Is the volume retained after defecation a valuable parameter at defecography?

Reappraising the Role of Enterocele in the Obstructed Defecation Syndrome: Is Radiological Impaired Rectal Emptying Significant in Enterocele?

Objectives:

The role of enterocele in the obstructed defecation syndrome (ODS) has remained to be controversial, as patients with enterocele frequently exhibit multiple risk factors, including aging, parity, concomitant different abnormalities, previous histories of pelvic surgery, and incomplete emptying of the rectum. Thus, in this study, we aimed to investigate the association between enterocele and ODS using multivariate analysis.

Methods:

Between June 2013 and June 2021, 336 women underwent defecography as they had symptoms of ODS. Of those, 293 women (87%) who had anatomical abnormalities were included in this study.

Results:

Enterocele was detected in 104 (36%) patients. More women with enterocele had histories of hysterectomy compared to those without enterocele (29% vs. 10%, P < 0.0001). The frequency of radiological incomplete emptying was found to be significantly lower in women with enterocele (36%) than in those without enterocele (50%), whereas the mean (95% confidence interval) ODS scores in women with enterocele were significantly higher than those without enterocele [12.1 (11.0-13.3) versus 10.8 (10.5-11.5), P = 0.023]. As per the results of our multivariate analysis, it was determined that the presence of enterocele was associated with higher ODS scores (P = 0.028). However, the small differences in the mean score (1.3) would be clinically negligible. The specific radiological type of enterocele which compressed the rectal ampulla at the beginning of defecation was not associated with the increased ODS scores.

Conclusions:

The presence of enterocele may not be a primary cause of ODS. Other anatomical abnormalities combined with enterocele, or the hernia itself, may have a role in causing ODS.

Comparison of changes in rectal area and volume during MR evacuation proctography in healthy and constipated adults

BACKGROUND

During proctography, rectal emptying is visually estimated by the reduction in rectal area. The correlation between changes in rectal area, which is a surrogate measure of volume, is unclear. Our aims were to compare the change in rectal area and volume during magnetic resonance (MR) proctography and to compare these parameters with rectal balloon expulsion time (BET).

METHODS

In 49 healthy and 46 constipated participants, we measured BET and rectal area and volume with a software program before and after participants expelled rectal gel during proctography.

KEY RESULTS

All participants completed both tests; six healthy and 17 constipated patients had a prolonged (>60 seconds) BET. During evacuation, the reduction in rectal area and volume was lower in participants with an abnormal than a normal BET (P < 0.01). The reduction in rectal area and volume were strongly correlated (r = 0.93, P < 0.001) and equivalent for identifying participants with abnormal BET. Among participants with less evacuation, the reduction in rectal area underestimated the reduction in rectal volume. A rectocele larger than 2 cm was observed in eight of 18 (44%) participants in whom the difference between change in volume and area was ˃10% but only 14 of 77 (18%) participants in whom the difference was ≤10% (P = 0.03).

CONCLUSIONS

Measured with MR proctography, the rectal area is reasonably accurate for quantifying rectal emptying and equivalent to rectal volume for distinguishing between normal and abnormal BET. When evacuation is reduced, the change in rectal area may underestimate the change in rectal volume.

Changes in anorectal physiology following injection sclerotherapy using aluminum potassium sulfate and tannic acid versus transanal repair in patients with symptomatic rectocele; a retrospective cohort study

Background

Following injection sclerotherapy using ALTA (aluminum potassium sulfate and tannic acid) (ALTAS) and transanal rectocele repair (TAR), changes in anorectal physiology were analyzed to compare the significance of the two treatments.

Methods

ALTAS was administered to 23 patients and 18 patients were treated using TAR. Efficacy measures included changes in defecography, anorectal manometry and constipation scoring system value.

