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PubMed2006

Multimedia article. External pelvic rectal suspension (the express procedure) for internal rectal prolapse, with or without concomitant rectocele repair: a video demonstration.

PURPOSE: Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol), designed to correct internal rectal prolapse, with or without rectocele. METHODS INCLUSION CRITERIA: severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol patch in the rectovaginal plane. RESULTS: Short-term results for the "Express" are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography. CONCLUSIONS: This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.

Collagen↗
PubMed1991

Evacuation proctography in normal volunteers.

Constipated patients evaluated by evacuation proctography may be subjected to vigorous medical therapy or surgery, even colectomy, based on radiographic findings that have been called "abnormal" in the literature. Criteria for normal defecography are not uniformly established, nor has correlation of structural or functional findings with symptoms been clearly documented. We prospectively studied 21 asymptomatic volunteers to assess the frequency of findings in a control population, and to establish a quantitative measure of normal rectal emptying. Standard defecography technique demonstrated rectocele, intussusception, pelvic descent, or puborectalis spasm in 14/21 volunteers (67%). The range of rectal emptying was 12.5% to 100%, with four subjects (19%) evacuating less than or equal to 40% of the barium paste. There was no correlation between severity of radiographic findings and degree of evacuation. Defecography results in patients being considered for symptomatic intervention should be interpreted cautiously, given the wide range of normal variation in a control population.

Defecation↗
PubMed1991

Normal anorectum: dynamic MR imaging anatomy.

In this study, the anatomy of the anorectum in relation to the surrounding structures and the anorectal angle were analyzed with magnetic resonance (MR) imaging at rest, during perineal contraction, and during straining in 10 asymptomatic subjects. The intra- and inter-observer and intra- and interpatient variations in the measurements of the anorectal angle, position of the anorectal junction, and position of the plica of Kohlrausch in the rectum were established at rest, during perineal contraction, and during straining. The values for the anorectal angle and position of the anorectal junction obtained with MR imaging were compared with standard radiography defecography findings. It was shown that MR imaging has the potential for measuring these parameters in a more precise and more patient-friendly way than defecography. Unlike dynamic defecography, MR imaging is able to depict the mobility of the posterior rectal wall. A descent of over 20 mm from rest to straining should be considered pathologic. This finding might play a role in patient selection for operation.

Adult↗
PubMed1999

[Motility diagnosis in chronic constipation].

Scintigraphy is generally considered as gold-standard for the diagnosis of delayed gastric emptying. The 13C-acetate and -octanoate breath tests represent an alternative to this method, which has been extensively validated. Gastric and small bowel manometry are very important tools for the research of motility disorders. In clinical practice, this method has only few indications. Sonographic measurement of gastric emptying is a useful procedure for the diagnosis of delayed gastric emptying, provided that the investigation is done by an experienced person. It is not clear so far, whether MRI is an alternative to the methods mentioned above. If delayed gastric emptying is excluded, the H2-lactulose breath test is a simple screening test for the disorders of small bowel transit. Colonic transit time can reliably be measured with radiopaque markers. Anorectal disorders are diagnosed by manometry and defecography. MRI-defecography gives additional information compared to the conventional defecography. These methods have an important role in the evaluation of chronic constipation. The rational combination of the displayed methods is the most appropriate way to approach the patients' problems.

Chronic Disease↗
PubMed2006

[Image analysis of puborectalis syndrome and its clinical significance].

OBJECTIVE: To discuss the clinical value and application range of defecography, CT and MRI in diagnosis of puborectalis syndrome (PRS). METHODS: The clinical data of 83 PRS patients, including defecography, CT and MRI scanning in pelvic floor resting and defecation at maximum exertion, measurement of anorectal angle (ARA), length and depth of ARA impression and the thickness of the puborectalis muscle, were collected, and compared with those of 56 normal persons. RESULTS: For normal persons, ARA at maximum exertion was more significantly increased than that at resting. In 62 cases with PRS, ARA at maximum exertion was more obviously reduced than that at resting and associated with puborectalis muscle (PRM) impression. In the other 21 cases, ARA showed no changes at either maximum exertion or resting, a little or no excretion of barium appeared and "shelving syndrome" was showed. The cross-sectional images of CT and MRI showed that the puborectalis of PRS patients were thicker than that of normal persons (P<0.01). PRS patients also showed clear pelvic floor muscle, fasciae and peripheral crevice. CONCLUSIONS: Defecography, manifested the abnormal function of the puborectalis muscles, is a reliable method for diagnosis of PRS. In the meantime, CT and MRI are able to clearly display the position, growth status and size of the puborectalis muscles as well as its relation with adjacent structures, which provide further understandings on anatomical changes, abnormal adjacent structure and other functional diseases of pelvic floor in PRS patients. Therefore, an appropriate combination of the 3 methods play an important role in the early diagnosis of PRS and guidance for surgical treatment.

