Associations of defecography and physiologic findings in male patients with rectocele

A possible physiological mechanism of rectocele formation in women

BACKGROUND

We aimed to determine the anorectal physiological factors associated with rectocele formation.

METHODS

Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected.

RESULTS

Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011).

CONCLUSION

Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.

Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era

BACKGROUND

More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful.

PURPOSE

We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

Do Age and Sex Influence Anorectal Manometry Parameters?

Background

High-resolution anorectal manometry (HRM) is widely used in the evaluation of anal incontinence and constipation, which become increasingly prevalent with age. However, the impact of age and comorbidities on physiological digestive parameters remains poorly understood. In this study, we aimed to evaluate the effect of age on anorectal function.

Methods

We conducted a retrospective study on patients at our digestive motility clinic between January 2016 and May 2019. All patients with a normal HRM were included. Clinical data and HRM parameters were collected in a database. Multivariate regression analyses were performed to evaluate the effects of age, sex, medical comorbidities and obstetric history on anorectal HRM parameters.

Key Results

One hundred and forty-four patients were included (mean age: 53 ± 16 years, 72% females). The main indications for anorectal HRM were incontinence (44%), constipation (37%) and anorectal pain (9%). Age was significantly associated with higher maximum tolerable volume (β = +0.48 mL year^-1, P = 0.04) and higher rectal compliance (β = +0.04 mL year^-1, P = 0.01). Independently from age and medical comorbidities, female demonstrated significantly lower mean endurance squeeze pressure (β = −44.4 mmHg, P < 0.001), maximal squeeze pressure (β = −62.3 mmHg; P < 0.001), volume at first urge (β = −16.7 mL, P = 0.02) and maximum tolerable volume (β = −16.1 mL, P = 0.046). Vaginal birth was associated with lower tolerable maximum pressure (β = −39.4 mmHg, P = 0.046).

Conclusion

Age and sex are independent factors which influence anorectal HRM parameters. These findings should be taken into consideration when interpreting anorectal HRM.

MRI of the Male Pelvic Floor

The pelvic floor is a complex structure that supports the pelvic organs and provides resting tone and voluntary control of the urethral and anal sphincters. Dysfunction of or injury to the pelvic floor can lead to gastrointestinal, urinary, and sexual dysfunction. The prevalence of pelvic floor disorders is much lower in men than in women, and because of this, the majority of the published literature pertaining to MRI of the pelvic floor is oriented toward evaluation of the female pelvic floor. The male pelvic floor has sex-specific differences in anatomy and pathophysiologic disorders. Despite these differences, static and dynamic MRI features of these disorders, specifically gastrointestinal disorders, are similar in both sexes. MRI and MR defecography can be used to evaluate anorectal disorders related to the pelvic floor. MRI can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding MR cystourethrography, and subsequently, to assess causes of incontinence treatment failure. Increased tone of the pelvic musculature in men secondary to chronic pain can lead to sexual dysfunction. This article reviews normal male pelvic floor anatomy and how it differs from the female pelvis; MRI techniques for imaging the male pelvis; and urinary, gastrointestinal, and sexual conditions related to abnormalities of pelvic floor structures in men.Online supplemental material is available for this article.^©RSNA, 2019.

The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome

BACKGROUND

The aim of the present study was to assess the relationship between symptoms of obstructed defecation and findings on magnetic resonance (MR) defecography in males with obstructed defecation syndrome (ODS).

METHODS

Thirty-six males with ODS who underwent MR defecography at our institution between March 2013 and February 2016 were asked in a telephone interview about their symptoms and subsequent treatment, either medical or surgical. Patients were divided into 2 groups, one with anismus (Group 1) and one with prolapse without anismus (Group 2). The interaction between ODS type and symptoms with MR findings was assessed by multivariate analysis for categorical data using a hierarchical log-linear model. MR imaging findings included lateral and/or posterior rectocele, rectal prolapse, intussusception, ballooning of levator hiatus with impingement of pelvic organs and dyskinetic puborectalis muscle.