Results

This was a retrospective cohort analysis conducted on prospectively collected data. Comparing anorectal physiology pre- and post- ALTAS, a statistically significant difference in push was observed with pre-ALTAS treatment (pre-A) at 104.33 ± 4.91° compared with post-ALTAS treatment (post-A) at 113.95 ± 4.74° (p < 0.001). With a pre-A value of 1.55 ± 0.18 cm and a post-A value of 2.46 ± 0.34 cm, perineal descent also showed an increase as well (p < 0.001). The rectocele size decreased post-A from a pre-A value of 7.74 ± 0.86 cm compared with a post-A value of 2.91 ± 0.52 cm (p < 0.001). The rectal sensation improved post-A compared with pre-A. Comparing anorectal physiology results of ALTAS and TAR treatments, no differences in defecography and rectal sensation were detected pre- and post-treatment. However, in terms of anorectal manometry, the mean resting pressure and maximal squeezing pressure showed statistical difference with two treatments.

Conclusions

ALTAS treatment is a feasible option resulting in rapid and effortless long-term outcome, with low rates of complications. Therefore, this treatment may be an effective alternative for patients with symptomatic rectocele.

Functional Disorders: Rectocele

Rectoceles are a very common finding in patients, and symptoms most commonly include pelvic pain, pressure, or difficulty with passing stool. However, there are often other associated pelvic floor disorders that accompany rectoceles, making the clinical significance of it in an individual patient often hard to determine. When evaluating a patient with a rectocele, a thorough history and physical exam must be conducted to help delineate other causes of these symptoms. Treatment consists of addressing other defecatory disorders through various methods, with surgery reserved for select cases in which obstructed defecation is well documented.

Defecography

Defecography, a dynamic imaging modality, plays an important role in the diagnosis of functional and morphologic abnormalities of the anorectal region. We have here summarized the principle and techniques as well as observations of defecography, with special emphasis on morphologic measurements, clinical relevance, and limitations. The application of MR imaging in examination of anorectal function has also been addressed.

Evacuation proctography: a reappraisal of normal variability

AIM

Interpretation of evacuation proctography (EP) images is reliant on robust normative data. Previous studies of EP in asymptomatic subjects have been methodologically limited. The aim of this study was to provide parameters of normality for both genders using EP.

METHOD

Evacuation proctography was prospectively performed on 46 healthy volunteers (28 women). Proctograms were independently analysed by two reviewers. All established and some new variables of defaecatory structure and function were assessed objectively: anorectal dimensions; anorectal angle changes; evacuation time; percentage contrast evacuated; and incidence of rectal wall morphological 'abnormalities'.

RESULTS

Normal ranges were calculated for all main variables. Mean end-evacuation time was 88 s (95% CI: 63-113) in male subjects and 128 s (95% CI: 98-158) in female subjects; percentage contrast evacuated was 71% (95% CI: 63-80) in male subjects and 65% (95% CI: 58-72) in female subjects. Twenty-six (93%) of 28 female subjects had a rectocoele with a mean depth of 2.5 cm (upper limit = 3.9 cm). Recto-rectal intussusception was found in nine subjects (approximately 20% of both genders); however, recto-anal intussusception was not observed. Only rectal diameter differed significantly between genders. Qualitatively, three patterns of evacuation were present.

CONCLUSION

This study defines normal ranges for anorectal dimensions and parameters of emptying, as well as the incidence and characteristics of rectal-wall 'abnormalities' observed or derived from EP. These ranges can be applied clinically for subsequent disease comparison.

Recto-anal manometric characteristics of type 2 diabetic patients who have sensation of incomplete defecation

INTRODUCTION

Many diabetic patients report symptoms of incomplete defecation. We aimed to clarify the recto-anal manometric characteristics related to these symptoms.

MATERIAL AND METHODS

A questionnaire regarding gastrointestinal symptoms was distributed to 35 diabetics (19 women and 16 men) aged between 39 and 81 years. Nineteen reported incomplete defecation sensation (WS) and 16 did not (NS). Recto-anal manometry was performed for all patients. Data are presented as mean±SD.

