Rectal Symptoms Research Articles

Are patients in the IBD clinic at risk of proctitis secondary to sexually transmitted infections?

ObjectiveTo gauge the potential risk of sexually transmitted infection (STI) as a cause of proctitis in a cohort of patients with inflammatory bowel disease (IBD) and to gauge whether this...

Image-Guided Radiotherapy Dose Escalation in Intermediate and High Risk Cancer Prostate Patients and Its Effect on Treatment Toxicity

Purpose: To study the effect of escalating radiation dose; in intermediate and high risk prostate cancer patients; via online image-guidance on acute toxicities. Patients and Methods: thirty-eight prostate cancer patients were treated by using simultaneous integrated boost-intensity modulated radiation therapy (SIB-IMRT) with online image guided correction via kilo voltage cone beam computed tomography (KV-CBCT)/electronic portal imaging device (EPID) of trans-rectal ultrasound (TRUS)-inserted intraprostatic gold fiduciary markers. High-risk patients received a median dose of 80.5 Gy to prostate and 56 Gy to pelvic nodes in 35 fractions over 7 weeks. Intermediate-risk patients received a similar prostate dose over the same overall treatment time. Acute toxicity (bladder, rectal and bowel symptoms) was reported once weekly during the radiation course and up to 3 months from the end of the radiation course. Results: The image guided (IG)-IMRT allows escalating the radiation dose delivered to the prostate through minimizing the margin of setup error to less than 0.5 cm with subsequent sparing of nearby organs at risk. Out of thirty-eight patients, no patient developed >grade 1 acute rectal toxicity, 7.9% of patients experienced grade 3 urinary toxicity and there was no reported small intestinal toxicity. Conclusion: Escalating the radiation dose more than 80 Gy in intermediate and high risk prostate cancer patients was safe and not associated with grade 3 - 4 RTOG toxicity when guided by online verification of intra-prostatic fiducial markers.

Investigation of the operation time in children with tethered cord syndrome

Objectives To investigate the operation time in children with tethered cord syndrome and to search for the evidence of the evidence-based medicine of prophylactic surgery in tethered cord syndrome. Methods The clinical data of 145 children with tethered cord syndrome admitted to the Department of Neurosurgery, Shanghai Children's Hospital, Shanghai Jiao Tong University from January 2011 to December 2013 were analyzed retrospectively. The age at presentation was 1 day to 13 years (mean 38.6±3.4 months), 93 of them were males and 52 were females. The follow-up time was 24 months. Their preoperative symptoms were documented according to 4 categories: focal symptoms, bladder and/or rectal symptoms, symptoms of motor function impairment, and other symptoms. The follow-up was conducted by means of questionnaire survey after procedure. At 1, 3, 6, 9, 12, and 24 months after procedure, they came to hospital and a questionnaire survey was conducted by the follow-up specialists. They were documented and divided into excellent (no postoperative symptoms), improvement, no improvement, and aggravation (worse or having new symptoms), respectively according to whether their preoperative and postoperative symptoms were improved or not. Results In the preoperative symptoms, 73 patients (50.3%) had focal symptoms, 41 (28.3%) had bladder and/or rectal symptoms, 21 (14.5%) had motor function impairments, and 10 (6.7%) had other symptoms. During the follow-up after procedure, 59.3% (86/145) were excellent, 24.1% (35/145) were effective, 9.7% (14/145) were ineffective, and 6.9%(10/145) were aggravated. The statistical analysis showed that in children with focal symptoms before operation, the postoperative excellent rate was significantly higher than the children having symptoms before procedure (97.3% vs. 20.9%; P<0.05). Conclusions Children with tethered cord syndrome should be treated surgically in the presence of the symptoms of nervous system damage. It is recommended to complete the operation before 24 months. The safety of the preventive operation is higher and the clinical effect is satisfactory. Key words: Tethered cord syndrome; Neurosurgical procedures; Operation timing; Follow-up; Child

Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction.

Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients. Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery. Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50% of patients, the majority of which (65%) were present for >1year. The commonest sensation reported was the feeling of faeces in a normal rectum (24%). Disturbances in quality of life were apparent in 44%; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice. Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

Working up rectal bleeding in adult primary care practices.

Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation. We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups. Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance. Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation.

Rectal chlamydia - should screening be recommended in women?

