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References: Laxative

Eur J Gastroenterol Hepatol. 1996 Dec;8(12):1207-11.
Decreased substance P levels in rectal biopsies from patients with slow transit constipation.

Tzavella K, Riepl RL, Klauser AG, Voderholzer WA, Schindlbeck NE, Muller-Lissner SA.

Medizinische Klinik, Klinikum Innenstadt, University of Munich, Germany.

OBJECTIVE: Previous studies in patients with chronic constipation found abnormalities in the nervous tissue of the large intestine, predominantly in the muscularis externa. Since there is evidence that the nervous system of mucosa and submucosa is also involved in the control of colonic motility we investigated the contents of vasoactive intestinal polypeptide (VIP), somatostatin and substance P in rectal biopsies of patients with slow colonic transit constipation. DESIGN AND METHODS: Twenty-two patients (17 females, 5 males) with chronic slow transit constipation (oro-anal transit with radio-opaque markers on high fibre diet > 70 h) and long-term use of laxatives, and 20 controls (12 females, 8 males) with no history of constipation, were included in this study. Large rectal biopsy specimens including the submucosa were obtained from 5 cm above the dentate line and frozen in liquid nitrogen. After microdissection of the biopsies into mucosa and submucosa the neuropeptides were extracted by boiling and homogenizing the tissue in acetic acid and determined using validated radioimmunoassays. RESULTS: Patients with slow transit constipation showed, compared to healthy controls, significantly lower levels of the excitatory neurotransmitter substance P in the mucosa and submucosa of rectal biopsies. There was no difference between the two groups concerning the levels of the inhibitory neurotransmitters, VIP and somatostatin. CONCLUSION: Slow transit constipation is associated with abnormalities of the substance P content of the enteric nervous system of mucosa and submucosa. This seems not to be related to chronic laxative use, since anthranoids cause a reduction in the levels of inhibitory neurotransmitte

Am J Obstet Gynecol. 1996 Dec;175(6):1438-41; discussion 1441-2.
Diagnosis and assessment of sigmoidoceles.

Fenner DE.

Department of Obstetrics and Gynecology, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL 60612, USA.

OBJECTIVE: This study analyzed the clinical presentation, incidence, characteristics as demonstrated by defecating proctography, and surgical outcomes of sigmoidoceles. STUDY DESIGN: Defecating proctograms were obtained on all women with clinical evidence of pelvic floor defects between June 1, 1991, and June 30, 1995. The proctograms were retrospectively reviewed for the presence of a sigmoidocele and concomitant pelvic hernias. The distance between the maximum point of sigmoid descent with strain and the perineal body was measured. A chart review was performed to obtain clinical history, physical examination results, surgical treatment, and outcome. RESULTS: Nine sigmoidoceles (4.0%) were noted in 234 defecating proctograms. The leading edge of the sigmoid hernia ranged from 3.8 cm beyond the perineal body to 8 cm above the perineal body. All nine patients were found to have concomitant rectoceles by proctography, whereas only three were found to have enteroceles. Physical examination before proctography suggested that six patients had vaginal vault prolapse with enterocele, one patient had uterine prolapse with an enterocele, and two patients had rectoceles alone. Five of the seven patients clinically diagnosed with an enterocele showed no small bowel herniation on defecography. No sigmoidoceles were suspected by physical diagnosis alone. All rectoceles were diagnosed by clinical examination. All patients except one, who had concomitant rectal prolapse, complained of constipation. Two patients required manual pressure to the perineum or vagina to defecate. Seven of the nine patients underwent pelvic reconstructive surgery. The surgical procedure for sigmoidocele was determined by severity of constipation, degree of prolapse, and sigmoid redundancy at the time of surgery. Two patients und

Br J Obstet Gynaecol. 1997 Jan;104(1):82-6.
Posterior colporrhaphy: its effects on bowel and sexual function.

Kahn MA, Stanton SL.

Department of Obstetrics and Gynaecology, St. George's Hospital, London, UK.

OBJECTIVE: To determine the anatomical cure rate of posterior colporrhaphy and its effect on bowel and sexual function one to six years later. DESIGN: Retrospective observational study. SETTING: Urogynaecology Unit, St George's Hospital, London. PARTICIPANTS: Two hundred and thirty-one women who underwent posterior colporrhaphy. MAIN OUTCOME MEASURES: Anatomical and symptomatic cure of rectocoele. METHODS: The charts of 231 women who underwent 244 posterior colporrhaphies between 1 January 1989 and 4 January 1994 were reviewed. One hundred and seventy one (74%) were interviewed; 140 (61%) were examined. Mean follow up time was 42.5 months (range 11-74). RESULTS: Two hundred and nine women had prior or concurrent vaginal and/or bladder neck surgery including 38 previous posterior colporrhaphies. Postoperatively prolapse symptoms due to rectocoele decreased (64% vs 31%). Constipation (22% vs 33%), incomplete bowel emptying (27% vs 38%), incontinence of faeces (4% vs 11%) and sexual dysfunction (18% vs 27%) increased. Those with incontinence of stool were more likely to have had two or more posterior colporrhaphies. Sixty-two percent felt that they improved over all after surgery. Additional postoperative symptoms included: vaginal and/or perineal splinting (33%), soiling and/or inability to wipe clean (16%), rectal digitation (23%), incontinence of flatus (19%), and rectal and/or vaginal pain (22%). Thirty-three women (24%) had large rectocoeles, seven of whom did not have impaired bowel emptying. CONCLUSIONS: Posterior colporrhaphy corrects the vaginal defect in 76% of women. It does not necessarily correct and may contribute to bowel and sexual dysfunction, particularly in those requiring multiple procedures. The presence of the anatomical defect does not imply dysfunction. The prevalence o

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