Absent or impaired rectoanal inhibitory reflex as a diagnostic factor for high-grade (grade III\u2013V) rectal prolapse: a retrospective study

Byung-Soo Park,Su Jin Kim,Hyun Sung Kim,Dae Gon Ryu,Myunghee Yoon,Yong-Hoon Cho,Tae Un Kim,Dong Soo Suh,Su Bum Park,Cheol Woong Choi,Gyung Mo Son,Sung Hwan Cho,Hong Jae Jo,Hyung Wook Kim

doi:10.1186/s12876-021-01729-1

Byung-Soo Park, Su Jin Kim + Show 12 more

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https://doi.org/10.1186/s12876-021-01729-1

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Abstract

BackgroundClinically diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse.MethodsIn this retrospective study, we evaluated 107 patients who underwent both anorectal manometry and defecography between July 2012 and December 2019. Rectal prolapse was classified in accordance with the Oxford Rectal Prolapse Grading System. Patients in the high-grade (III–V) rectal prolapse (high-grade group, n = 30), and patients with no rectal prolapse or low-grade (I, II) rectal prolapse (low-grade group, n = 77) were analyzed. Clinical variables, including symptoms such as fecal incontinence, feeling of prolapse, and history were collected. Symptoms were assessed using yes/no surveys answered by the patients. The manometric results were also evaluated.ResultsFrequencies of fecal incontinence (p = 0.002) and feeling of prolapse (p < 0.001) were significantly higher in the high-grade group. The maximum resting (77.5 vs. 96 mmHg, p = 0.011) and squeezing (128.7 vs. 165 mmHg, p = 0.010) anal pressures were significantly lower in the high-grade group. The frequency of absent or impaired RAIR was significantly higher in the high-grade group (19 cases, 63% vs. 20 cases, 26%, p < 0.001). In a multivariate analysis, the feeling of prolapse (odds ratio [OR], 23.88; 95% confidence interval [CI], 4.43–128.78; p < 0.001) and absent or impaired RAIR (OR, 5.36; 95% CI, 1.91–15.04, p = 0.001) were independent factors of high-grade (III–V) rectal prolapse. In addition, the percentage of the absent or impaired RAIR significantly increased with grading increase of rectal prolapse (p < 0.001). The sensitivity of absent or impaired RAIR as a predictor of high-grade prolapse was 63.3% and specificity 74.0%.ConclusionsAbsent or impaired RAIR was a meaningful diagnostic factor of high-grade (III–V) rectal prolapse. Furthermore, the absent or impaired reflex had a positive linear trend according to the increase of rectal prolapse grading.

Highlights

Diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked
Rectal prolapse consists of external rectal prolapse (ERP) and internal rectal prolapse (IRP) [2]
Patients with high-grade (III–V) rectal prolapse were designated for the high-grade group (n = 30), and patients without rectal prolapse and those with low-grade (I, II) rectal prolapse were designated for the low-grade group (n = 77) (Fig. 1)

Summary

Introduction

Diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse. Rectal prolapse is diagnosed when the rectum has protruded through the anal sphincter as observed by physical examination. Another way of diagnosing rectal prolapse, especially IRP, is by radiologic defecography. Defecography is commonly used as a diagnostic tool for rectal prolapse grading. ERP and high-grade (III–IV) IRP are indications for surgical treatment once the conservative treatment fails [2]

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