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Alshiek J, Murad-Regadas SM, Mellgren A, Glanc P, Khatri G, Quiroz LH, Weinstein MM, Rostaminia G, Oliveira L, Arif-Tiwari H, Ferrari L, Bordeianou L, Shobeiri SA. Consensus definitions and interpretation templates for dynamic ultrasound imaging of defecatory pelvic floor disorders : Proceedings of the consensus meeting of the pelvic floor disorders consortium of the american society of colon and rectal surgeons, the society of abdominal radiology, the international continence society, the American urogynecologic society, the international urogynecological association, and the society of gynecologic surgeons. Int Urogynecol J 2023; 34:603-619. [PMID: 36617601 DOI: 10.1007/s00192-022-05414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Jonia Alshiek
- Department of Obstetrics and Gynecology, Inova Health System, Fairfax, VA, USA
- Urogynecology Unit, Technion Medical School, Hillel Yaffe Medical Center, Hadera, Israel
| | - Sthela M Murad-Regadas
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
| | - Anders Mellgren
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Phyllis Glanc
- Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lieschen H Quiroz
- Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Milena M Weinstein
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Pelvic Floor Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, Northshore Hospital, Chicago, IL, USA
| | - Lucia Oliveira
- Department of Colorectal Surgery Hospital Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, AZ, USA
| | | | - Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, Pelvic Floor Disorders Center, Harvard Medical School, 55 Fruit St, GRB 425, Boston, MA, 02114, USA.
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Health System, Fairfax, VA, USA
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Consensus Definitions and Interpretation Templates for Dynamic Ultrasound Imaging of Defecatory Pelvic Floor Disorders. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:327-343. [PMID: 36652546 DOI: 10.1097/spv.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Alshiek J, Murad-Regadas SM, Mellgren A, Glanc P, Khatri G, Quiroz LH, Weinstein MM, Rostaminia G, Oliveira L, Arif-Tiwari H, Ferrari L, Bordeianou LG, Shobeiri SA. Consensus Definitions and Interpretation Templates for Dynamic Ultrasound Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons. Dis Colon Rectum 2023; 66:200-216. [PMID: 36627252 DOI: 10.1097/dcr.0000000000002651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Jonia Alshiek
- Department of Obstetrics and Gynecology, Inova Health System, Fairfax, Virginia
- Urogynecology Unit, Hillel Yaffe Medical Center, Technion Medical School, Hadera, Israel
| | - Sthela M Murad-Regadas
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
| | - Anders Mellgren
- Department of Surgery, University of Illinois, Chicago, Illinois
| | - Phyllis Glanc
- Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lieschen H Quiroz
- Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Milena M Weinstein
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Pelvic Floor Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, Northshore Hospital, Chicago, Illinois
| | - Lucia Oliveira
- Department of Colorectal Surgery' Hospital Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, Arizona
| | - Linda Ferrari
- Pelvic Floor Unit, St. Thomas' Hospital, London, United Kingdom
| | - Liliana G Bordeianou
- Department of Surgery, Massachusetts General Hospital, Pelvic Floor Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Health System, Fairfax, Virginia
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van Gruting IM, Stankiewicz A, Thakar R, Santoro GA, IntHout J, Sultan AH. Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome. Cochrane Database Syst Rev 2021; 9:CD011482. [PMID: 34553773 PMCID: PMC8459393 DOI: 10.1002/14651858.cd011482.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. OBJECTIVES To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. SEARCH METHODS We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. SELECTION CRITERIA Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. MAIN RESULTS Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. AUTHORS' CONCLUSIONS In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
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Affiliation(s)
- Isabelle Ma van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, Netherlands
| | | | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
| | - Giulio A Santoro
- Section of Anal Physiology and Ultrasound, Department of Surgery, Regional Hospital, Treviso, Italy
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