Chlamydia trachomatis is the most common bacterial sexually transmitted infection in Europe and has large impacts on patients' physical and emotional health. Unidentified asymptomatic rectal Chlamydia trachomatis could be a partial explanation for the high Chlamydia trachomatis prevalence. In this study, we evaluated rectal Chlamydia trachomatis testing in relation to symptoms and sexual habits in women and men who have sex with men. Rectal Chlamydia trachomatis prevalence was 9.1% in women and 0.9% in men who have sex with men. None of the patients reported any rectal symptoms; 59.0% of the women with a rectal Chlamydia trachomatis infection denied anal intercourse and 18.8% did not have a urogenital infection; 9.4% did neither have a urogenital infection nor reported anal sex. We suggest that rectal sampling should be considered in women visiting sexually transmitted infection clinics regardless of rectal symptoms and irrespective of anal intercourse, since our data suggest that several cases of rectal Chlamydia trachomatis otherwise would be missed, thus enabling further disease transmission.

Long-term outcome of perineal rectosigmoidectomy for rectal prolapse

IntroductionRectal prolapse is a disabling condition that often affects older patients with multiple comorbidities making complex surgeries impossible to perform. MethodsA retrospective review of patients who underwent perineal rectosigmoidectomy (Altemeier procedure) for rectal prolapse from January 1999 to March 2015 was performed in a Reference Hospital, being evaluated complications and surgery recurrence. ResultsThirty-six Altemeier procedures were performed in 33 patients during the study. Twenty-five (76.8%) were women and the mean age was 67 (range 31–91) years. The mean duration of rectal prolapse symptoms was 7.8 years; other complaints were: pain, bleeding, mucus discharge, constipation and fecal incontinence. The mean operative time was 134.8 min and the blood loss was little. The mean postoperative length of hospital stay was 3.9 days. There was no mortality. Early postoperative complications occurred in 3 (9.1%). Patientsan acute pulmonary edema, an urinary infection and a surgical site infection with partial anastomotic leak. This patient developed anastomotic stenosis requiring dilatation. The recurrence rate was 26.7% (8 patients), with a mean follow-up of 50 months, and three of them were treated with repeat Altemeier repair. Many patients complain of some degree of fecal incontinence, but all reported improvement in their quality of life after surgery. ConclusionThe Altemeier procedure showed low morbidity but it was associated with significant recurrence rate. The same procedure can be repeated in case of recurrence with satisfactory results.

P081 An audit of the management and aetiology of proctitis in men who have sex with men (MSM): Abstract P081 Table 1

Background Proctitis remains an important presentation of MSM to sexual health clinics. It causes significant morbidity and facilitates the transmission of other infections including HIV. Aims To audit the management and aetiology of proctitis in a UK sexual health clinic and determine the pattern of STIs presenting with rectal symptoms. Methods 100 consecutive notes of MSM presenting with rectal symptoms were examined (December 2014 – March 2015). The local clinical management standard is proctoscopy and Gram stain for gonorrhoea; gonorrhoea culture; gonorrhoea/chlamydia NAAT; HSV1/HSV2/ T.pallidum PCR; syphilis serology. Positive chlamydia NAATs are tested for LGV-associated serovars. Results 88/100 had proctoscopy performed. The tests undertaken and test results are summarised in the table below. 43 patients had all the recommended tests. 66 infections were diagnosed in 53 patients. 42 patients had one infection, 9 had two infections and 2 had three infections. 35 patients were diagnosed HIV positive before presentation, 64 patients tested HIV negative at presentation and one patient declined testing. Discussion This audit confirms that the majority of MSM presenting with rectal symptoms had proctoscopy but there is room for improvement in practice as only a minority had all tests undertaken. STIs are a common cause of anal symptoms in MSM and this data strongly supports a low threshold for STI screening. Routine HSV testing in MSM with rectal symptoms is useful.

O022 Rectal chlamydia infection in women – have we been missing the point?: Abstract O022 Table 1

Background/introduction BASHH standards recommend rectal chlamydia sampling in women with increased risk. However, studies show high rates of rectal chlamydia in women, with concerns over treatment failures and risk of genital re-infection Aim(s)/objectives To determine if rectal chlamydia screening in females should be universal. Methods As part of a selfswab versus clinician trial we asked females about frequency of vaginal, receptive anal, and oral sex, and correlated this with chlamydia NAATs from these sites. Results Recruitment to February 2016 included 1041 women. All consented to rectal sampling; none had rectal symptoms. 53% reported no prior receptive anal sex. 204 women had chlamydia (CT) positive NAATs at one or more sites: 176 (16.9%) VVS positive (86% of all CT positives); 190 (18.3%) rectal positive (93% of total CT positives); 49 (4.7%) pharyngeal positive. Rectal swabs were significantly more likely to detect CT than VVS: OR 2.75 (95% CI 1.22–6.18) p = 0.02 McNemar test. The table shows percentage women by positive site(s) reporting no anal sex. 92/190 (48.4%) of those with one site or combination rectal CT reported no previous anal sex. Of the 168 with VVS and rectal positive NAATs, the AC2 Reactive Light Units levels were equivalent, suggesting active infection at both sites. Discussion/conclusion In this sample of women with no rectal symptoms, the rectum was the most prevalent site for chlamydia infection, and rectal swabs found significantly more infections than VVS. There was no association with reported anal sex indicating sexual risk history is unreliable for targeted screening in women.