RESULTS

Resting rectal pressure was 14.4±10.1 mmHg and 8.8±3.9 mmHg, p<.03; first sensation was 61.0±27.8 ml and 83.1±35.7 ml, p<.04; and maximum tolerable volume was 174.2±81.5 ml and 235.0±89.5 ml, p<.04 for WS and NS, respectively. The WS group was further divided into 2 groups according to symptom severity (less severe and very severe). Significant differences were found in resting external anal sphincter pressure (50.4±15.6 and 34.3±17.4, p<.04) and the recto anal inhibitory reflex (48.6±19.8 and 26.3±23.2, p<.03) between the less severe and very severe groups, respectively.

CONCLUSIONS

(1) Resting rectal pressure was significantly higher in symptomatic individuals. (2) First sensation and maximum tolerable volume were higher in asymptomatic diabetics. (3) In diabetics with more severe symptoms, the resting external anal sphincter pressures were significantly lower. (4) The degree of relaxation in the recto-anal inhibitory reflex was significantly higher in individuals without complaints.

Rectocele--does the size matter?

OBJECTIVES

Large rectoceles (>2 cm) are believed to be associated with difficulty in evacuation, constipation, rectal pain, and rectal bleeding. The aim of our study was to determine whether rectocele size is related to patient's symptoms or defecatory parameters.

METHODS

We conducted a retrospective study on data collected on patients referred to our clinic for the evaluation of evacuation disorders. All patients were questioned for constipation, fecal incontinence, and irritable bowel syndrome and were assessed with dynamic perineal ultrasonography and conventional anorectal manometry.

RESULTS

Four hundred eighty-seven women were included in our study. Rectocele was diagnosed in 106 (22%) women, and rectocele diameter >2 cm in 93 (87%) women. Rectocele size was not significantly related to demographic data, parity, or patient's symptoms. The severity of the symptoms was not correlated to the size or to the position of the rectocele. The diagnosis of irritable bowel syndrome was neither related to the size of the rectocele. Rectocele location, occurrence of enterocele, and intussusception were not related to the size of the rectocele. Full evacuation of rectoceles was more common in small rectoceles (79% vs. 24%, p = 0.0001), and no evacuation was more common in large rectoceles (37% vs. 0, p = 0.01). Rectal hyposensitivity and anismus were not related to the size of the rectocele.

CONCLUSION

In conclusion, only the evacuation of rectoceles was correlated to the size of the rectoceles, but had no clinical significance. Other clinical, anatomical factors were also not associated to the size of the rectoceles. Rectoceles' size alone may not be an indication for surgery.

Treatment of obstructed defecation

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve an optimal outcome. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. As the pelvis contains many structures, a pelvic support or function defect frequently affects other pelvic organs. Optimal outcomes can only be achieved by selecting appropriate treatment modalities that address all of the components of a patient's problem.

Rectocele

Rectoceles are common and involve a herniation of the rectum into the posterior vaginal wall that results in a vaginal bulge. Women with rectoceles generally complain of perineal and vaginal pressure, obstructive defecation, constipation, or the need to splint or digitally reduce the vagina to effectuate a bowel movement. Rectoceles are associated with age and parturition and arise from either a tear or stretching of the rectovaginal fascia, and can be repaired via a vaginal, anal, or perineal approach. Although the rate of successful anatomic repair is high, reports of functional outcome are more variable.

Transperineal rectocele repair with polyglycolic acid mesh: a case series

PURPOSE

This study was designed to evaluate the outcome of transperineal rectocele repair using polyglycolic acid mesh.

METHODS

Eighty-three consecutive females with predominant, symptomatic Stage II or Stage III rectocele underwent transperineal rectocele repair using polyglycolic acid (Soft PGA Felt(R)) mesh and finished their six-month follow-up. No additional interventions, including levatoroplasty or perineorraphy, were performed. The preoperative and postoperative symptom scores and stages of the posterior vaginal wall prolapse were recorded. The end points were reassessed at six months, postoperatively.