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Jeong HY, Yang SJ, Cho DH, Park DH, Lee JK. Comparison of 3-Dimensional Pelvic Floor Ultrasonography and Defecography for Assessment of Posterior Pelvic Floor Disorders. Ann Coloproctol 2020; 36:256-263. [PMID: 32178497 PMCID: PMC7508475 DOI: 10.3393/ac.2020.02.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/09/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE The aim of this study was to determine the accuracy of 3-dimensional (3D) pelvic floor ultrasonography and compare it with defecography in assessment of posterior pelvic disorders. METHODS Eligible patients were consecutive women undergoing 3D pelvic floor ultrasonography at one hospital between August 2017 and February 2019. All 3D pelvic floor ultrasonography was performed by one examiner. A total of 167 patients with suspected posterior pelvic disorder was retrospectively enrolled in the study. The patients were divided into 3 groups according to the main symptoms. RESULTS There were 82 rectoceles on defecography (55 barium trapping) and 84 on 3D pelvic floor ultrasonography. Each modality identified 6 enteroceles. There were 43 patients with pelvic floor dyssynergia on defecography and 41 on ultrasonography. There were 84 patients with intussusception on defecography and 41 on 3D pelvic floor ultrasonography. Agreement of the 2 diagnostic tests was confirmed using Cohen's kappa value. Rectocele (kappa, 0.784) and enterocele (kappa, 0.654) both indicated good agreement between defecography and 3D pelvic floor ultrasonography. In addition, pelvic floor dyssynergia (kappa, 0.406) showed moderate agreement, while internal intussusception (kappa, 0.296) had fair agreement. CONCLUSION This study showed good agreement for detection of posterior pelvic disorders between defecography and 3D pelvic floor ultrasonography.
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Affiliation(s)
| | - Shi-Jun Yang
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Dong Ho Cho
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Duk Hoon Park
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Jong Kyun Lee
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
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Regadas FSP, Murad-Regadas SM, Rodrigues LV, Regadas Filho FSP, Vilarinho AS, Morano DP. Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes. Tech Coloproctol 2019; 24:65-73. [PMID: 31828573 DOI: 10.1007/s10151-019-02131-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 11/25/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results. METHODS Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6 months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis. RESULTS A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications. CONCLUSIONS The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.
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Affiliation(s)
- F S P Regadas
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil.
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil.
| | - S M Murad-Regadas
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Unit of Pelvic Floor and Anorectal Physiology, Clinical Hospital, Federal University of Ceará, Fortaleza, CE, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - L V Rodrigues
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - F S P Regadas Filho
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - A S Vilarinho
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
- Department of Colorectal Surgery, Sao Carlos Hospital, Fortaleza, CE, Brazil
| | - D P Morano
- Department of Surgery, School of Medicine, School of Medicine of the Federal University of Ceará, Av Atilano de Moura 430, Fortaleza, Ceará, 60810-180, Brazil
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Pubovisceral muscle and anal sphincter defects in women with fecal or urinary incontinence after vaginal delivery. Tech Coloproctol 2018; 23:117-128. [PMID: 30478651 DOI: 10.1007/s10151-018-1895-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 11/21/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vaginal delivery is the most frequent cause of direct anal sphincter trauma as well as pelvic floor muscle defects in women with corresponding signs and symptoms. The aim of the present study was to identify anatomical and functional abnormalities of the anal canal and pelvic floor in women who had had a vaginal delivery and determine the relationship between such abnormalities and the symptoms and severity of fecal incontinence (FI). METHODS Consecutive female patients with symptoms of fecal and/or urinary incontinence were recruited through the colorectal and gynecological outpatient clinics at two large university hospitals and were eligible if they had had at a vaginal delivery. All women were assessed for symptoms FI by means of the Cleveland Clinic Florida Incontinence Scale (CCFIS) and for urinary incontinence symptoms, including the presence of complaints of any involuntary leakage