P225 Lymphogranuloma venereum: case report of simultaneous penile ulceration and bubo formation

Background/introduction Lymphogranuloma venereum (LGV) has become an important UK public health issue since 2003. HIV positive men who have sex with men (MSM) continue to be the predominant risk group for contracting LGV in the UK. Aim(s)/objectives LGV commonly presents as proctitis alone; we present an unusual case of a patient who presented with simultaneous rectal symptoms, penile ulceration and bubo. Methods A 25 year old HIV (CD4 996 (43%)/viral load undetectable) and Hepatitis C co-infected MSM presented to A&E with a 2 week history of painful left inguinal swelling. Additional history revealed episodes of bloody diarrhoea which the patient related to a previous diagnosis of Inflammatory Bowel disease. Examination revealed a left inguinal bubo and 3 areas of penile ulceration (2 painful, one indurated/painless). Proctoscopy was normal. Empirical treatment with Doxycycline and Aciclovir was commenced. Results Nucleic acid amplification testing (NAAT) was performed on pharynx, rectum, urine and penile ulcers. Urine NAAT was positive for Chlamydia trachomatis; penile ulcer NAAT was positive for LGV specific DNA. Herpes simplex and Treponemal PCR from the ulcers were negative. Rectal NAAT was negative for Chlamydia trachomatis . An Ultrasound of the left inguinal bubo revealed abscess formation with frank pus seen on aspiration. Discussion/conclusion LGV is commonly associated with proctitis and genital ulcers of LGV are evanescent. Persistence of LGV ulceration until bubo formation has not been reported to-date. The negative Rectal NAAT for Chlamydia was unusual however the diarrhoeal symptoms settled with Doxycycline.

Heterotopic gastric mucosa in the anus and rectum: first case report of endoscopic submucosal dissection and systematic review.

Background: Heterotopic gastric mucosa (HGM) is the most reported epithelial heterotopia, but it is very rare in the rectum and anus.Methods: The first case of an asymptomatic adult male with a large nonpolypoid HGM in the low rectum underwent complete resection by endoscopic submucosal dissection (ESD) is reported. The systematic review was based on a comprehensive search of MEDLINE, EMBASE and Google Scholar. Studies on humans were identified with the term ‘heterotopic gastric mucosa in the rectum and /or anus.’Results: The search identified 79 citations, and 72 cases were evaluated comprising the present report. Congenital malformations were observed in 17 (24%) patients; rectal duplication accounted for most of the cases. The HGM was located in the anus and perineal rectum in 25 cases (41%) and low, middle and proximal pelvic rectum in 20 (33%), five (8%) and 11 cases (18%), respectively. Morphology was nonpolypoid in 37 cases (51%), polypoid in 26 cases (36%) and ulcerated in nine cases (13%). Specific anorectal symptoms were reported by 50 (69%) patients of the whole study population, and by 33 (97%) of 34 patients ≤ 18 years. Complications were observed in 23 cases (32%). The HGM was excised in 50 cases (83%). Endoscopic resection was performed in 17 cases (34%); resection was piecemeal in five of 12 lesions ≥15 mm, required argon plasma coagulation in two cases and was associated with residual tissue in two (17%). Intestinal metaplasia and an adenoma with low-grade dysplasia were described in three adults (4%).Discussion: This systematic review shows that the HGM in the rectum and anus may be associated with specific rectal symptoms and serious complications, mainly in the pediatric population, and a risk of malignancy in adults. Its complete excision should be recommended, and the ESD can overcome the technical limits of conventional endoscopic snare resection and avoid unnecessary surgery.

Colitis cystica profunda of the rectum: An unexpected operative finding

Colitis cystic profunda is a rare entity benign condition of the colon and rectum that can mimic suspicious polyps or malignancy. The commonest sites of affectation are the rectum and the sigmoid colon but it can be unusually widely distributed in the colon. The aetiology of this condition is not fully elucidated and confident diagnosis can only be made on histological features. We hereby describe a patient who presented with significant rectal symptoms and an unexpected finding of a submucosal mucous cyst mimicking a suspicious rectal polyp and highlighted its significance and the review of the literature.