RESULTS

Preoperatively, 39 patients had Stage II and 44 patients had Stage III rectocele. The mean total symptom score was 9.87 +/- 1.93, which was reduced to 1.62 +/- 0.59 postoperatively (P < 0.0001). Objective evaluation of anatomic repair revealed that 74 patients (89.2 percent) had anatomic cure. Surgical complications were seen in a total of seven patients (8.4 percent), including hemorrhage (3.6 percent) and wound infection (4.8 percent). Mesh erosion, mesh infection, or worsening of sexual function was not noted.

CONCLUSIONS

Transperineal repair of rectocele with the polyglycolic acid mesh is an efficient therapy for patients with rectocele. It is highly successful in eliminating symptoms of obstructed defecation, and it is free of significant complications.

Treatment of obstructed defecation

Obstructed defecation is a common problem that adversely affects the quality of life for many patients. Known causes of obstructed defecation include pelvic dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse. Management of this condition requires an understanding of urinary, defecatory, and sexual function to achieve optimal outcomes. The goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions. However, there is a poor correlation between anatomic and functional results. It must be remembered that the pelvis contains many structures and that defects of pelvic support or function frequently affect other pelvic organs. Optimal outcomes can be achieved only by selecting appropriate treatment modalities that address all of the components of an individual patient's problem.

Rectocele: pathogenesis and surgical management

BACKGROUND

Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty.

DISCUSSION

The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation.

CONCLUSION

The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

Dynamic evaluation of the anorectum

The evaluation of EP is complicated by the lack of any gold standard and a shifting clinical emphasis as management regimens go in and out of favor. As with all functional bowel disease, there is a residue of patients who are difficult to manage, and in whom a clinician will want maximum information before deciding on treatment. The examination has been criticized as lacking clinical relevance, and of having poor interobserver reliability except for rectal emptying and rectocele formation. Others have found a higher (83.3%) observer accuracy and a high yield of positive diagnoses. A questionnaire showed that clinicians found EP of major benefit in 40%, altering management from surgical to medical in 14% and vice versa in 4%. Radiographic examinations only impact on clinical management when findings alter management. Management protocols are evolving in functional disorders, but important features that EP reveals are anismus, trapping in rectoceles, IAI, and rectal prolapse. EP is the only method to diagnose some of these conditions and within defined parameters is extremely valuable in clinical management.

How could management of rectoceles be optimized?

A posterior vaginal wall prolapse, also known as a rectocele, is a common condition and is an outpouching of the posterior vaginal wall and anterior rectal wall into the lumen of the vagina.1-5 Although more common in parous women, rectoceles of over 1 cm in size have been demonstrated in over 40% of nulliparous women. As rectoceles may be asymptomatic, their true prevalence is not clear. Many women with rectoceles present to their gynaecologist who may not ascertain any anorectal symptoms or perform a rectal examination. Conversely, colorectal surgeons often disregard a vaginal examination.6 Conventionally, gynaecologists have managed rectoceles, but increasingly colorectal surgeons are involved because of the prevalence of anorectal symptoms. There are many surgical techniques for the management of a symptomatic rectocele. There is, however, little data to suggest which is the most effective technique, or whether specific techniques are more appropriate in certain circumstances.7

Constipation: evaluation and management

Constipation is a common symptom that can result from several disorders. Most patients with chronic constipation do not have a medical disorder contributing to the constipation and, therefore, require limited evaluation. Initial intervention should include dietary measures and fiber supplements; however, if fiber supplementation is ineffective, other agents can be used. Surgery should be reserved for patients who meet specific clinical criteria.

Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects

OBJECTIVE

The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse.

MATERIALS AND METHODS

Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination.

RESULTS

Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding.