of urine, leakage on exertion, sneezing, or coughing, and/or leaking or losing urine associated with an urge to urinate. All women underwent anorectal and endovaginal three-dimensional ultrasonography and anal manometry. The extent of the anal sphincter and PVM defects identified by ultrasound was scored from 1 to 6 based on the longitudinal involvement of the external and internal anal sphincter, the radial angle of the anterior external anal sphincter defect and the longitudinal involvement of the PVM. RESULTS There were 130 women and 89 (68%) had at least one defect of the anal sphincter or the pubovisceral muscle or both (42/32% had a pubovisceral muscle defect with or without sphincter defects, 47/36% women had an intact pubovisceral muscle but sphincter defect); and 41 (32%) had intact anal sphincter and pubovisceral muscles. The mean levator hiatus area at rest in women with anal sphincter and/or pubovisceral muscle defects was 18 (± 4 SD) which was significantly greater than in women with no defects (16 ± 3 SD; p = 0.01). Women with PVM defects had significantly higher ultrasound scores (median ultrasound score = 4/range 1-10 vs Intact = 2/range 2-5), indicating more extensive defects (p = 0.001). Bivariate analysis revealed a positive association (p < 0.05) between increasing FI symptom severity (CCFIS score) and women with PVM defects (ρ = 0.6913). Within the group of women with defects mean maximum anal squeeze pressure was significantly lower in women with PVM defect (mean 73 ± 34 SD mmHg vs mean 93 ± 38 SD; p = 0.04). Women with PVM defects had significantly higher median CCFIS scores (median score, 7/range 0-16) compared to women with intact PVM (4/range 0-10) (p < 0.001). There was a significant positive correlation between the CCFIS and ultrasound scores (ρ = 0.625; p < 0.001). Bivariate analysis revealed a negative correlations between the CCFIS score and the lengths of the anterior EAS (ρ = - 0.5621, p < 0.001), IAS (ρ = - 0.40, p < 0.001) and the area of the levator hiatus (ρ = 0.5211, p = 0.001). However, no significant correlations were observed between CCFIS scores and the gap measurement (ρ = 0.101; p = 0.253) or the resting (ρ = - 0.08, p = 0.54) or squeeze pressure (ρ = - 0.12; p = 0.34) values on anal manometry. The variables associated with worsening FI symptom severity (CCFIS score) that remained significant in multiple linear regression included the shorter lengths of the anterior EAS and/or the lengths of the anterior IAS and increased area of the levator hiatus. CONCLUSIONS The study data demonstrate that half of the women had combined defects of PVM and sphincter. There were correlations between anatomical abnormalities including the anal sphincter and/or pubovisceral muscle defects with decrease in the anal pressures and increased severity of FI.
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Dynamic translabial ultrasound versus echodefecography combined with the endovaginal approach to assess pelvic floor dysfunctions: How effective are these techniques? Tech Coloproctol 2017; 21:555-565. [PMID: 28674949 DOI: 10.1007/s10151-017-1658-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the role of dynamic translabial ultrasound (TLUS) in the assessment of pelvic floor dysfunction and compare the results with echodefecography (EDF) combined with the endovaginal approach. METHODS Consecutive female patients with pelvic floor dysfunction were eligible. Each patient was assessed with EDF combined with the endovaginal approach and TLUS. The diagnostic accuracy of the TLUS was evaluated using the results of EDF as the standard for comparison. RESULTS A total of 42 women were included. Four sphincter defects were identified with both techniques, and EDF clearly showed if the defect was partial or total and additionally identified the pubovisceral muscle defect. There was substantial concordance regarding normal relaxation and anismus. Perfect concordance was found with rectocele and cystocele. The rectocele depth was measured with TLUS and quantified according to the EDF classification. Fair concordance was found for intussusception. There was no correlation between the displacement of the puborectal muscle at maximum straining on EDF with the displacement of the anorectal junction (ARJ), compared at rest with maximal straining on TLUS to determine perineal descent (PD). The mean ARJ displacement was similar in patients with normal and those with excessive PD on TLUS. CONCLUSIONS Both modalities can be used as a method to assess pelvic floor dysfunction. The EDF using 3D anorectal and endovaginal approaches showed advantages in identification of the anal sphincters and pubodefects (partial or total). There was good correlation between the two techniques, and a TLUS rectocele classification based on size that corresponds to the established classification using EDF was established.
