The inevitable consequences of any of the serious forms of ulceration above described are, if recovery ensues, and usually even if it does not, the formation of cicatricial constrictions by which varying degrees of rectal stricture are produced. Rectal strictures, then, are to be grouped as:
- 1. Those due to previous and more or less active, morbid intrinsic processes;
- 2. Those due to the presence of organized exudate, tumors, or other compressing causes from without;
- 3. Those due to traumatism.
The symptoms and signs of rectal stricture include those of ulceration and obstruction, or difficulty in defecation. A history of alternating constipation and diarrhea, with perhaps tenesmus, and with discharge of pus or blood, will prove the presence of some obstruction. One characteristic feature met with in some strictures is the passage of stools which when solid or semisolid have a characteristic tape- or cord-like shape, as though extruded through a constricted passage-way. This is not a feature necessarily present, and may be produced even in non-malignant cases, as when the rectum is obstructed by uterine myomas.
With respect to any suspected rectal or colonic stricture it is necessary to determine: (1) Its existence; (2) its location; (3) its character; (4) any other circumstances bearing upon the case which might affect the question of treatment. The latter is particularly important when the question of syphilis is raised.
The above features are determined by careful physical examination for which the finger alone may be sufficient, or which may require instruments and postures already described.
Treatment.
—Treatment of rectal strictures is necessarily mechanical, but will depend in large measure upon their cause and extent. Thus a stricture produced by conditions extrinsic to the rectum proper might require abdominal section and removal of a pelvic tumor or other similar operation. Many a patient with retroflexed uterus will complain of a rectal condition which is essentially one of stricture, the overturned uterine fundus being forced against the rectum and pressing upon it, demanding not a rectal operation but one for suspension of the uterus. The obstipation which is produced by ptosis of the sigmoid, or by hypertrophy and abnormal arrangement of the folds and rectal valves, may necessitate operation upon the colon (coloplication or colopexy) or a careful division of hypertrophied mucosa through the proctoscope, as used by one skilled in its manipulation.
Fig. 592
Stricture of rectum. (Bryant.)