Clinical scores results are as follows:
• Cleveland Clinic Constipation Score
using a score of 15 as threshold value for the definition of "constipation":
-12 patients score> 15;
-18 patients score≤ 15.
• Wexner Continence Grading Scale
using a score of 10 as threshold value for the definition of "incontinence":
-10 patients score> 10;
-20 patients score ≤ 10.
As concern MRI findings:
• Intussusception and Rectocele
-in14 patients (47%),
it is visible and measurable,
at MR-defecography,
relapse of rectocele,
with or without rectal intussusception;
-in 16 patients (53%),
preexisting rectal prolapse/rectocele is no longer visible.
Starting from the objective MRI findings,
patients are classified as "negative",
i.e.
no recurrence of rectocele after surgery,
and "positive",
i.e.
relapse of rectocele.
According to CCCS scoring system,
used to objectively quantify the severity of constipation,
these two groups patients are further classified.
In particular,
patients who score >15 are considered "symptomatic",
while patients who score ≤15 are defined "no symptomatic".
By comparing MRI and CCCS,
4 classes of patients are created,
defined respectively:
-“negative no-symptomatic patients” or “true-negative ones”: patients without evidence of rectocele or rectal prolapsed at MRI and who score ≤15 at CCCS;
-“negative-symptomatic patients” or “false negative ones”: while presenting clear absence of disease on MRI,
these patients scored >15 at CCCS,
with persistent constipation after surgery;
-“positive-symptomatic patients” or “true-positive ones”: patients with rectocele relapse disease at MRI and a CCCS score >15;
-“positive no-symptomatic patients” or “false positive ones”: patients with recurrent rectocele or rectal prolapse at MR-defecography,
without constipation (CCCS score ≤15).
For each category identified with this clinical-MRI follow-up,
it is defined a precise multidisciplinary and shot/long-term monitoring after STARR.
“Negative no-symptomatic or true-negative patients”
According protocol,
it is possible to suggest to patients without constipation and without rectocele relapse at MR:
-annual surgical examination;
-annual MR-defecography,
for 5 years;
-biofeedback rehabilitative therapy in case of fecal incontinence (Fig.5),
corresponding to a score >10 on Wexner Continence Grading Scale.
“Negative symptomatic or false negative patients”
While presenting absence of recurrent rectocele disease at MR-defecography,
these patients score >15 at CCCS and considered symptomatic for constipation.
Differences between clinic and MRI suggest a more complex long-term monitoring,
that may include:
-annual MR-defecography,
for 5 years;
-biofeedback rehabilitative therapy in patients with fecal incontinence (score >10 at WCGS) and with dyssynergia of puborectal muscles (Fig.6) [7];
-gastroenterological consulting in order to determine the cause of persistent constipation (e.g.
colonic transit constipation or irritable bowel syndrome),
considering the success STARR surgery;
-if necessary,
psychological support.
“Positive symptomatic or true positive patients”
In patients whose MR-defecography evidences recurrent rectocele or rectal prolapse,
and who report persistent constipation,
with score >15 at CCCS,
it is considered the possibility of reintervention:
-STARR or other surgical operation to correct the anatomical alteration,
generally in absence of enterocele and uro-genital prolapse,
as demonstrated at MR-defecography (Fig.7-8);
-combined surgery for rectocele,
enterocele and uro-genital prolapse correction in patients with descending perineum syndrome (Fig.9).
“Positive no-symptomatic or false positive patients”
Although presenting recurrent rectocele disease at MRI (Fig.10),
these patients are considered no-symptomatic,
as reported score ≤15 at the CCCS.
In such case,
because of discrepancy between clinic and imaging features,
a short-term monitoring is advisable.
In fact there is the real risk that a silent rectocele is becoming evident conditioning ODS,
therefore such patients are recommended:
-MR-defecography every 6 months,
-surgical examination every 6 months.