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Hainsworth AJ, Solanki D, Hamad A, Morris SJ, Schizas AMP, Williams AB. Integrated total pelvic floor ultrasound in pelvic floor defaecatory dysfunction. Colorectal Dis 2017; 19:O54-O65. [PMID: 27886434 DOI: 10.1111/codi.13568] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/30/2016] [Indexed: 02/08/2023]
Abstract
AIM Imaging for pelvic floor defaecatory dysfunction includes defaecation proctography. Integrated total pelvic floor ultrasound (transvaginal, transperineal, endoanal) may be an alternative. This study assesses ultrasound accuracy for the detection of rectocele, intussusception, enterocele and dyssynergy compared with defaecation proctography, and determines if ultrasound can predict symptoms and findings on proctography. Treatment is examined. METHOD Images of 323 women who underwent integrated total pelvic floor ultrasound and defaecation proctography between 2011 and 2014 were blindly reviewed. The size and grade of rectocele, enterocele, intussusception and dyssynergy were noted on both, using proctography as the gold standard. Barium trapping in a rectocele or a functionally significant enterocele was noted on proctography. Demographics and Obstructive Defaecation Symptom scores were collated. RESULTS The positive predictive value of ultrasound was 73% for rectocele, 79% for intussusception and 91% for enterocele. The negative predictive value for dyssynergy was 99%. Agreement was moderate for rectocele and intussusception, good for enterocele and fair for dyssynergy. The majority of rectoceles that required surgery (59/61) and caused barium trapping (85/89) were detected on ultrasound. A rectocele seen on both transvaginal and transperineal scanning was more likely to require surgery than if seen with only one mode (P = 0.0001). If there was intussusception on ultrasound the patient was more likely to have surgery (P = 0.03). An enterocele visualized on ultrasound was likely to be functionally significant on proctography (P = 0.02). There was, however, no association between findings on imaging and symptoms. CONCLUSION Integrated total pelvic floor ultrasound provides a useful screening tool for women with defaecatory dysfunction such that defaecatory imaging can avoided in some.
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Affiliation(s)
- A J Hainsworth
- The Pelvic Floor Unit, Guy's and St Thomas' Hospital, London, UK
| | - D Solanki
- The Pelvic Floor Unit, Guy's and St Thomas' Hospital, London, UK
| | - A Hamad
- The Pelvic Floor Unit, Guy's and St Thomas' Hospital, London, UK
| | - S J Morris
- The Pelvic Floor Unit, Guy's and St Thomas' Hospital, London, UK
| | - A M P Schizas
- The Pelvic Floor Unit, Guy's and St Thomas' Hospital, London, UK
| | - A B Williams
- The Pelvic Floor Unit, Guy's and St Thomas' Hospital, London, UK
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Correlation Between Echodefecography and 3-Dimensional Vaginal Ultrasonography in the Detection of Perineal Descent in Women With Constipation Symptoms. Dis Colon Rectum 2016; 59:1191-1199. [PMID: 27824705 DOI: 10.1097/dcr.0000000000000714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Defecography is an established method of evaluating dynamic anorectal dysfunction, but conventional defecography does not allow for visualization of anatomic structures. OBJECTIVE The purpose of this study was to describe the use of dynamic 3-dimensional endovaginal ultrasonography for evaluating perineal descent in comparison with echodefecography (3-dimensional anorectal ultrasonography) and to study the relationship between perineal descent and symptoms and anatomic/functional abnormalities of the pelvic floor. DESIGN This was a prospective study. SETTING The study was conducted at a large university tertiary care hospital. PATIENTS Consecutive female patients were eligible if they had pelvic floor dysfunction, obstructed defecation symptoms, and a score >6 on the Cleveland Clinic Florida Constipation Scale. INTERVENTIONS Each patient underwent both echodefecography and dynamic 3-dimensional endovaginal ultrasonography to evaluate posterior pelvic floor dysfunction. MAIN OUTCOME MEASURES Normal perineal descent was defined on echodefecography as puborectalis muscle displacement ≤2.5 cm; excessive perineal descent was defined as displacement >2.5 cm. RESULTS Of 61 women, 29 (48%) had normal perineal descent; 32 (52%) had excessive perineal descent. Endovaginal ultrasonography identified 27 of the 29 patients in the normal group as having anorectal junction displacement ≤1 cm (mean = 0.6 cm; range, 0.1-1.0 cm) and a mean anorectal junction position of 0.6 cm (range, 0-2.3 cm) above the symphysis pubis during the Valsalva maneuver and correctly identified 30 of the 32 patients in the excessive perineal descent group. The κ statistic showed almost perfect agreement (κ = 0.86) between the 2 methods for categorization into the normal and excessive perineal descent groups. Perineal descent was not related to fecal or urinary incontinence or anatomic and functional factors (sphincter defects, pubovisceral muscle defects, levator hiatus area, grade II or III rectocele, intussusception, or anismus). LIMITATIONS The study did not include a control group without symptoms. CONCLUSIONS Three-dimensional endovaginal ultrasonography is a reliable technique for assessment of perineal descent. Using this technique, excessive perineal descent can be defined as displacement of the anorectal junction >1 cm and/or its position below the symphysis pubis on Valsalva maneuver.