An interesting case of an adult with perineal testis presenting with rectal symptoms

An interesting case of an adult with perineal testis presenting with rectal symptoms

Highly diverse MLVA-ompA genotypes of rectal Chlamydia trachomatis among men who have sex with men in Brighton, UK and evidence for an HIV-related sexual network

ObjectivesIn this prospective study, we aimed to determine the distribution of genotypes by multilocus variable number tandem repeat (VNTR) analysis plus analysis of the ompA gene (MLVA-ompA) of rectal Chlamydia...

Restricted Eating Patterns in Chronic Constipation Are Associated With Bloating and Abdominal Symptoms More so Than Rectal and Stool Symptoms

Introduction: Many patients with chronic constipation attribute their symptoms to dietary factors, and restrictive eating is a common phenomenon in patients in this population. We aimed to determine which clinical factors affected restricted eating in these patients. Methods: We enrolled consecutive patients referred to our center for anorectal manometry in the setting of chronic constipation. Patients completed a validated disease-specific quality of life questionnaire (CR-QOL), which included an Eating Subscale where higher scores reflect more restricted eating. Patients also completed a symptom severity questionnaire (PAC-SYM) with subscales corresponding to abdominal symptoms (pain, discomfort, and bloating), rectal symptoms, and stool symptoms, the Hospital Anxiety and Depression Score inventory (HADS), a Rome III constipation module, and the Patient Health Questionnaire 15 (PHQ-15), a measure of somatization. Additionally, patients were asked which symptom was most bothersome about their constipation: painful bowel movements, infrequent bowel movements, straining, incomplete bowel movements, and bloating/fullness. Multivariable linear regression adjusting for confounders defined independent effect of measures of constipation severity, comorbidities, and demographics on eating patterns. Results: We enrolled 115 patients (101 females) with a mean age of 47.9 years referred for evaluation of chronic constipation. On univariate analysis, overall symptom severity from the PAC-SYM (R=0.22, P=0.03), as well as the abdominal symptom subscale (R=0.31, P=0.001) correlated with restricted eating. There was no association between rectal symptoms and stool symptoms and restricted eating. Additionally, somatization (P=0.007), anxiety (P=0.02), and depression (P=0.004) all had mild correlation to restricted eating (all Rs< 0.3). After multivariate adjustment, only abdominal symptoms remained an independent predictor of restricted eating (P=0.02). Patients complaining of bloating as their primary complaint had a mean Eating Subscale score of 10.4±3.7 compared to 8.5±3.4 for those with a primary complaint of straining, incomplete evacuation, infrequentBMs, or painful BMs (P=0.01). Conclusion: Among patients presenting for evaluation of chronic constipation, abdominal symptoms (including bloating) were the primary driver of restricted eating patterns. These patients may derive the greatest benefit from structured, evidence-based dietary interventions rather than self-imposed restrictions.

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

003.3 The prevalence ofmycoplasma genitaliumandchlamydia trachomatisat various anatomical sites of men who have sex with men in five cities of china

Introduction To determine the prevalence of Mycoplasma genitalium and Chlamydia trachomatis in urethra, rectum and pharynx of men who have sex with men (MSM) in China, and to analyse the association between the agents detection and clinical manifestations. Methods 388 MSM were recruited at gay bars in five cities of China from September 2007 to November 2008. Rectal and pharyngeal swabs and first void urine were tested for M. genitalium and C trachomatis by PCR. Bivariate and multivariable analyses were performed to determine the association between the infections and clinical manisfestations. Results The prevalence of M. genitalium infection at urethral, rectal and pharyngeal sites was 17.2% (95% CI: 13.4% to 21.0%), 11.8% (95% CI: 8.4% to 15.2%), and 13.5% (95% CI: 9.9% to 17.1%), respectively. C trachomatis was more commonly detected in rectum (16.0%, 95% CI: 12.2% to 19.8%) than in urethra (9.4%, 95% CI: 6.4% to 12.3%) and in pharynx (0.8%, 95% CI: 0.1% to 1.6%). Urethral M. genitalium infection was significantly associated with urethral discomfort in the past 3 months (AOR: 2.22, 95% CI: 1.09–4.52) and polymorphonuclear leucocyte (PMNL) counts per high-power microscope field (AOR: 2.40, 95% CI: 1.02–5.62). Rectal M. genitalium infection was independently associated with rectal discharge in the past 3 months (AOR: 6.06, 95% CI: 1.59–23.11). For C trachomatis infection, PMNL counts per high-power microscope field (AOR: 4.66, 95% CI: 1.80–12.07) and having receptive anal intercourse with a male in the past 3 months (AOR: 2.27, 95% CI: 1.14–4.54) were associated with urethral and rectal C trachomatis infection, respectively. Conclusion High prevalence of M. genitalium infection was observed among MSM in China at urethral, rectal and pharyngeal sites. M. genitalium infection was significantly associated with urethral and rectal symptoms. C trachomatis was more commonly detected in rectum and more likely to be asymptomatic. Disclosure of interest statement No potential conflicts of interest.

