World Journal of Colorectal Surgery

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1 World Journal of Colorectal Surgery Volume 6, Issue Article 8 Sigmoidocele: A Rare Cause Of Constipation In Males Noor Shah MD Milind Kachare MD Craig Rezac MD Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, The United States Of America, noorshah@rwjms.rutgers.edu Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, The United States Of America, milindkachare@gmail.com Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, The United States Of America, rezaccr@rwjms.rutgers.edu Copyright c 2017 The Berkeley Electronic Press. All rights reserved.

2 Sigmoidocele: A Rare Cause Of Constipation In Males Noor Shah MD, Milind Kachare MD, and Craig Rezac MD Abstract Background: Sigmoidoceles are an uncommon but important cause of constipation and obstructive defecation syndrome (ODS) that is found almost exclusively in females. The redundancy of the sigmoid colon causes it to extend 4.5 cm below the pubococcygeal line. It cannot be diagnosed via a physical examination or traditional imaging techniques, thus it is often missed as the etiology of constipation. Case Report: We present the case of a 52-year-old male suffering from chronic constipation, who now presents with symptoms of obstructive defecation syndrome and a presumed diagnosis of a diverticular structure from a prior colonoscopy and CT scan of the abdomen/pelvis. Results: Direct visualization during a low anterior resection revealed a redundant sigmoid in the pelvis consistent with a diagnosis of sigmoidocele; all symptoms resolved upon 2 month follow-up with no post-operative complications. Conclusion: Although it is an extremely rare entity in the general population and even more so in men, sigmoidocele can be the cause of constipation and ODS in certain patients, but can be effectively diagnosed with a defecating proctography and definitively managed with a sigmoid resection. KEYWORDS: constipation; obstructive defecation syndrome; prolapse; low anterior resection

3 Shah et al.: Sigmoidocele: A Rare Cause Of Constipation In Males 1 Introduction Constipation is a common complaint in the United States, with a prevalence ranging from 1.9% to 27.2% in North America, due to the varying definitions of constipation [1]. Although it is often accredited to a poor lifestyle and diet, a more ominous pathology can be the underlying cause. In women, laxity of pelvic ligaments from childbirth, as well as the inherently wider pelvic diameter, lend to increased incidences of pelvic and gastrointestinal prolapse, the latter of which can lead to symptoms of obstructive defecation [2]. Obstructed defecation syndrome (ODS) is defined as a prolonged (more than 6 months) history of difficult rectal evacuation, including excessive straining, feeling of incomplete evacuation or inability to evacuate without digitation [2]. One of the more uncommon versions of these prolapses is a sigmoidocele, which occurs due to a break in the fascial supports of the upper vagina creating a defect through which the sigmoid colon can herniate through during times of increased abdominal pressure [3]. Sigmoidocele is a very uncommon cause of constipation. In one study sigmoidocele was found to be the culprit in only 4% of 234 women who suffered from chronic constipation [3]. Furthermore, sigmoidocele is almost never described to occur in men [4]. Here, we describe the case of a male who presented with chronic constipation and new onset abdominal pain. Although he was originally thought to have a diverticular stricture, the patient was found to have a sigmoidocele upon direct visualization in the operating room. Case Report A fifty-two year-old male with a history of chronic constipation presented to the colorectal surgery clinic with a six-month history of intermittent, cramping abdominal pain. The pain occurs approximately 3 times a week and is located in the left lower quadrant. He states that he must strain to pass a bowel movement, which although common for him due to his constipation, was now resulting in explosive, liquid bowel movements. The patient saw a gastroenterologist 3 months ago who performed a colonoscopy, which showed a significant diverticular stricture in the sigmoid colon. Of note, he had an episode of uncomplicated diverticulitis about 2 years ago that resolved with a 3-day admission to the hospital and treatment with bowel rest, intra-venous fluids and antibiotics. After evaluation at the clinic, the patient agreed to undergo a robotic low anterior resection to remove the presumed strictured area in the sigmoid colon to provide relief of his symptoms. During the procedure, many adhesions were noted in the Produced by The Berkeley Electronic Press, 2016