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Use of Biofeedback Combined With Diet for Treatment of Obstructed Defecation Associated With Paradoxical Puborectalis Contraction (Anismus): Predictive Factors and Short-term Outcome. Dis Colon Rectum 2016; 59:115-21. [PMID: 26734969 DOI: 10.1097/dcr.0000000000000519] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Numerous studies have described the use of biofeedback therapy for the treatment of anismus. Success rates vary widely, but few data are available regarding factors predictive of success. OBJECTIVE Our aim was to evaluate short-term results of biofeedback associated with diet in patients with obstructed defecation because of anismus and to investigate factors that may affect the results. DESIGN Patients were identified from a single-institution prospectively maintained database. SETTINGS This study was conducted in a tertiary hospital. PATIENTS Consecutive patients who had obstructed defecation associated with anismus and were treated with biofeedback associated with diet were eligible. INTERVENTIONS Each patient underwent anal manometry and/or dynamic anal ultrasound. Patients with anismus and were treated with biofeedback associated with diet. MAIN OUTCOME MEASURES Patients classed as having a satisfactory response to therapy and those classed as having an unsatisfactory response were compared with regard to sex, age, Cleveland Clinic Florida constipation score, functional factors (anal resting and squeeze pressures and reversal of paradoxical puborectalis contraction on manometry), and anatomic factors in women (history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery). RESULTS A total of 116 patients were included (75 women and 41 men). Overall, 59% were classed as having a satisfactory response (decrease in constipation score, >50%). Patients with satisfactory responses to biofeedback plus diet did not differ from those with unsatisfactory responses with regard to clinical, anatomic, and physiological factors. LIMITATIONS This was not a randomized controlled trial. CONCLUSIONS Biofeedback combined with diet is a valuable treatment option for patients with obstructed defecation syndrome associated with anismus, and more than half of our patients of both sexes achieved a satisfactory response. Improvement was not related to reversal of paradoxical contraction of puborectalis muscles at manometry. Patient sex, age, previous anorectal surgery, anorectal manometry pressures, and vaginal delivery, menopause, and hysterectomy in women did not significantly affect outcome.