Abdominal Symptoms Are Common and Benefit from Biofeedback Therapy in Patients with Dyssynergic Defecation.

Objectives:Dyssynergic defecation (DD) is a subtype of chronic constipation that responds to biofeedback therapy (BFT). Abdominal, anorectal, and stool symptoms are commonly reported by DD patients, but limited data exist to demonstrate the improvement of these associated symptoms to BFT. Aims to prospectively study the response of constipation and associated abdominal, rectal, and stool symptoms to biofeedback in a population with dyssynergia.Methods:Patients with DD as determined by anorectal manometry and balloon expulsion testing were included into the study. All patients completed a validated survey, the Personal Assessment of Constipation Symptom (PAC-SYM) questionnaire, before and following BFT. The PAC-SYM is a clinical tool to assess constipation-related symptom frequency and severity.Results:Seventy-seven dyssynergic patients fulfilled the study requirements. Abdominal symptoms were present in up to 74% of patients with dyssynergia. PAC-SYM summation scores improved following completion of biofeedback by 48%, from 22.08 to 11.48 (P<0.001). The proportion of patients with at least moderate symptoms decreased in all 12 questionnaire items, including all abdominal symptoms, after completing BFT (46.8% to 14.3%, P<0.001).Conclusions:Abdominal symptoms are common in patients with dyssynergia. BFT improves both anorectal-related constipation symptoms and associated abdominal symptoms in patients with DD. Limitations of this study are observational design, lack of control group, and lack of long-term follow-up.

Imaging of tailgut cysts.

Tailgut cysts are congenital lesions that arise from the primitive hindgut in the true embryonic tail but fail to regress during gestation. These lesions are rare and more frequently encountered later in life and more commonly in women, and are the most common primary retrorectal tumor. Tailgut cysts may be asymptomatic or cause rectal bleeding, pain, or symptoms related to mass effect on the rectum or bladder. Pathologically, tailgut cysts are typically multilocular, lined with a variety of epithelial cell types, and are most frequently benign. Imaging is the linchpin of diagnosis due risks associated with biopsy. The purpose of this pictorial review is to present the spectrum of imaging findings associated with tailgut cysts on CT and MRI with focus on the use of advanced MRI and diffusion-weighted imaging. We present case examples of tailgut cysts, their CT and MR imaging findings, and diagnostic and management considerations.

P27 Extra-genital chlamydia testing in heterosexual patients. is it worth it?

<h3>Background/introduction</h3> Current clinic policy is to offer extra-genital testing to all patients reporting a history of active oral sex and/or receptive anal sex. These swabs are analysed using the Aptima Combo II platform for <i>Chlamydia trachomatis</i> (CT). <h3>Aim(s)/objectives</h3> With analysis costing £6.20 per swab we sought to explore the cost effectiveness and review positive case with collateral contact information and symptoms history to support a positive diagnosis. <h3>Methods</h3> Inclusion criteria were heterosexual patients with exclusively extra-genital CT who did not present as CT contact. We performed retrospective case note review of 63 sets of notes to determine symptom history, concurrent STI diagnosis and contact diagnosis. <h3>Results</h3> Over the year, a total of 12076 throat swabs were sent in this group. There were 39 confirmed positive results giving swabs sent per positive result ratio of 310:1. Or a cost of £1922 per positive result. For rectal swabs; a total of 1156 were sent. There were 24 positive results giving swabs sent per positive result ratio of 48:1, or a cost of £297.60 per positive result. 5% of patients with a positive extra-genital swab result gave a history of throat or rectal symptoms. 4% had a concurrent STI diagnosis, 40% of those with traceable contacts had at least one positive contact. <h3>Discussion/conclusion</h3> Routine extra-genital screening is costly but this review demonstrates its value for detection of individual cases which would have been missed. In addition the high proportion of positive contacts adds weight to the debate for extra-genital testing of all contacts.