RESULTS

There were 21 males with ODS due to anismus (Group 1) and 15 with ODS due to rectal prolapse/intussusception (Group 2). Mean age of the entire group was 53.6 ± 4.1 years (range 18-77 years). Patients in Group 1 were slightly older than those in Group 2 (age peak, sixth decade in 47.6 vs 20.0%, p < 0.05). Symptoms most frequently associated with Group 1 patients included small volume and hard feces (85.0%, p < 0.01), excessive strain at stool (81.0%, p < 0.05), tenesmus and fecaloma formation (57.1 and 42.9%, p < 0.05); symptoms most frequently associated with Group 2 patients included mucous discharge, rectal bleeding and pain (86.7%, p < 0.05), prolonged toilet time (73.3%, p < 0.05), fragmented evacuation with or without digitation (66.7%, p < 0.005). Voiding outflow obstruction was more frequent in Group 1 (19.0 vs 13.3%; p < 0.05), while non-bacterial prostatitis and sexual dysfunction prevailed in Group 2 (26.7 and 46.7%, p < 0.05). At MR defecography, two major categories of findings were detected: a dyskinetic pattern (Type 1), seen in all Group 1 patients, which was characterized by non-relaxing puborectalis muscle, sand-glass configuration of the anorectum, poor emptying rate, limited pelvic floor descent and final residue ≥ 2/3; and a prolapsing pattern (Type 2), seen in all Group 2 patients, which was characterized by rectal prolapse/intussusception, ballooning of the levator hiatus with impingement of the rectal floor and prostatic base, excessive pelvic floor descent and residue ≤ 1/2. Posterolateral outpouching defined as perineal hernia was present in 28.6% of patients in Group 1 and were absent in Group 2. The average levator plate angle on straining differed significantly in the two patterns (21.3° ± 4.1 in Group 1 vs 65.6° ± 8.1 in Group 2; p < 0.05). Responses to the phone interview were obtained from 31 patients (18 of Group 1 and 13 of Group 2, response rate, 86.1%). Patients of Group 1 were always treated without surgery (i.e., biofeedback, dietary regimen, laxatives and/or enemas) which resulted in symptomatic improvement in 12/18 cases (66.6%). Of the patients in Group 2, 2/13 (15.3) underwent surgical repair, consisting of stapled transanal rectal resection (STARR) which resulted in symptom recurrence after 6 months and laparoscopic ventral rectopexy which resulted in symptom improvement. The other 11 patients of Group 2 were treated without surgery with symptoms improvement in 3 (27.3%).

CONCLUSIONS

The appearance of various abnormalities at MR defecography in men with ODS shows 2 distinct patterns which may have potential relevance for treatment planning, whether conservative or surgical.

The usefulness of MR defecography in the evaluation of pelvic floor dysfunction: our experience using 3T MRI

PURPOSE

To assess the usefulness of MR defecography in evaluating pelvic floor dysfunction, and to correlate several pelvic organ abnormalities with each other and with patients' symptoms and characteristics.

METHODS

MR defecographic examinations performed in 3T MRI machine of 95 patients (70 females, 25 males; mean age 48) were retrospectively reviewed. Pelvic organ abnormalities from all three compartments were recorded, including the anorectal junction descent, anterior rectocele, and cystocele. These were graded according to the known HMO system in relation to the pubococcygeal line. The correlation between these different abnormalities and their relation to patient symptoms and characteristics were evaluated.

RESULTS

Anorectal junction descent and anterior rectocele were most commonly observed, predominantly manifesting in female patients. Both were associated with abnormalities from all compartments. The middle compartment was the least affected, and its abnormality of uterine/vaginal descent tended to occur in association with the anterior compartment abnormality (cystocele). Anismus was low in incidence, and was not associated with other compartments abnormalities. Both enterocele/peritoneocele and intussusception were uncommon.

