Practical performance of defecography for the evaluation of constipation and incontinence

Evaluation of Perineal Descent Measurements on Pelvic Floor Imaging

Objectives: The aim of this study is to validate a uniform method for measuring perineal descent which can be used for different imaging methods, to establish cut-off values for this measurement, and to assess diagnostic test accuracy (DTA) of imaging techniques using these cut-off values. Secondly, the study aims to correlate perineal descent to symptoms, signs and imaging findings in women with obstructed defaecation syndrome (ODS) to assess its clinical relevance. Methods: Cross-sectional study of 131 women with symptoms of ODS. Symptoms and signs were assessed using validated methods. These women underwent evacuation proctography (EP), magnetic resonance imaging (MRI), transperineal ultrasound (TPUS) and endovaginal ultrasound (EVUS). Perineal descent was measured on EP and MRI as the position of anorectal junction (ARJ) with respect to the pubococcygeal line (PCL) at rest (i.e., static descent) and during evacuation (i.e., descent at Valsalva). Dynamic perineal descent was measured on all four imaging techniques as the difference between the position of the ARJ at rest and Valsalva. DTA of dynamic perineal descent was estimated using Latent Class Analysis in the absence of a reference standard. Results: Interobserver agreement of dynamic perineal descent measurements was good for MRI and EVUS (ICC 0.86 and 0.85) and moderate for EP and TPUS (ICC 0.61 and 0.59). The systematic differences in measurements between imaging techniques show the need for individual cut-off values. New established cut-off values for dynamic descent are for EP 20 mm, MRI 35 mm, TPUS 15 mm and EVUS 15 mm. Sensitivity was moderate for EP (0.78) and MRI (0.74), fair for TPUS (0.65) and poor for EVUS (0.58). Specificity was similar for all imaging techniques (0.73-0.77). Static perineal descent correlated with symptoms of pelvic organ prolapse (POP) (r = 0.19), prolapse of all three compartments (r = 0.19-0.36), presence of levator ani muscle avulsion (p = 0.01) and increased hiatal area (r = 0.51). Dynamic perineal descent correlated with excessive straining (r = 0.24) and use of laxatives (r = 0.24). Classic symptoms of ODS (incomplete evacuation and digitation) did not correlate with perineal descent measurements. Static and dynamic perineal descent were associated with presence of rectocele, enterocele, intussusception, and absence of anismus. Conclusions: Dynamic perineal descent is a reliable measurement that can be applied to different imaging techniques to allow standardisation. Static descent is more often present in women with POP and dynamic descent is more often present in women with constipation. Perineal descent does not correlate with typical symptoms of ODS. Specificity of TPUS and EVUS is comparable to EP and MRI, hence ultrasound could be used for the initial assessment of pelvic floor dysfunction.

The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children

BACKGROUND

Defecography is a study to assess anorectal function during evacuation.

OBJECTIVE

To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders.

MATERIALS AND METHODS

We reviewed all fluoroscopic defecography studies performed (2003-2009) in children with defecation problems and normal anorectal motility studies. Results were classified into three groups: (1) normal pelvic floor function; (2) pelvic floor dyssynergia, including incomplete relaxation of pelvic musculature, inconsistent change in anorectal angle and incomplete voluntary evacuation; (3) structural abnormality, including excessive pelvic floor descent with an intra-rectal intussusception, rectocele or rectal prolapse.

RESULTS

We included 18 patients (13 boys, median age 9.1 years). Indication for fluoroscopic defecography was chronic constipation in 56%, fecal incontinence in 22% and rectal prolapse in 22%. Defecography showed pelvic floor dyssynergia in 9 children (50%), a structural abnormality in 4 (22%) and normal pelvic floor function in 5 (28%). In 12 children (67%) the outcome of fluoroscopic defecography directly influenced therapeutic management. After defecography 4 children (22%) were referred for anorectal biofeedback treatment, 4 children (22%) for surgery, 2 children (11%) for additional MR defecography, and 1 child to the psychology department, and medication was changed in 1 child. In 6 children (33%) the result did not change the management. In 9 children (75%) the change of management was successful.

CONCLUSIONS

Fluoroscopic defecography can be a useful tool in understanding the pathophysiology and it may provide information that impacts management of children with refractory defecation disorders.

A practical approach to diagnosis and management of functional constipation in adults

Chronic constipation is a frequently complained condition in clinical practice and may be primary (idiopathic) or due to secondary causes. The definition of the various forms of constipation is presently made according to the Rome III criteria, which recently incorporated also specific diagnostic algorithms. The diagnosis of constipation relies on the patient's history, including use of drugs, physical examination, and specific investigations (transit time, anorectal manometry, balloon expulsion test, defecography). These will often be useful to start a targeted therapeutic schedule that may include fibres, laxatives, biofeedback training and, in extreme cases, a surgical approach. This review will analyse the clinical and diagnostic aspects of chronic constipation in adult patients, with emphasis on recent therapeutic approaches.

A novel three-dimensional dynamic anorectal ultrasonography technique for the assessment of perineal descent, compared with defaecography

AIM

The purpose of the study was to describe a novel three-dimensional dynamic anorectal ultrasonography technique (dynamic 3-DAUS) for assessment of perineal descent (PD) and establishment of normal range values, comparing it with defaecography. Secondarily, the study compares the ability of the two techniques to identify various pelvic floor dysfunctions.

METHOD

A prospective study was undertaken in 29 women (mean age 43 years) with obstructed defecation disorder. All patients underwent defaecography and dynamic 3-DAUS and the results were compared. Lee kappa coefficients (K) were used.

RESULTS

On defaecography, PD > 3 cm was detected in 12 patients. On dynamic 3-DAUS, 10 of these patients had PD > 2.5 cm. Seventeen had normal PD on defaecography and PD ≤ 2.5 cm on dynamic 3-DAUS (K 0.85). Normal relaxation was observed in 10 patients and anismus in 14 with both techniques (K 0.65). Both techniques identified five patients without rectocele, two with grade I rectocele (K 0.89 and 1.00, respectively) and 10 with grade II and nine with grade III (K 0.72 and 0.77, respectively). Rectal intussusception was identified in six patients on defaecography. These were confirmed on dynamic 3-DAUS in addition to the identification of another seven cases indicating moderate agreement (K 0.46). Enterocele/sigmoidocele grade III was identified in one patient with both techniques, indicating substantial agreement (K 0.65).

CONCLUSION

Dynamic 3-DAUS was shown to be a reliable technique for the assessment of PD and pelvic floor dysfunctions, identifying all disorders and confirming findings from defaecography.

Predictive capability of anorectal physiologic tests for unfavorable outcomes following biofeedback therapy in dyssynergic defecation

The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population.