CONCLUSION

Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

Surgical treatment of constipation and fecal incontinence

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Rectal prolapse, rectal intussusception, rectocele, and solitary rectal ulcer syndrome

Rectal prolapse can be diagnosed easily by having the patient strain as if to defecate. A laparoscopic rectopexy should be recommended. Intussusception is more an epiphenomenon than a cause of defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining, and therapy should include restoring a normal defecation habit. Rectocele should be left alone; an operation may be considered if it is larger than 3 cm and is causing profound symptoms despite maximizing medical therapy for the associated defecation disorder.

Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation

PURPOSE

The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation.

METHODS

All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5-54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair.

RESULTS

Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19 vs. 10, preoperative vs. postoperative; P = 0.02) and the need to use digital assistance vaginally (13 vs. 6; P = 0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22 vs. 18 percent; P = 0.95), the percentage reduction in rectocele area (65 vs. 62 percent; P = 0.95), or a rectocele width of more than 2 cm (44 vs. 50 percent; P = 0.80), did vs. did not feel improved, respectively.

CONCLUSION

Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.

Symptoms in chronic constipation

OBJECTIVES

This study was designed to evaluate whether detailed symptom analysis would help to identify pathophysiologic subgroups in chronic constipation.

METHODS

In 190 patients with chronic constipation (age, 53 (range, 18-88) years; 85 percent of whom were women), symptom evaluation, transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, anorectal manometry, defecography) were performed. Patients were classified on the basis of objective data from all tests in four different groups ("disordered defecation," "slow gastrointestinal transit," "disordered defecation combined with slow-transit stool," and "no pathologic finding").

RESULTS

In 59 percent of patients, disordered defecation was found, and 27 percent had slow-transit stool. In 6 percent of patients, a combination of both was found; in only 8 percent of patients, there were no pathologic findings. Straining was reported by the vast majority in all groups (82-94 percent). Infrequent bowel movements and abdominal bloating were more common in slow-transit stool (87 and 82 percent vs. 69 and 55 percent, respectively; both P < 0.01). Feeling of incomplete evacuation was more common in disordered defecation (84 vs. 46 percent; P < 0.0001). However, specificity of these symptoms was discouraging (for slow-transit stool: infrequent bowel movements had a sensitivity of 87 percent and a specificity of 32 percent and abdominal bloating had a sensitivity of 82 percent and specificity of 45 percent; for disordered defecation: feeling of incomplete evacuation had a sensitivity of 84 percent and a specificity of 54 percent). Only the sense of obstruction and digital maneuvers were acceptably specific (79 and 85 percent, respectively) for disordered defecation, but sensitivity was low.

CONCLUSIONS

Definition of chronic constipation by infrequent bowel movements alone is of little value; the symptom "necessity to strain" is much better suited (94 percent sensitivity). Specificity of infrequent bowel movements for slow-transit stool was discouraging. Sense of obstruction and digital manipulation for evacuation are relatively specific for disordered defecation but insensitive. Therefore, symptoms of chronically constipated patients are not well suited to differentiate between the pathophysiologic subgroups suffering chronic constipation.

Does surgical repair of a rectocele improve rectal emptying?

PURPOSE

This study was undertaken to assess results of surgical repair of rectocele and to identify possible determinants of outcome from patient's history and preoperative defecography. Another aim was to evaluate how surgery affects rectal evacuation.

METHOD

Thirty-four women with constipation and rectal emptying difficulties underwent surgery with a transanal technique. A preoperative defecography was performed in each patient. They were followed up after a median of 10 (range, 2-60) months with a questionnaire (n = 34) and a defecography (n = 31). Computer-based image analysis of defecographies was used to evaluate rectal evacuation.

RESULTS

In 27 patients (79 percent), the result of surgery was good with subjectively improved emptying. The need for vaginal or perineal digitation preoperatively was related to a good result (P < 0.05), whereas a previous hysterectomy (P < 0.01) and a large rectal area on defecography (P < 0.01) related to a poor result. Preoperative use of enemas, motor stimulants, or several types of laxatives also related to a poor outcome (P < 0.05). Surgical treatment resulted in reduction of the rectocele (P < 0.001), an elevated position of the anorectal junction (P < 0.05), and improved rectal evacuation on defecographies (P < 0.001).