CONCLUSION

MR defecography is the modality of choice in assessing pelvic floor dysfunction, because it can neatly show various pelvic organ abnormalities from all compartments in a dynamic fashion, which are frequently coexistent. It can even show clinically silent or unsuspected abnormalities which can impact the management of patients.

Laparoscopic ventral mesh rectopexy in male patients with internal or external rectal prolapse

AIM

Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients.

METHOD

A password-protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient-reported outcome measures were evaluated.

RESULTS

Sixty-eight men of median age 35 years and body mass index 26 kg/m(2) underwent LVMR for external rectal prolapse (18) or Grade III-V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled 'chronic idiopathic pelvic pain' and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow-up was 42 (IQR 26-61) months. CCIS score improved from 4 (IQR 0-8) to 0 (IQR 0-0) (P < 0.001) and the ODS score from 18.5 (IQR 16-22) to 6 (IQR 5-8) (P < 0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ-22) at 3 months (P = 0.000). The QoL and the VAS for bowel symptoms were maintained at 4 years. At the last follow-up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse.

CONCLUSION

LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

Conventional videodefecography: Pathologic findings according to gender and age

OBJECTIVES

To review the most common disorders depicted with conventional videodefecography, and to compare the defecographic abnormalities between symptomatic patients according to their gender and age.

METHODS

Conventional videodefecography studies of 300 patients (24 men, 266 women; mean age - 57.7) performed in a 32-month period were reviewed for the following parameters: anorectal angle, movement of the pelvic floor, intussusceptions, incontinence and rectocele. The results were analyzed using the chi-square test.

RESULTS

Normal findings were observed in 16.7% men and 7.5% women. In women, the most frequent pathological findings were rectocele (62%), descending perineum syndrome (42.8%), intussusceptions (33.8%), incontinence (10.5%), dyskinetic puborectalis syndrome (9.4%) and rectal prolapse (4.5%); in men the most frequent pathology was the dyskinetic puborectalis syndrome (37.5%). This syndrome is more likely in men than in women (p = 0.01; OR 5.78); descending perineum syndrome (p = 0.027; OR 2.8) is more likely to occur in women. Women with perineal descent younger than 50 years frequently present an increased descent during evacuation (81.8%), while those older than 50 years already have a low pelvic floor during rest (60.3%) (p < 0.001; OR 6.8), with little change in evacuation.

CONCLUSION

Videodefecographic findings vary with age and gender.

Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: which is the "functional" examination for anorectal and pelvic floor dysfunction?

"Functional" imaging of anorectal and pelvic floor dysfunction has assumed an important role in the diagnosis and management of these disorders. Although defecography has been widely practiced for decades to evaluate the dynamics of rectal emptying, debate concerning its clinical relevance, how it should be done and interpreted continues. Due to the recognition of the association of defecatory disorders with pelvic organ prolapse in women, the need to evaluate the pelvic floor as a unit has arisen. To meet this need, defecography has been extended to include not only evaluation of defecation disorders but also the rest of the pelvic floor by opacifying the small bowel, vagina, and the urinary bladder. The term "dynamic cystocolpoproctography" (DCP) has been appropriately applied to this examination. Rectal emptying performed with DCP provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing defecatory disorders, this method of examination demonstrates maximum pelvic organ descent and provides organ-specific quantification of organ prolapse, information that is only inferred by means of physical examination. It has been found to be of clinical value in patients with defecation disorders and the diagnosis of associated prolapse in other compartments that are frequently unrecognized by history taking and the limitations of physical examination. Pelvic floor anatomy is complex and DCP does not show the anatomical details pelvic magnetic resonance imaging (MRI) provides. Technical advances allowing acquisition of dynamic rapid MRI sequences has been applied to pelvic floor imaging. Early reports have shown that pelvic MRI may be a useful tool in pre-operative planning of these disorders and may lead to a change in surgical therapy. Predictions of hypothetical increase cancer incidence and deaths in patients exposed to radiation, the emergence of pelvic floor MRI in addition to questions relating to the clinical significance of DCP findings have added to these controversies. This review analyses the pros and cons between DCP and dynamic pelvic floor MRI, addresses imaging and interpretive controversies, and their relevance to clinical management.

Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation

BACKGROUND

Defecography is the gold standard for assessing functional anorectal disorders but is limited by the need for a specific radiologic environment, exposure of patients to radiation, and inability to show all anatomic structures involved in defecation. Echodefecography is a 3-dimensional dynamic ultrasound technique developed to overcome these limitations.

OBJECTIVE

This study was designed to validate the effectiveness of echodefecography compared with defecography in the assessment of anorectal dysfunctions related to obstructed defecation.

DESIGN

Multicenter, prospective observational study.

PATIENTS

Women with symptoms of obstructed defecation.

SETTING

Six centers for colorectal surgery (3 in Brazil, 1 in Texas, 1 in Florida, and 1 in Venezuela).

INTERVENTIONS

Defecography was performed after inserting 150 mL of barium paste in the rectum. Echodefecography was performed with a 2050 endoprobe through 3 automatic scans.

MAIN OUTCOME MEASURES

The κ statistic was used to assess agreement between echodefecography and defecography in the evaluation of rectocele, intussusception, anismus, and grade III enterocele.

RESULTS

Eighty-six women were evaluated: median Wexner constipation score, 13.4 (range, 6-23); median age, 53.4 (range, 26-77) years. Rectocele was identified with substantial agreement between the 2 methods (defecography, 80 patients; echodefecography, 76 patients; κ = 0.61; 95% CI = 0.48-0.73). The 2 techniques demonstrated identical findings in 6 patients without rectocele, and in 9 patients with grade I, 29 with grade II, and 19 patients with grade III rectoceles. Defecography identified rectal intussusception in 42 patients, with echodefecography identifying 37 of these cases, plus 4 additional cases, yielding substantial agreement (κ = 0.79; 95% CI = 0.57-1.0). Intussusception was associated with rectocele in 28 patients for both methods (κ = 0.62; 95% CI = 0.41-0.83). There was substantial agreement for anismus (κ = 0.61; 95% CI = 0.40-0.81) and for rectocele combined with anismus (κ = 0.61; 95% CI = 0.40-0.82). Agreement for grade III enterocele was classified as almost perfect (κ = 0.87; 95% CI = 0.66-1.0).

LIMITATIONS

Echodefecography had limited use in identification of grade I and II enteroceles because of the type of probe used.

CONCLUSIONS

Echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorectal dysfunctions found by defecography. It is minimally invasive and well tolerated, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved in defecation.

Rectocele in children: a case report

Rectocele is an abnormal protrusion of the anterior wall of the rectum into the vagina. When symptomatic, it will typically cause obstructed defecation. It is almost exclusively found in females with rare reports in males and never been described in the literature in children younger than 18 years of age so far. We are presenting 3 cases of rectocele with obstructed defecation in the pediatric population. These children presented with the complaints of constipation along with refractory straining. They were diagnosed by defecography. Two were treated surgically and one conservatively. Surgical intervention completely cured the problem with uneventful postoperative course. Further multicenter studies with the aid of radiologic studies on children with "hard to treat" constipation should be considered to better define that disorder in the pediatric age group. A more vigilant approach may have implications in the prevention of more severe rectal and uterovaginal prolapse in the future.