Adolescent↗
PubMed1991

Functional radiology of the ano-rectal region.

Chronic constipation is probably the most common symptom resulting in a referral of patients for a dynamic radiologic investigation of the GI tract. The primary usefulness of defecography in chronic constipation is to provide details about the dynamic phenomenon of evacuation which cannot be elicited by any other medical technique. It is employed to demonstrate or rule out the presence of an anatomical deformity (prolapse, rectocele, intussusception) and/or a localized dysfunction (outlet obstruction, rectal inertia) of the distal GI tract. Defecography can distinguish between a grossly obstructed pattern and an overtly normal one, but a definitive diagnosis is made by manometry and electromyographic studies. On the other hand, it should be noted that a failure to show abnormalities by defecography does not necessarily imply a normal anorectal function. A better understanding of anorectal physiology is expected in the future from combined video-pressure studies, which will provide the exact timing between the pressure drop and barium passage through the distal colon.

Adult↗
PubMed1991

[Diseases detected with defecographic examination in 300 patients].

Defecography is a radiological examination providing morphological details of the anorectal tract. Over almost 3 years, 300 patients were examined. The authors report on the method and the pathologic conditions they observed. The patients were seated in latero-lateral position on a radiolucent water-filled commode: lead marks were taped to define perianal skin. 150 ml of high-density barium paste were introduced into the rectum and radiographs were then acquired, at rest and during squeezing and straining. All examination phases, especially the study of dynamic evacuation, were recorded on a videotape connected to a brilliance intensifier. From their experience, the authors conclude that defecography is a valuable tool in the diagnosis and evaluation of: rectocele, occult rectal prolapse, and elevator ani tone. The technique proved less useful in the evaluation of fecal incontinence. The authors strongly suggest that the patient be previously examined by a coloproctologist. Defecography is thought to help the surgeon in the choice of therapy, together with other diagnostic procedures and with clinical history.

Adult↗
PubMedDate not supplied

[Functional evaluation of the anorectal region].

Defecography is a method allowing the morphodynamic evaluation of the anorectal region. The technique we employed needs two complementary times: "phase" defecography and dynamic defecography. In our series of patients affected with severe constipation, 2 groups could be identified. Group A included those patients (mean age: 38.7 years) in whom no significant changes were observed in anorectal angle and in the distance of anorectal angle from pubococcygeal line in comparison with normal subjects (Student's t-test). Group B included those patients (mean age: 63.3 years) in whom significant reduction was observed in anorectal angle on straining, together with increased distance of anorectal angle from pubococcygeal line on squeezing in comparison with normal subjects (Student's t-test). In constipated patients narrowed anal canal was observed (60%), together with rectocele (42.6%), mucosal prolapse (27.8%), rectal prolapse (18%) and solitary ulcer (14.7%). In idiopathic incontinence patients (mean age: 63.3 years), increased distance was observed of anorectal angle from pubococcygeal line on squeezing and, in the most severe cases, even at rest, with the patient sitting (Student's t-test). In incontinent patients larger anal canal was observed (67.6%), together with rectocele (36.7%), mucosal prolapse (14.7%), and rectal prolapse (11.7%).

Adult↗
PubMed1993

Radiologic evaluation of constipation and anorectal disorders.

This article has outlined the orderly radiographic approach to evaluating the patient who presents with constipation or other anorectal complaints. Defecography alone provides only a visual record of events taking place during defecation, and it seems likely that further understanding of the pathophysiology will require manometric, electromyographic, and proctographic data in those patients. Defecography is potentially more available than these other techniques because every hospital has a fluoroscopy suite. Studies that relate the proctographic findings with other physiologic studies are underway and necessary. More studies relating pre- and postoperative defecography with clinical results are needed.