CONCLUSIONS

Surgical repair reduces the size of the rectocele and improves rectal emptying. These changes are accompanied by a symptomatic improvement in the majority of patients. Preoperative patient data and defecography may help in selecting patients for surgery.

Is barium trapping in rectoceles significant?

PURPOSE

This study was designed to determine whether rectocele size and contrast retention are significant.

METHODS

Evacuation proctography and simultaneous intrarectal pressure measurements from a small, noncompliant balloon catheter were performed in three matched groups of 11 constipated female patients with rectoceles, rectoceles and contrast trapping of > 10 percent, and no rectocele. Computerized image analysis was used to measure rectocele area and evacuation.

RESULTS

In the two groups with rectoceles, there was no significant difference in rectocele area or width pre-evacuation. The anorectal angle, pelvic floor descent, maximum anal canal width, evacuation time or completeness, maximum and distal intrarectal pressure, or need to digitate did not differ significantly between the groups. In seven patients with barium trapping (64 percent) the intrarectal pressure dropped abruptly as the balloon entered the rectocele, suggesting that trapping results from sequestration into the vagina, closing part of the rectocele from the normal intrarectal pressure zone.

CONCLUSION

Because no impairment of evacuation appears to be associated with either a large rectocele or trapping, these evacuation problems should not be directly attributed to these proctographic findings.

Intrarectal pressures and balloon expulsion related to evacuation proctography

Seventy four patients with constipation were examined by standard evacuation proctography and then attempted to expel a small, non-deformable rectal balloon, connected to a pressure transducer to measure intrarectal pressure. Simultaneous imaging related the intrarectal position of the balloon to rectal deformity. Inability to expel the balloon was associated proctographically with prolonged evacuation, incomplete evacuation, reduced anal canal diameter, and acute anorectal angulation during evacuation. The presence and size of rectocoele or intussusception was unrelated to voiding of paste or balloon. An independent linear combination of pelvic floor descent and evacuation time on proctography correctly predicted maximum intrarectal pressure in 74% of cases. No patient with both prolonged evacuation and reduced pelvic floor descent on proctography could void the balloon, as maximum intrarectal pressure was reduced in this group. A prolonged evacuation time on proctography, in combination with reduced pelvic floor descent, suggests defecatory disorder may be caused by inability to raise intrarectal pressure. A diagnosis of anismus should not be made on proctography solely on the basis of incomplete/prolonged evacuation, as this may simply reflect inadequate straining.

Interobserver agreement in defecography

PURPOSE

This study was designed to test the reproducibility of the diagnostic assessment of defecographies in patients with a suspected disorder of defecation.

METHODS

To evaluate interobserver agreement, 100 defecographic series of patients with complaints suggesting a disordered defecation were evaluated independently by three observers with a standardized questionnaire. After six weeks, a random sample of 35 of 100 defecographies was evaluated a second time with clinical data provided (history, proctologic examination). To evaluate whether the position of residual volume in the rectum would affect agreement, patients with substantial retention either in the upper or lower rectum were also evaluated separately.

RESULTS

Total agreement regarding rectocele and internal prolapse was 0.81 and 0.75, respectively (1.0 = complete agreement), and was significantly higher than chance agreement. Total agreement regarding residual volume in the rectum at the end of defecography and clinical relevance of findings was not different from chance agreement, providing clinical data did not significantly improve agreement. When residual volume was situated in the lower rectum, agreement regarding incompleteness of emptying and its clinical relevance was much better (0.93).

CONCLUSIONS

Interobserver agreement is good regarding the deformation of the rectum during defecography but not different from chance agreement regarding the completeness of evacuation.

Defecography. Results of investigations in 2,816 patients

PURPOSE

This study was designed to analyze the frequency of different findings at defecography in patients with defecation disorders and see in what way the evaluation could be improved.