The evaluation of constipation

Constipation is a major medical problem in the United States, affecting 2% to 28% of the population. Individual patients may have different conceptions of what constipation is, and the findings overlap with those in other functional gastrointestinal disorders. In 1999, an international panel of experts laid out specific criteria for the diagnosis of constipation known as the Rome II criteria. When patients present with complaints of constipation, a complete history and physical examination can elicit the cause of constipation. It is imperative to rule out a malignancy or other organic causes of the patient's symptoms prior to making the diagnosis of functional constipation. Many patients' symptoms can be relieved with lifestyle and dietary modification, both of which should be implemented before other potentially unnecessary tests are performed. Functional constipation is divided into two subtypes: slow transit constipation and obstructive defecation. Because many different terms are used interchangeably to describe these subtypes of constipation, physicians need to be comfortable with the language. Slow transit constipation is due to abnormal colonic motility. The diagnosis is made with the use of a colonic transit study. We continue to use a single-capsule technique as first described in the literature, but modifications of the capsule technique as well as scintigraphic techniques are validated and can be substituted in place of the capsule. Obstructive defecation is a much more complex problem, with etiologies ranging from rare diseases such as Hirschsprung's to physiologic abnormalities such as paradoxical puborectalis contraction. To fully evaluate the patient with obstructive defecation, anorectal manometry, defecography, and electromyography should be utilized. The different techniques available for each test are fully covered in this article. When evaluating each patient with constipation, it is important to keep in mind that the disease may be specific to one subtype or a combination of both subtypes. Because it is difficult to differentiate the subtypes from the patient's history, we feel it is imperative to evaluate patients fully for both slow transit and obstructive defecation prior to any surgical intervention. Furthermore, we have described many tests that need to be applied to one's population of patients on the basis of the capabilities and expertise the institution offers.

Gender influence on defecographic abnormalities in patients with posterior pelvic floor disorders

AIM

To compare defecographic abnormalities in symptomatic men and women and to analyze differences between men and age- and symptom-matched women.

METHODS

Sixty-six men (mean age: 55.4 years, range: 20-81 years) who complained of constipation and/or fecal incontinence and/or pelvic pain underwent defecography after intake of a barium meal. Radiographs were analyzed for the diagnosis of rectocele, enterocele, intussusception and perineal descent. They were compared with age- and symptom-matched women (n = 198) who underwent defecography during the same period.

RESULTS

Normal defecography was observed in 22.7% of men vs 5.5% of women (P < 0.001). Defecography in men compared with women showed 4.5% vs 44.4% (P < 0.001) rectocele, and 10.6% vs 29.8% (P < 0.001) enterocele, respectively. No difference was observed for the diagnosis of intussusception (57.6% vs 44.9%). Perineal descent at rest was more frequent in women (P < 0.005).

CONCLUSION

For the same complaint, diagnosis of defecographic abnormalities was different in men than in women: rectocele, enterocele and perineal descent at rest were observed less frequently in men than in women.

Outcomes after transanal repair of rectoceles

PURPOSE

To determine the outcomes of patients after transanal rectocele repair.

METHODS

The Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ-22), a validated instrument to evaluate bowel and urinary symptoms, was completed preoperatively by all patients undergoing transanal rectocele repair and postoperatively at a median interval of 8 months. The BBUSQ-22 was also administered to a control group of 50 asymptomatic female patients. The preoperative and postoperative BBUSQ-22 results for the 9 items pertaining to bowel function were compared to each other and to the responses from the control group.

RESULTS

Between April 1, 2001 and December 31, 2003, 88 women underwent transanal rectocele repair. Compared to the control group, patients with rectocele were significantly more symptomatic on all of the questions except the ability to hold bowel movements longer than 5 minutes. A significant improvement was reported postoperatively in all areas except pain with bowel movement and ability to hold bowel movements longer than 5 minutes. When the postoperative responses were compared to the control group, there were no significant differences except for a more frequent need for digital assistance and painful defecation in the surgical group.

CONCLUSION

Transanal rectocele repair results in significant improvement in defecation and continence, with postoperative bowel function comparable to control patients in 7 of the 9 areas evaluated.