Barium Sulfate↗
PubMed2005

Evacuation of neorectal reservoirs after TME.

Colon pouch reconstruction after deep rectal resection is functionally superior to straight colorectal/anal anastomosis. However, stool evacuation difficulties could jeopardize the functional benefit of neorectal reservoirs. Beside the well proven colon J-pouch, the transverse coloplasty pouch may represent a viable alternative. We examined evacuation and functional outcome after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and distal third of rectum underwent a total mesorectal excision. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Eight months after surgery, video defecography, anal manometry and pouch volumetry were performed and the patients were interviewed according to a standardized continence questionnaire. Rectal resection and reconstruction with transverse coloplasty pouch anastomosis could be performed in all patients. No insufficiency of the pouch occurred. In the follow-up, no patient had difficulties to evacuate the pouch, none of these patients needed enemas or suppositories to facilitate defecation. All patients were continent for solid stools. Twenty-five of 27 patients had up to three bowel movements per day. Patients with reduced pelvic floor movement in the defecography proved more likely to suffer from urgency, fragmented evacuation and incontinence. Transverse coloplasty pouch reconstruction after total mesorectal excision is not associated with stool evacuation problems. Urgency and incontinence, which are rarely seen after this type of reconstruction, correlate with impaired pelvic floor movement rather than with pouch size or anal sphincter tonus.

Aged↗
PubMed1999

Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus.

PURPOSE: Rectocele is often associated with anorectal symptoms. Various surgical techniques have been described to repair the rectocele. The surgical results are variable. This study evaluated the results of transanal repair of rectocele, with particular emphasis on the impact of concomitant anismus on postoperative functional outcome. METHODS: Fifty-nine consecutive females who underwent transanal repair of rectocele for obstructed defecation were prospectively reviewed. All 59 patients were parous with a median parity of 2 (range, 1-6) and a median age of 58 (range, 46-68) years. The median length of follow-up was 19 (range, 6-40) months. Anismus was detected by anorectal physiology and defecography. The functional outcome was assessed by a standard questionnaire, physical examination, anorectal manometry, neurophysiology, and defecography. The quality-of-life index was obtained using a visual analog scale (from 1-10, with 10 being the best). RESULTS: The functional outcome of transanal repair of rectocele was superior in patients without anismus. Forty (93 percent) of the 43 patients without anismus showed improved evacuation after repair compared with 6 (38 percent) of the 16 patients with anismus (P<0.05). The quality-of-life index improved (9 vs. 4) if anismus was not present (P<0.05). There were minimal complications. Hemorrhage requiring blood transfusion (2 units) occurred in one patient and urinary retention in another. CONCLUSION: Transanal repair of rectocele is safe and, in the absence of anismus, effectively corrects obstructed defecation.

Aged↗
PubMed1998

Which physiologic tests are useful in patients with constipation?

PURPOSE: Physiologic tests such as manometry, colonic transit times, balloon compliance, defecography, pudendal nerve latency, and electromyography are used to evaluate patients with severe constipation. Patients referred because of severe constipation between 1991 and 1996 were studied to examine the role that physiologic testing played in making a diagnosis and directing treatment. METHODS: Of 139 patients referred for severe idiopathic constipation, physiologic testing was recommended in 127, and 104 patients underwent the studies. The pretesting impression was noted, and test results were evaluated to determine diagnostic accuracy. If a specific initial impression was documented, tests were classified as refuting it, confirming it or confirming and adding significant information. If there was no clear pretest impression, tests were evaluated for their ability to indicate a diagnosis. The patient's history also was evaluated to determine what information was most useful in making a diagnosis. Historical features including duration of constipation, symptoms consistent with outlet obstruction or dysmotility, age, associated urinary incontinence, and prior hysterectomy were analyzed. Data were collected prospectively, then reviewed by an independent observer. RESULTS: Ninety-eight study patients remained after 29 were excluded who did not undergo the recommended studies (19) or because no initial impression was documented (10). In 43 patients (44 percent), testing did not provide additional useful information. In 8 patients, testing confirmed the initial impression and added information impacting the treatment plan. Test results clearly refuted the initial impression in only one patient. In 46 (47 percent) patients the initial impression was uncertain, and in 43 (94 percent) of these, testing aided in making the diagnosis. In three cases, the diagnosis remained uncertain after testing. Prior hysterectomy (P = 0.003), urinary incontinence (P < 0.001), and symptoms of pelvic outlet obstruction (P = 0.03) were associated with a high incidence of rectocele. Defecography and transit times were the most useful tests. Surprisingly, symptoms of outlet obstruction or dysmotility did not show an overall correlation with transit times. CONCLUSIONS: In one-half of these patients with severe constipation, physiologic testing added significant information, leading to a specific diagnosis. Pretesting history and symptoms did not predict which patients were most likely to benefit from these studies.