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de la Portilla F, Rubio Manzanares Dorado M, Pino Díaz V, Vazquez Monchul JM, Palacios C, Díaz Pavón JM, Sánchez Gil JM, García Cabrera AM. Utilidad de la ecografía dinámica tridimensional en el estudio del suelo pélvico. Cir Esp 2015; 93:530-5. [DOI: 10.1016/j.ciresp.2014.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 11/04/2014] [Accepted: 11/23/2014] [Indexed: 10/24/2022]
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van Gruting IMA, Stankiewicz A, Thakar R, IntHout J, Santoro GA, Sultan AH. Imaging modalities for the detection of posterior compartment disorders in women with obstructed defaecation syndrome. Hippokratia 2015. [DOI: 10.1002/14651858.cd011482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Isabelle MA van Gruting
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
| | - Aleksandra Stankiewicz
- Croydon University Hospital; Department of Radiology; 530 London Road Croydon UK CR7 7YE
| | - Ranee Thakar
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
| | - Joanna IntHout
- Radboud university medical center; Radboud Institute for Health Sciences; Geert Grooteplein noord 21; route 133 Nijmegen Netherlands 6500 HB
| | - Giulio A Santoro
- Regional Hospital; Section of Anal Physiology and Ultrasound, Department of Surgery; Piazzale Ospedale 1 Treviso Italy 31100
| | - Abdul H Sultan
- Croydon University Hospital NHS Trust; Department of Obstetrics and Gynaecology; 530 London Road Croydon Surrey UK CR7 7YE
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García del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, Gutiérrez Velasco L, Fraga Rivas P, Manzano Paradela M, Díez Pérez de las Vacas MI, Marco Sanz AG, Fraile Moreno E. MR Imaging–based Assessment of the Female Pelvic Floor. Radiographics 2014; 34:1417-39. [DOI: 10.1148/rg.345140137] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Is it possible to predict the presence of intestinal angioectasias? DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2014; 2014:461602. [PMID: 24771990 PMCID: PMC3977092 DOI: 10.1155/2014/461602] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/25/2014] [Accepted: 02/13/2014] [Indexed: 12/18/2022]
Abstract
Background and Aim. Angioectasias are the most common vascular anomalies found in the gastrointestinal tract. In small bowel (SB), they can cause obscure gastrointestinal bleeding (OGIB) and in this setting, small bowel capsule endoscopy (SBCE) is an important diagnostic tool. This study aimed to identify predictive factors for the presence of SB angioectasias, detected by SBCE. Methods. We retrospectively analyzed the results of 284 consecutive SBCE procedures between April 2006 and December 2012, whose indication was OGIB, of which 47 cases with SB angioectasias and 53 controls without vascular lesions were selected to enter the study. Demographic and clinical data were collected. Results. The mean age of subjects with angioectasias (70.9 ± 14.7) was significantly higher than in controls (53.1 ± 18.6; P < 0.001). The presence of SB angioectasias was significantly higher when the indication for the exam was overt OGIB versus occult OGIB (13/19 versus 34/81, P = 0.044). Hypertension and hypercholesterolemia were significantly associated with the presence of SB angioectasias (38/62 versus 9/38, P < 0.001 and 28/47 versus 19/53, P = 0.027, resp.). Other studied factors were not associated with small bowel angioectasias. Conclusions. In patients with OGIB, overt bleeding, older age, hypercholesterolemia, and hypertension are predictive of the presence of SB angioectasias detected by SBCE, which may be used to increase the diagnostic yield of the SBCE procedure and to reduce the proportion of nondiagnostic examinations.
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Use of dynamic 3-dimensional transvaginal and transrectal ultrasonography to assess posterior pelvic floor dysfunction related to obstructed defecation. Dis Colon Rectum 2014; 57:228-36. [PMID: 24401886 DOI: 10.1097/dcr.0000000000000028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND New ultrasound techniques may complement current diagnostic tools, and combined techniques may help to overcome the limitations of individual techniques for the diagnosis of anorectal dysfunction. A high degree of agreement has been demonstrated between echodefecography (dynamic 3-dimensional anorectal ultrasonography) and conventional defecography. OBJECTIVE Our aim was to evaluate the ability of a combined approach consisting of dynamic 3-dimensional transvaginal and transrectal ultrasonography by using a 3-dimensional biplane endoprobe to assess posterior pelvic floor dysfunctions related to obstructed defecation syndrome in comparison with echodefecography. DESIGN AND SETTING This was a prospective, observational cohort study conducted at a tertiary-care hospital. PATIENTS Consecutive female patients with symptoms of obstructed defecation were eligible. INTERVENTION Each patient underwent assessment of posterior pelvic floor dysfunctions with a combination of dynamic 3-dimensional transvaginal and transrectal ultrasonography by using a biplane transducer and with echodefecography. MAIN OUTCOME MEASURES Kappa (κ) was calculated as an index of agreement between the techniques. Diagnostic accuracy (sensitivity, specificity, and positive and negative predictive values) of the combined technique in detection of posterior dysfunctions was assessed with echodefecography as the standard for comparison. RESULTS A total of 33 women were evaluated. Substantial agreement was observed regarding normal relaxation and anismus. In detecting the absence or presence of rectocele, the 2 methods agreed in all cases. Near-perfect agreement was found for rectocele grade I, grade II, and grade III. Perfect agreement was found for entero/sigmoidocele, with near-perfect agreement for rectal intussusception. Using echodefecography as the standard for comparison, we found high diagnostic accuracy of transvaginal and transrectal ultrasonography in the detection of posterior dysfunctions. LIMITATIONS This combined technique should be compared with other dynamic techniques and validated with conventional defecography. CONCLUSIONS Dynamic 3-dimensional transvaginal and transrectal ultrasonography is a simple and fast ultrasound technique that shows strong agreement with echodefecography and may be used as an alternative method to assess patients with obstructed defecation syndrome.