A novel three-dimensional dynamic anorectal ultrasonography technique (echodefecography) to assess obstructed defecation, a comparison with defecography

AIM

To test the effectiveness of echodefecography, the dynamic 3D anorectal ultrasonography technique -(EDF). To assess women with obstructed defecation (OD), as compared with conventional defecography (DF).

METHODS

A prospective study was carried out with 30 women with OD symptoms, the mean validated Wexner constipation score was 14 (range 7-25) and the mean age 47.7 years. All patients were submitted to DF followed by EDF and the results compared.

RESULTS

Six patients were normal at DF and five were normal at EDF. Defecography identified grade I rectocele in five patients (average size: 1.8 cm), grade II in seven (average size: 2.9 cm) and grade III in 12 (average size: 4.6 cm). Different sizes of anorectocele were also observed at EDF and quantified according to DF classification (grade I: </=0.6 cm; grade II: 0.7-1.3 cm; grade III: >1.3 cm). Significant differences were observed between anorectocele sizes (p < 0.05) and between normal patients and grade I (p < 0.001). The level of agreement between the techniques was high (kappa = 0.902), with only one normal case wrongly identified as anorectocele III at EDF. Rectal intussusception was identified in five patients at DF; EDF confirmed these cases and revealed seven others, demonstrating moderate agreement (kappa = 0.462). Anismus was identified in nine patients in DF and in eight in EDF (kappa = 0.901).

CONCLUSION

Echodefecography may be used as an alternative method to assess patients with OD as it has been shown to detect the same anorectal dysfunctions observed in DF. It is minimally invasive, well tolerated, inexpensive, avoids exposure to radiation, and clearly demonstrates all the anatomic structures involved with defecation.

Ultrasonographic patterns in patients with obstructed defaecation

BACKGROUND

Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal-vaginal-dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls.

MATERIALS AND METHODS

Ninety-two consecutive patients (77 women; mean age 51 years; range 21-71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated.

RESULTS

The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values.

CONCLUSION

Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.

A novel procedure to assess anismus using three-dimensional dynamic anal ultrasonography

OBJECTIVE

This study aimed to determine the value of three-dimensional (3D) dynamic endosonography in the assessment of anismus.

METHOD

Sixty-one women submitted to anorectal manometry were enrolled including 40 healthy women and 21 patients with anismus diagnosed by manometry. Patients were submitted to 3D endosonography. Images were acquired at rest and during straining and analysed in axial and midline longitudinal planes. Sphincter integrity was quantified. The angle between the internal edge of the puborectalis with a vertical line according to the anal canal axis was calculated at rest and during straining.

RESULTS

The angle increased in 39 of the 40 normal individuals and decreased in all patients with anismus during straining compared with the angle at rest (88.36 degrees ) and straining (98.65 degrees ) in normal individuals. In the anismus group, the angle decreased at rest (90.91 degrees ) and straining (84.89 degrees ). The difference between angle sizes in normal and anismus patients during straining was statistically significant (P < 0.5).

CONCLUSION

Three-dimensional endosonography is a useful method to assess patients with anismus confirming the anorectal manometric results.

Dynamic imaging of posterior compartment pelvic floor dysfunction by evacuation proctography: techniques, indications, results and limitations

The clinical management of patients with anorectal and pelvic floor dysfunction is often difficult. Evacuation proctography has evolved from a method to evaluate the anorectum for functional disorders to its current status as a practical method for evaluating anorectal dysfunction and pelvic floor prolapse. It has a high observer accuracy and yield of positive diagnosis. Clinicians find it of major benefit and has altered management from surgical to medical and vice versa in a significant number of cases.