4 2 World Journal of Colorectal Surgery Vol. 6, Iss. 5 [2016], Art. 8 right lower quadrant between the terminal ileum and the abdominal wall, which were subsequently lysed. The small bowel was then mobilized out of the pelvis, which revealed that the entire sigmoid colon and descending colon was confined in the pelvis, consistent with a sigmoidocele. The pelvis was also noted to be extremely wide for a male [Figure I]. There was no significant diverticular disease nor was there an area of induration or chronic inflammation consistent with the presumed diagnosis of a diverticular stricture. The adhesions were lysed to free the colon from the abdominal wall and the sigmoid colon and proximal rectum were removed, Continuity was restored with a primary end-to-end descending colon to rectum anastomosis. On 2-month follow-up, the patient s symptoms of constipation and abdominal cramping have completely resolved. Discussion Although a sigmoidocele is a rare occurrence in the general population and especially in men, it should be considered when a patient presents with either chronic constipation or symptoms of ODS with no easily discernable pathology. Unfortunately, sigmoidocele cannot be detected through routine physical exam or imaging. It is necessary to obtain a defecating proctography to obtain a true diagnosis [5]. This test allows visualization of the prolapsing segment of bowel during defecation via fluoroscopy [5]. Diagnosis of sigmoidocele is made by the visualization of the presence of gas-filled sigmoid loops in the pouch of Douglas [6]. Currently, there is no consensus on the gold standard treatment for a sigmoidocele. The two main forms of treatment in the literature are either a sigmoidopexy or a sigmoid resection, with the latter being reserved for those patients with severe prolapse unamenable to fixation [1]. One study found that the patients who underwent a fixation procedure alone were noted to have continued symptoms of constipation after the procedure, whereas those who had the resection had resolution of all symptoms [1]. Sigmoidocele is due to laxity of the fascial supports of the upper vagina in women [2]. It is also associated with lax pre-sacral fixation of the rectosigmoid colon [6], which may have been a part of the pathophysiology of disease in our patient. Our patient was also noted to have a wider than normal pelvis for the male, which may have contributed to tendency for the sigmoid colon to fill the pelvis, instead of remaining in the lower peritoneal cavity as it is normally expected to.

5 Shah et al.: Sigmoidocele: A Rare Cause Of Constipation In Males 3 Conclusion Although it is an extremely rare entity in the general population and even more so in men, sigmoidocele can be the cause of constipation and ODS in certain patients. Constipation is a frustrating problem that can lead to other more serious sequelae. Being able to identify and create a treatment plan can improve the quality of life of the patient and decrease the morbidities related with chronic constipation. Thus, we propose that if a patient presents with chronic constipation without any identifiable cause on routine screening, a defecating proctography should be considered, as it may identify a sigmoidocele as the culprit. References 1. Riss, Stefan. "Surgery for Obstructed Defecation Syndrome-Is There an Ideal Technique." World Journal of Gastroenterology WJG 21.1 (2015): Morandi, C., J. Martellucci, P. Talento, and A. Carriero. "Role of Enterocele in the Obstructed Defecation Syndrome (ODS): A New Radiological Point of View." Colorectal Disease 12.8 (2009): Fenner, Dee E. "Diagnosis and Assessment of Sigmoidoceles." American Journal of Obstetrics and Gynecology (1996): Jorge, J. Marcio N., Yung-Kang Yang, and Steven D. Wexner. "Incidence and Clinical Significance of Sigmoidoceles as Determined by a New Classification System." Diseases of the Colon & Rectum (1994): Kelvin, F. M., D. D. Maglinte, J. A. Hornback, and J. T. Benson. "Pelvic Prolapse: Assessment with Evacuation Proctography (defecography)." Radiology (1992): Web. 5. Nielsen, Michael Bachmann, Birgitte Buron, John Christiansen, and Viktor Hegedüs. "Defecographic Findings in Patients with Anal Incontinence and Constipation and Their Relation to Rectal Emptying." Diseases of the Colon & Rectum 36.9 (1993): Maglinte, Dean, et al. "Functional Imaging of the Pelvic Floor." Radiology (2011): Produced by The Berkeley Electronic Press, 2016

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Fecal Incontinence. What is fecal incontinence?

Fecal Incontinence. What is fecal incontinence? Scan for mobile link. Fecal Incontinence Fecal incontinence is the inability to control the passage of waste material from the body. It may be associated with constipation or diarrhea and typically occurs