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Videlock EJ, Lembo A, Cremonini F. Diagnostic testing for dyssynergic defecation in chronic constipation: meta-analysis. Neurogastroenterol Motil 2013; 25:509-20. [PMID: 23421551 DOI: 10.1111/nmo.12096] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 01/11/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Dyssynergic defecation (DD) results from inadequate relaxation of the pelvic floor on attempted defecation. The prevalence of DD in patients with chronic constipation (CC) is not certain. Aims of this study are to estimate the prevalence of abnormal findings associated with DD across testing modalities in patients referred for physiological testing for CC. METHODS Systematic search of MEDLINE, EMBASE and PUBMED databases were conducted. We included full manuscripts reporting DD prevalence in CC, and specific findings at pelvic floor diagnostic tests. Random effects models were used to calculate pooled DD prevalences (with 95% CI) according to individual tests and specific findings. KEY RESULTS A total of 79 studies on 7581 CC patients were included. The median prevalence of any single abnormal finding associated with DD was 37.2%, ranging from 14.9% (95% CI 7.9-26.3) for absent opening of the anorectal angle (ARA) on defecography to 52.9% (95% CI 44.3-61.3) for a dyssynergic pattern on ultrasound. The prevalence of a dyssynergic pattern on manometry was 47.7% (95% CI 39.5-56.1). The prevalence of DD was similar across specialty and geographic area as well as when restricting to studies using Rome criteria to define constipation. CONCLUSIONS & INFERENCES Dyssynergic defecation is highly prevalent in CC and is commonly detected across testing modalities, type of patient referred, and geographical regions. We believe that the lower prevalence of findings associated with DD by defecography supports use of manometry and balloon expulsion testing as an initial evaluation for CC.
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Affiliation(s)
- E J Videlock
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Xu CY, Ding SQ, Xue YH, Ding YJ. Diagnostic value of pelvic floor ultrasound in constipation due to female pelvic floor dysfunction. Shijie Huaren Xiaohua Zazhi 2012; 20:2931-2936. [DOI: 10.11569/wcjd.v20.i30.2931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Constipation caused by female pelvic floor dysfunction (FPFD) is closely related to pathological changes in the front, middle and back basins. Constipation caused by pathological changes in the back basin manifests itself as rectocele, internal rectal intussusception, enterocele, descending perineum, and pelvic floor dyssynergia. Constipation due to the pathological changes in the front and middle basins not only manifests the above symptoms but also exhibits the symptoms of uterine and bladder prolapse. Pelvic floor ultrasound allows observing pathological changes in the front, middle and back basins in patients with constipation caused by FPFD, analyzing the changes in structure and function of static and dynamic pelvic floors, and making a more systematic assessment of female pelvic floor lesions, which is conducive to guiding constipation treatment. Therefore, pelvic floor ultrasound has great value in constipation caused by FPFD. In this paper, we review the diagnostic value of pelvic floor ultrasound in constipation due to female pelvic floor dysfunction.
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