: short-term functional results.
Colorectal Dis 2010;12:97-104.
30 Pescatori M, Gagliardi G. Postoperative complications after procedure
for prolapsed haemorrhoids (PPH) and stapled transanal rectal
resection (STARR) procedures. Tech Coloproctol 2008;12:7-19.
31 Jayne DG, Schwandner O, Stuto A. Stapled transanal resection for
obstructed defecation syndrome: one year results of the European
STARR registry. Dis Colon Rectum 2009;52:1205-12.
32 Lehur PA, Stuto A, Fantoli M, Villani RD, Queralto M, Lazorthes F, et al.
Outcomes of stapled transanal rectal resection vs biofeedback for the
treatment of outlet obstruction associated with rectal intussusception
and rectocele: a multicentre, randomized, controlled trial. Dis Colon
Rectum 2008;51:1611-8.
33 Jarrett M, Wijffels N, Slater A, Cunningham C, Lindsey I. Enterocele is a
marker of severe pelvic floor weakness. Colorectal Dis 2009, published
online Aug 5.
34 Maher C, Feiner B, Baessler K, Adams EJ, Hagen S, Glazener CM. Surgical
management of pelvic organ prolapse in women. Cochrane Database
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35 Yamana T, Takahashi T, Iwadare J. Clinical and physiological outcomes
after transvaginal rectocele repair. Dis Colon Rectum 2006;49:661-7.
36 Tsujinaka S, Tsujinaka Y, Matsuo K, Akagi K, Hamahata Y. Changes in
bowel function following transanal and transvaginal repair. Dig Surg
2007;24:46-53.

No of articles/year

Higgins BJ, Johanson JF. Epidemiology of constipation in North America:

a systematic review. Am J Gastroenterol 2004;99:750-9.
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Obstetric anal sphincter injury. BMJ 2010;341:140-5.
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in normal women. Int J Colorectal Dis 1997;12:225-9.
Higgins PD, Johanson JF. Epidemiology of constipation in North America:
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Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of
anal incontinence. JAMA 1995;274:559-61.
Wallner C, van Wissen J, Maas CP, Dabhoiwala NF, DeRuiter MC, Lamers
WH. The contribution of the levator ani nerve and the pudendal nerve to
the innervation of the levator ani muscles: a study in human foetuses.
Eur Urol 2008;54:1136-42.
Jorge JM, Wexner SD. Etiology and management of fecal incontinence.
Dis Colon Rectum 1993;36:77-97.
Hallan RI, Marzouk DE, Waldron DJ, Womack NR, Williams NS.
Comparison of digital and manometric assessment of anal sphincter
function. Br J Surg 1989;76:973-5.
Read M, Read NW, Barber DC, Duthie HL. Effects of loperamide on anal
sphincter function in patients complaining of chronic diarrhea with fecal
incontinence and urgency. Dig Dis Sci 1982;27:807-14.
Lauti M, Scott D, Thompson-Fawcett MW. Fibre supplementation in
addition to loperamide for fecal incontinence in adults: a randomized
trial. Colorectal Dis 2008;10:553-62.
Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in
adults. Lancet 2004;364:621-32.
Shorvon PJ, McHugh S, Diamant NE, Somers, Stevenson GW. Defecography
in normal volunteers: results and implications. Gut 1989;30:1737-49.
Myers JO, Rothenberger DA. Sugar in the reduction of incarcerated
prolapsed bowel. Report of two cases. Dis Colon Rectum 1991;34:416-8.
Madiba TE, Baig MK, Wexner SD. Surgical management of rectal
prolapse. Arch Surg 2005;140:63-73.
Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal
prolapse in adults. Cochrane Database Syst Rev 2008;4:CD001758.
Association of Coloproctology of Great Britain and Ireland. Randomised
trial of rectal prolapse surgery (PROSPER). National Research Register
and ISRCTN Register (first accessed 2000). ISRCTN01911755.
Sajid MS, Siddqui MR, Baig MK. Open vs laparoscopic repair of
full-thickness rectal prolapse: a re-meta-analysis. Colorectal Dis
2010;12:515-25.
Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I.
Laparoscopic anterior rectopexy for external rectal prolapse is safe and
effective in the elderly. Does this make perineal procedures obsolete?
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2001;38:771-832.

No of articles/year

Year

329