Adolescent↗
PubMed2000

Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction.

PURPOSE: The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS: From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent). RESULTS: Whereas 65 patients failed to complete the course of biofeedback therapy, 108 (62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5 (8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P = not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION: Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

Aged↗
PubMed2000

Botulinum toxin in the treatment of outlet obstruction constipation caused by puborectalis syndrome.

PURPOSE: Puborectalis syndrome has been difficult to treat. We investigated the efficacy of botulinum toxin in treating patients with puborectalis syndrome who had previously failed to respond to electromyographic biofeedback sessions and who refused to use anal dilators. METHODS: Of a group of 50 patients with chronic outlet obstruction constipation, four patients with puborectalis syndrome were included in the study. The patients were studied using anorectal manometry, defecography, and electromyography and then treated with 30 units of Type A botulinum toxin, injected into two sites on either side of the puborectalis muscle, under ultrasonographic guidance. RESULTS: One patient was lost to follow-up. After treatment in other patients, the frequency of natural bowel movements increased from zero to six per week and laxatives were needed by only one patient. Anorectal manometry demonstrated decreased tone during straining from (mean +/- standard deviation) 96.2 +/- 12 mmHg to 42.5 +/- 13 mmHg at four weeks (P = 0.003) and 63.2 +/- 22 mmHg at eight weeks (P = 0.009). Defecography performed eight weeks after treatment showed improvement in the anorectal angle, which increased from 94 +/- 11 degrees to 114 +/- 13 degrees (P = 0.01), and evacuation of barium paste. Electromyography demonstrated mild paradoxical contraction. However, 16 weeks after treatment one of these three patients suffered symptomatic recurrence. This patient was re-treated with 50 units of toxin; eight months later he required a further 60 units. Seven months after the last injection he reported normal daily bowel movements without the use of laxatives. CONCLUSIONS: Botulinum toxin injection should be considered as a simple therapeutic approach in patients with puborectalis syndrome. The use of higher dosage and a more precise method of toxin injections under transrectal ultrasonography account for the long-term higher success rate. However, because the effects of the toxin wear off within three months of administration, repeated injections could be necessary to maintain the clinical improvement.

Adult↗
PubMed2004

Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography.

The aim of the present study was to compare clinical and radiological findings when assessing posterior vaginal wall prolapse. Defecography can be used to complement the clinical evaluation in patients with posterior vaginal wall prolapse. Further development of the defecography technique, using contrast medium in the urinary bladder and intraperitoneally, have resulted in cystodefecoperitoneography (CDP). Thirty-eight women underwent clinical examination using the pelvic organ prolapse quantification system (POP-Q) followed by CDP. All patients answered a standardized bowel function questionnaire. Statistical analysis measuring correlation between POP-Q and CDP using Pearson's correlation coefficient (r) and Spearman's rank order correlation coefficient (rs) demonstrated a poor to moderate correlation, r=0.49 and rs=0.55. Although there was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001), severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging. Vaginal topography and POP-Q staging predict neither radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological evaluation may therefore be a useful complement in selected patients.

Adult↗
PubMed1998

Imaging of constipation in infants and children.

The aims of this review article are to present epidemiology, important definitions, clinical considerations, and etiologic and pathogenetic aspects of constipation in infants and children. Anatomy, physiology, and pathophysiology of the the anorectum are described. Special attention is given to the indications for diagnostic imaging, imaging techniques, and imaging findings with different causes of constipation. Other diagnostic modalities, such as anorectal manometry, electromyography, and biopsy techniques are briefly discussed. The central question as to whether diagnostic imaging is needed for the diagnostic workup of infants and children suffering from constipation can be answered affirmatively. Especially the combination of barium enema or defecography and anorectal manometry allows definition of those infants and children who do not need biopsy and surgery for Hirschsprung's disease. The special role of defecography in this context is underlined.