Ecodefecografia tridimensional dinâmica: nova técnica para avaliação da Síndrome da Defecação Obstruída (SDO)

O objetivo deste estudo é apresentar novas técnicas para avaliação da SDO, utilizando a ultra-sonografia endorretal tridimensional dinâmica e comparando os resultados com a defecografia. Foram incluídas neste estudo 25 mulheres adultas, distribuídas em dois grupos. Grupo I: 15 mulheres normais, idade média de 52,4 anos (23-76) e todas se submeteram ao exame proctológico completo e à ultra-sonografia anorretal tri-dimensional dinâmica para se estabelecer os padrões de normalidade do canal anal e reto. Grupo II: 10 pacientes mulheres com evacuação obstruída, idade média de 47,8 anos (33 a 65 anos), apresentando como principais sintomas a sensação de evacuação incompleta, disquezia e digitação vaginal ou perineal. Submeteram-se a exame proctológico completo, seguindo-se defecografia e posteriormente ecodefecografia por dois examinadores que desconheciam o resultado do exame anterior. A ecodefecografia dinâmica foi realizada com um equipamento B-K Medical®, sonda 360º, tipo 2050, com escaneamento automático durante 50 segundos com 6 cm de extensão. O tamanho médio do ângulo formado pelo músculo PR no repouso foi 87,13º (variação 78,9 - 90,8°) (± 1,01) e no esforço evacuatório 99,22º (variação 84,9 - 114,5°) (± 1,84) nas mulheres normais (grupo I). Houve elevação do ângulo em todas as pacientes normais, significando relaxamento normal do PR durante o esforço evacuatório. Com relação à avaliação da anoretocele, a parede posterior da vagina se manteve na posição horizontal durante todo o esforço evacuatório, exceto nas portadoras de anoretocele. Foram diagnosticadas anoretocele (grau I = 1, grau II = 5, grau III = 4) em todas as pacientes do grupo II pelo exame clínico e defecografia. Todos os casos foram confirmados pela ecodefecografia. A partir destes resultados, foram estabelecidos os valores para classificar a anorectocele de acordo com a ecodefecografia (grau I - distância entre as posições da parede vaginal até 5,0mm, grau II de 6,0 a 12,0mm, grau III além de 12,0mm). Foi identificado anismus em uma paciente com anoretocele grau II e em outra com grau III na defecografia e confirmado na ecodefecografia pela redução no ângulo formado pelo PR ao comparar as posições em repouso e durante o esforço evacuatório. A defecografia demonstrou também quatro casos de intussuscepção enquanto a ecodefecografia confirmou estes casos e identificou dois outros. Em conclusão, a ecodefecografia pode ser utilizada como um método alternativo para o diagnóstico da SDO, pois identifica e quantifica todas as disfunções anorretais responsáveis pela evacuação obstruída. Apresenta também a grande vantagem de avaliar os distúrbios da continência, identificando lesões esfincterianas, mesmo ocultas. É minimamente invasivo, bem tolerado, baixo custo, não expondo o paciente à radiação e demonstrando com precisão todas as estruturas anatômicas envolvidas com a defecação.

Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation

BACKGROUND

Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty.

PATIENTS AND METHODS

Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression.

RESULTS

Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05).

CONCLUSIONS

Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.

Pelvic outlet obstruction

Despite the wide variety of definitions and descriptions of constipation, ideally, the diagnostic approach should be uniform. The evaluation process should begin with a careful and thorough patient history and physical exam; appropriate efforts should be made to exclude organic causes of constipation. Patients suffering from pelvic outlet obstruction often respond poorly to conservative treatment. Diagnostic tests include intestinal transit studies, anorectal manometry, defecography, balloon expulsion, and anal sphincter electromyography. For many patients constipation is multifactorial and accordingly, so is the treatment. In our opinion the first line of treatment should be based on conservative measures including adequate intake of fluids, dietary fiber supplementation, and laxatives. Biofeedback training should be offered, particularly to patients with paradoxical puborectalis contraction. Surgical management can, in very limited circumstances, be offered only to those patients with disabling symptoms who have failed other standard therapeutic measures.

[Obstructed defecation]

Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.

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.