METHODS

The reports of investigations in 2,816 patients were analyzed.

RESULTS

Twenty-three percent of the investigations were considered normal. Thirty-one percent of the patients had rectal intussusception, 13 percent had rectal prolapse, 27 percent had rectocele, and 19 percent had enterocele. Twenty-one percent of the patients had a combination of two or three of these diagnoses. The combination of rectocele and enterocele was rare. The majority of patients with enterocele had other concomitant findings. Patients with or without abnormal perineal descent had similar frequencies of rectal prolapse, rectal intussusception, and enterocele. Rectocele was more common in patients with abnormal perineal descent.

CONCLUSIONS

Defecography is valuable when investigating patients with defecation disorders. Pathologic findings were found in 77 percent of the patients. A standardized protocol should ensure a complete evaluation of defecography.

Quantification of evacuation proctography

PURPOSE

This study was designed to determine if evacuation proctography provides a clinically acceptable estimate of the time and completeness of rectal evacuation.

METHODS

Rectodynamics, using a weight transducer and chart recorder to quantify the weight and rate of contrast expelled, was combined with evacuation proctography to assess agreement between the evacuation times recorded and the weight of contrast expelled compared with the lateral area change on proctography.

RESULTS

Mean difference of evacuation times measured by the techniques was 0.1 seconds and the standard deviation of the differences was 1.9 seconds with 95 percent agreement limits of +/- 3.9 seconds. The mean difference between the percentage of contrast evacuated by weight and the change in rectal area on proctography was 4.3 percent. The standard deviation of the differences was 11.9 percent with 95 percent agreement limits of -19.5 percent and +28.1 percent.

CONCLUSION

Evacuation proctography provides a valid estimation of the time and completeness of rectal evacuation.

Reproducibility of five anorectal morphologic measurements in defecography

RATIONALE AND OBJECTIVES

We evaluated the inter- and intraobserver reproducibility of measuring five morphologic parameters of the anorectum in defecography (evacuation proctography).

METHODS

Measurements from 42 defecographic studies were statistically analyzed. The parameters measured during resting, squeezing, and straining included two anorectal angles (posterior and axis), maximal width of the anal canal, maximal width of the rectal lumen, and size of the rectocele.

RESULTS

The results demonstrated only fair interobserver agreement (kappa = 0.22-0.38) for almost all measurements of the five morphologic parameters. There were high correlations (kappa = 0.62-1.00) among most intraobserver measurements.

CONCLUSION

For defecographic measurement, the five parameters we studied have relatively poor clinical value because of high inter- and intraobserver inconsistency.

Defecography: results in 55 patients and impact on clinical management

We reviewed the medical records and defecograms in 55 consecutive patients to determine the impact of results of defecography on clinical management. Main indication for defecography was constipation, present in 40 (73%) of 55 patients. In the remaining 15 patients, indications included obstructed defecation (5), incontinence (5), and miscellaneous symptoms (5). Defecography evaluated pelvic floor motion by assessing changes in the anorectal angle (ARA) and anorectal junction (ARJ) during various maneuvers, extent of evacuation, and structural abnormalities. Patients were grouped based on results of defecography as being normal (26) or abnormal (29). Comparison of measurements of the ARA and ARJ with various maneuvers showed no significant differences between the two groups. Clinical impact was determined by analyzing therapy done following defecography and subsequent patient response. In the normal group, 15 patients were managed medically, seven surgically, and four lost to follow-up. Clinical improvement occurred in 13 (59%) of 22 patients, with similar results between medical (60%) and surgical (57%) therapy. In the abnormal group, 16 had medical management, seven surgical therapy, and six lost to follow-up. Clinical improvement occurred in 13 (57%) of 23 patients but surgical therapy showed more improvement. In conclusion, most standard measurements of the ARA and ARJ were of no value in determining abnormality. Results of defecography did not alter selection of medical or surgical therapy, and had little impact on patient response to therapy.