Anal Canal↗
PubMed2004

New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial.

BACKGROUND AND AIMS: A randomised trial was undertaken to compare the clinical and functional results of two novel transanal stapled techniques in patients with outlet obstruction syndrome. MATERIALS AND METHODS: Ninety-six females with outlet obstruction were treated with medical therapy and biofeedback for 2 months; 67 non-responders were evaluated by the Constipation Scoring and Continence Grading Systems, clinical examination, endoscopy, dynamic defecography, anorectal manometry, transanal ultrasound and anal EMG, and 50 of them, all affected with descending perineum, intussusception and rectocele, were randomly assigned to two groups and operated on: 25 patients (mean age 53.2+/-15.3 years) underwent a single Stapled Trans-Anal Prolapsectomy, associated with Perineal Levatorplasty (STAPL Group), and the other 25 (mean 54.6+/-14.2 years) underwent a double Stapled Trans-Anal Rectal Resection (STARR Group). Patients were followed-up for a mean period of 23.4+/-5.1 months in STAPL Group and 22.3+/-4.8 in STARR Group. RESULTS: STARR Group showed a significantly (p<0.0001) lower pattern of postoperative pain and a greater decrease (P=0.0117) of the rectal sensitivity threshold volume; otherwise, no differences were found in operative time, hospital stay, or time of inability to work. Complications included delayed healing of the perineal wound (ten), dyspareunia (five), urinary retention (two) and stenosis (one) in STAPL Group, and urge to defecate (four), transitory incontinence to flatus (two), urinary retention (two), bleeding (one) and stenosis (one) in STARR Group. All constipation symptoms significantly improved without worsening of anal continence and with excellent/good outcome at 20 months in 76 and 88% of patients of STAPL Group and STARR Group, respectively. Seven patients of STAPL Group had a little residual rectocele, while both intussusception and rectocele were corrected in all patients of STARR Group. Neither operation modified anal pressures or caused lesions of anal sphincters. CONCLUSIONS: Both techniques are safe and effective in the treatment of outlet obstruction; nevertheless, the double Stapled Trans-Anal Rectal Resection seems to be preferable due to less pain, absence of dyspareunia, reduced rectal sensitivity threshold volume and absence of residual rectocele at defecography.

Anal Canal↗
PubMed2004

Perineal puborectalis sling operation for fecal incontinence: preliminary report.

PURPOSE: This study was designed to evaluate the safety efficacy, and impact on quality of life of the perineal puborectalis sling operation for fecal incontinence. METHODS: Since August 2001, we performed the perineal puborectalis sling operation on eight patients with idiopathic fecal incontinence. A specially designed polyester mesh sling was introduced along the puborectalis muscle, from a posterior perianal incision, running to a small suprapubic incision. The ends were tied together with moderate tension. Patients were evaluated with the Fecal Incontinence Severity Index, the Cleveland Clinic Score of Incontinence, and the Fecal Incontinence Quality of Life Scale. Manometry and defecography were performed before and six months after the operation. RESULTS: Eight patients (7 females; mean age, 63 (range, 44-77) years) were evaluated. A wound infection developed in one patient, which subsided with antibiotics. A rectal ulcer developed in one patient, necessitating sling removal. In the remaining seven patients, the Fecal Incontinence Severity Index improved from 27 to 9, and the Cleveland Clinic Score of Incontinence improved from 13 to 5 (P < 0.05). All parameters in the Fecal Incontinence Quality of Life Scale improved: lifestyle from 2.1 to 3.6; coping/behavior from 1.5 to 3.4; depression/self perception from 2.3 to 3.7; and embarrassment from 2 to 3.6 (P < 0.05). No significant difference was found between preoperative and postoperative maximum resting pressure and maximum squeeze pressure. However, the median anorectal angle on defecography after the operation was significantly reduced (P < 0.05). CONCLUSIONS: We believe that the perineal puborectalis sling operation is technically feasible, with low morbidity, and can be an effective procedure for idiopathic fecal incontinence.

Anal Canal↗